Earlier this year, a young man in his mid-thirties with non-Hodgkin’s Lymphoma came to my oncology clinic for a chemotherapy infusion while waiting on the development of his CAR-T treatment. Under normal circumstances, our practice can move quickly when scheduling patients for their treatments since our in-office infusion clinic maintains an inventory of necessary medications that we prepare ourselves onsite. But, unbeknownst to me, my patient’s health insurance plan included a policy called “white bagging,”- a policy which we soon discovered when they denied one of the chemotherapy drugs I prescribed.
Our clinical team repeatedly appealed the denial; however, the plan refused to cover the drug unless it was fulfilled through an unspecified designated specialty pharmacy associated with the patient’s pharmacy benefit manager. Eventually, we were able to negotiate coverage through our practice’s internal inventory, but by the time the patient was able to receive the drug four weeks had passed.
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This extensive delay took a devastating toll on my patient’s physical and mental health and well-being. Worse yet, these types of delays can lead to disease progression and worsen patient outcomes. As an oncologist who has been in practice for over a decade, it is deeply frustrating to witness how insurers and their middlemen – pharmacy benefit managers (PBMs) – stand between my patients and the treatments they need. “White bagging” is one of the most blatant examples of insurer and PBM policies that disrupt and delay care for cancer patients.
Traditionally, cancer patients seeking care at a community oncology practice like mine could access all the medications and infusions they need right in our local practice, allowing them to receive highly personalized care and tailored drug regimens.
Yet, insurers and PBMs are increasingly implementing white bagging policies, which require oncology practices to obtain physician-administered infusions and other medications from designated specialty pharmacies often owned by or affiliated with insurers and their PBMs. That means oncologists must order these treatments from specialty pharmacies prior to a patient’s arrival for treatment.
The pharmacy then must purchase, prepare, and ship the drug to our practice, which takes days. Moreover, white bagging risks the drugs being damaged or lost during the shipping process. Even more time is lost due to administrative delays caused by prior authorization—a frustrating process through which insurers scrutinize and often deny coverage for the care that doctors decide is best for a patient. When positive outcomes depend on timely access to treatment, any delay is unacceptable.
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On top of complicating the drug delivery process, white bagging also ties oncologists’ hands when it comes to tailored treatment. Because the infusion dosage is based on blood work done sometimes weeks before its arrival at our practice, it’s impossible to adjust dosage based on the most recent blood work performed on the day of treatment. If adjustments do need to be made, the entire process must start over. Moreover, because that specific white bagged treatment cannot be used on other patients, it must be discarded, leading to a tremendous amount of medical waste.
Fortunately, Delaware – the state where I treat patients – recently prohibited specialty pharmacies from delivering white bagged drugs, unless the dispensing pharmacist and prescribing physician agree that such an approach is in the individual patient’s best interest. This reform will spare countless patients from being forced to endure the same red tape, delays, and devastating health consequences that my patient experienced as a result of white bagging.
Delaware’s attention to this issue follows reform efforts in states like Texas, where state policymakers recently passed legislation to limit how and when insurers can use white bagging. Now, it’s time that all states take notice and pass legislation to protect patients from white bagging.
When it comes to life-saving cancer care, patients and their doctors – not their insurers or pharmacy benefit managers – should be the ultimate decision-makers. I urge state legislators around the country to prohibit white bagging mandates and enact legislation to stop insurance companies and PBMs from forcing patients into this dangerous practice.
Photo: FatCamera, Getty Images
Jamal Misleh, MD is a hematologist-oncologist and Practice President at Medical Oncology Hematology Consultants in Newark, Delaware.
