White bagging may not be a familiar concept for some rheumatologists, especially those in large practices or at academic institutions. For small and independent practices, however, this policy of designating specific sources for drugs represents a significant threat to patient safety and the way practices function. White bagging has also emerged as a hot topic of discussion in many state capitols this legislative session. None of the bills have passed yet, but the ACR is monitoring legislation in more than 10 states and expects that some of those states may approve bills this year.
What Is White Bagging?
Mandatory white bagging policies require physicians to acquire provider-administered drugs through a preferred specialty pharmacy designated by a payer or pharmacy benefit manager (PBM). Often, these preferred pharmacies are under the same corporate umbrella as the PBM or payer. Mandatory white bagging policies effectively end the buy and bill system that has worked for providers and patients for years.
In a buy and bill system, providers can purchase medications and administer them as needed to patients. By contrast, under a white bagging policy, a medication is ordered through a payer-preferred pharmacy for a specific patient and can only be used for that patient. If that patient is unable to receive the medication before it expires, the drug must be wasted; it cannot be used for another patient. White bagging also does not allow for last-minute adjustments by the provider. If, at the time of administration, less than the ordered amount of drug is needed, the excess must be wasted. If more is needed, the patient can’t receive an appropriate dose because there is no allowance for extra medication. One reason that the buy and bill system is so important to patient care is that it allows for adjustments right up to the moment of infusion. Buy and bill ensures that patient care is personalized and determined by the provider and not a payer or a PBM.
Additionally, white bagging raises serious issues related to safety and timeliness. White bagging relies on “just in time” delivery of medications to providers. Delivery systems have long been plagued by disruption issues, problems that have been exacerbated during the pandemic. Delivery delays increase the chances of mishandling and drug spoilage. They can also delay care, raising the risk of a patient having a flare or incurring irreversible damage.
State Activity
White bagging is attracting a lot of attention in state legislatures this year, largely driven by state hospital associations, because hospitals are an early target of white bagging policies. Thus far, hospital associations have been good partners on this issue. We have worked with them and our other partners in several states to ensure that the language in introduced bills is inclusive of providers.
