Consider the following scenario: A cancer patient comes into a community oncology clinic for their regularly scheduled chemotherapy treatment. After concluding the pre-treatment evaluation, the oncologist determines that the patient’s dose should be adjusted. Perhaps they need a higher dose than what we previously administered — a fairly common occurrence in the world of cancer treatment.
But there’s a problem. The doctor can’t just administer the new dose of medication right then and there, even if the practice has it stocked. That’s because the patient’s insurance company has implemented a policy called “white bagging” where all medications must be ordered and shipped from a specialty pharmacy to the practice.
As a result, the doctor must place a new order with the insurer and the patient must come back another time to receive their medication, which could be days or weeks down the road depending on the availability of appointments. On top of that, the old medication must now be thrown away as it was individually prepared for that specific patient at that specific dose, resulting in an egregious amount of drug waste.
Considering that community oncology practices treat hundreds of patients a year at each individual site, the overall potential drug waste is staggering.
In recent years, insurers have begun implementing white bagging policies, as well as a range of other so-called “savings enhancing” practices that ultimately are just steering patients toward getting their medications from mail order and/or specialty pharmacies owned by or affiliated with the plan’s pharmacy benefit manager (PBM). While insurers claim these policies are meant to reduce costs, taking specialty medication dispensing out of the hands of doctors can lead to delays in treatment and reduced quality of care — especially for cancer patients.
Delays in care caused by PBM pharmacy steering are not a new phenomenon. We have often seen the impact of these related delays over the years with patients whose treatment plans include oral chemotherapy medications. This is important to note because while my clinic has not yet experienced steering through white bagging policies, we can refer to our patients’ experienced rates of error in PBM mandatory mail order policies and reasonably predict that there will be (at minimum) similar waste and delays with white bagged infusion drugs.
While waste and delays with oral chemotherapy treatment is worrisome, our level of concern skyrockets at the thought of the harm caused by inappropriately dosed or delayed infusion drugs mixed off site. Since there are so many nuances that go into determining the appropriate dose of an infusion drug for a patient on the day of administration, there are so many more opportunities for error if these costly and volatile drugs are not mixed on site. Any error in preparation can cause delays and without the ability to take advantage of an on-site prescription drug inventory to tweak doses in real time, these delays can derail a patient’s whole treatment plan.
A recent study in The British Medical Journal (BMJ) found that there is an established association between treatment delay and mortality for the most common types of cancers: bladder, breast, colon, rectum, lung, cervical, and head and neck.
The study found that delaying treatment by just four weeks was associated with significantly increased mortality across surgical, systemic treatment (the treatment of cancer with medications), and radiotherapy indications for these seven cancers.
Our country is already facing a crisis of delayed cancer care stemming from the blanket cancellations of routine screenings and surgeries in the spring of 2020 as hospitals responded to the COVID-19 pandemic. The wave of delays is projected to hurt low-income and minority communities particularly hard. Insurer-mandated white bagging and crackdowns on in-office dispensing only serve to make this problem worse.
Thankfully, some state legislators are working on a solution to protect patients from these harmful practices. House Bill 451, sponsored by state Reps. Scott Oelslager and Gayle Manning would prevent insurers from imposing white bagging policies on practices in the state. This bill will ensure that cancer patient can get the care they need in a timely matter and keeps insurance companies out of the doctor-patient relationship. I urge our state lawmakers to sign on to this bill and join me in assuring patient health and safety remains our first priority.