Brown Bagging
Trey Melazzo, PharmD, MBA
Over recent years, more and more health systems have been affected by payer health care coverage policies referred to as “bagging.” These practices have come about as payers have vertically integrated with PBMs and specialty pharmacies owned by those PBMs.
With “bagging,” specialty medications are filled and then shipped either to the patient or directly to the patient’s health system. Medications used in bagging policies are often intravenous drugs—such as infusions for oncology or rheumatoid arthritis—requiring support by the provider for administration, although the provider is left with only the professional component of reimbursement.
“This is something that is going to end up affecting a lot of people inadvertently,” said Wendy Mobley-Bukstein, PharmD, BCACP, an ambulatory care pharmacist and associate professor of pharmacy practice at Drake University in Des Moines, IA. She said pharmacists in all health care settings should be familiar with these terms and recognize that the terms might change over time.
The chain of custody for how medications are filled, transported, and administered differentiate the various bagging terms:
- Brown bagging: The patient picks up a prescription at a pharmacy and takes it to the provider’s office for administration.
- White bagging: A specialty pharmacy, predominantly at the discretion of the provider or payer, ships the patient’s prescription directly to the provider, who holds the product until the patient arrives for treatment.
- Clear bagging: A provider’s internal specialty pharmacy (e.g., a health system–owned specialty pharmacy) dispenses the patient’s prescription and transports the product to the location for drug administration.
“Brown bagging is frowned upon almost exclusively,” said Mobley-Bukstein. With brown bagging, patients must be educated on the storage of the medication, and they must transport the medication to an appointment for preparation and administration. There are clear patient safety issues with brown bagging, while white bagging brings about its own issues.
The main concern with white bagging is continuity of a patient’s care. Oftentimes, patients are steered to a facility other than the health system in which the patient is currently being seen. This can be due to a contractual agreement set forth by a third-party payer and the outside facility to accept white-bagged medications and to provide preparation and administration under a contracted price.
“White bagging could cause a delay in treatment while the patient is locating a facility that will work with the third-party payer, setting up an appointment, and awaiting delivery of the drug,” said Mobley-Bukstein. ■
Issues caused by bagging
Bagging policies ultimately impact the patients being treated. Some common issues caused by bagging include
- Negatively affecting the quality of care for the patient because its medication procurement strategies do not meet chain of custody standards for pharmaceutical products moving from one entity to another. Normally, procuring strategies help ensure the exchanges of medications are accurate, timely, and follow best practices prior to administering the product to the patient.
- Restricting the providers’ ability to choose treatment options, which may lead to fragmented care between the patient, pharmacist, and other health care providers
- Limiting operational efficiencies that allow the patient’s choice of pharmacy, site of care, and continuity of care through collaborative efforts between providers
- Creating additional workload for pharmacists and other health care providers when patient treatments are delayed or restricted