To the Editor:

Fred Pane has written an excellent article on the recent and ever-expanding practice of “white bagging” to supply physician practices and hospitals with drugs for patient administration (“White Bagging: A New Challenge for Your Hospital,” December, page 38). As Mr. Pane stated, the intent of this model, in which the drugs are supplied by a specialty pharmacy company under contract with the insurer, is to reduce the costs associated with these expensive medications. Although there may be some benefits to this drug distribution model, on balance it raises significant operational issues. Thus, in Massachusetts, we are fighting against the “white bagging” requirement with one of the local insurance companies.

If we look at this issue from the patient’s perspective, there may be a lower co-payment if the drug is provided under the pharmacy benefit rather than medical benefit, as Mr. Pane stated. However, there also may be delays in therapy. Typically, there is a prior authorization process for many of these drugs, which can take a few days. If blood work to ensure the correct dosage is required before the drug can be shipped to the physician practice or hospital, further delays in patient care are possible. The alternative to prevent these delays is to send the drug to the provider prior to the results of the lab work or in some cases to send multiple doses of medication to the provider. Once again, Mr. Pane aptly stated that these patient-specific drugs are housed at the physician office or hospital awaiting the patient visit and the results of laboratory tests to verify the specific dose of medication. In my experience, however, there are times when these drugs are not administered to the patient due to changes in dosing, changes in the medical status of the patient or the death of the patient. The patient-specific drugs in these cases have been bought and billed by the specialty pharmacy, but will never be administered.

As I have informally surveyed pharmacists in hospitals, all relate that they have patient-specific drugs on their shelves that will never be administered, due to these factors. I believe there is an underappreciation of the significant costs that have been incurred by the insurance company in these cases.

Fortunately, there is a better way. If hospitals buy and bill for these medications on their own, they can eliminate the losses they’re incurring from undispensed drugs. Hospitals only mix the appropriate dose of the drug after the patient has been assessed during the clinic visit and the laboratory values have been evaluated to determine the appropriate dose of the drug. Hospital pharmacies do not want to manipulate drugs that have been prepared by the specialty pharmacy. If the medications are sent to the hospital pharmacy requiring compounding prior to administration, the pharmacy assumes liability and administrative overhead costs for which there is no reimbursement.

I encourage hospital pharmacists to communicate the undue burden, the inconvenience to patient care and hidden costs of the white bagging model to insurance companies that want to provide drugs to patients in this manner.

Ernest R. Anderson Jr., MS, RPh
System Vice President of Caritas Christi Health Care System
Brighton, Mass.