When my patients come to meet me, they usually manage complex autoimmune and musculoskeletal conditions that can cause inflammation, fatigue, and a lot of pain. That said, one of the most meaningful aspects of becoming a rheumatologist is the provision of new and innovative drugs to prevent further disease progression, control inflammation, relieve pain and most importantly, my patients are able to recover their lives.
However, many of these treatment options need to be managed under careful medical supervision, as they require precise administration and special treatment, or intravenous injection. In view of these requirements, practice usually retains these medications at any time and is convenient for patients during routine office visits. With an on-site drug list, rheumatologists can tailor treatments to ensure medication integrity and support better medication adherence to patients.
Unfortunately, in recent years, insurance companies and pharmacy welfare managers (PBMs) have become increasingly trending to change how certain physicians manage medications are covered. Rather than covering these drugs under the patient's medical benefits (which have long been the status quo), insurance companies and their PBMS rather than covering these drugs under the patient's pharmacy benefits. Although this may seem like a simple management adjustment, it fundamentally changes how practices can obtain and provide basic therapies.
When considered a medical benefit, practices can purchase medications in bulk, store them firmly on site, and manage them during office visits. This “buy and bill” approach is effective for both providers and patients. However, when transferring the drug to pharmacy-only coverage, a specialist pharmacy needs to be used to obtain the drug – a process called “white luggage.” This means that each patient's medication must be ordered separately, coordinated with external parties, tracked for delivery and stored separately.
This change not only presents significant unpaid administrative burden and dispatch challenges for providers, but also delays or limits access to patients with necessary medications. Delaying management of outbreaks or promoting treatment of bone density while reducing the risk of fractures can only put a health hazard to patients. But this is exactly what some of these insurance companies can do.
These policies also raise potential safety issues as rheumatologists are unable to track the drug through the shipment process. Furthermore, once a white drug has been reached, it can only be used by that particular patient. If the dose needs to be adjusted according to the patient's side effects or disease progression, the delivered medication must be thrown away and reordered, resulting in a large amount of drug waste.
Payers believe that the white luggage policy makes them pay less for the same medication and limits health care costs, but we know that this inefficient process increases costs for patients, who usually pay more co-insurance.
White bags have long threatened the sustainability of physician practices, and if paid based on patient care benefits, the infrastructure needed to provide care will be reimbursed accurately, including trained staff, dedicated storage devices, and the clinical supervision required to safely manage these therapies.
As a country, we must ask: Are health insurance companies working to improve care or create new barriers?
While solutions that manage rising health care costs are important, they are not allowed at the expense of access, continuity, or quality. I hope insurance companies, regulators and other stakeholders can find a better way forward. A person who supports sustainable care models, relieves unnecessary burdens and ultimately puts patients first. When PBMS indicates how and where the drug is delivered, this is not efficiency – it is interference, and the patient is at risk.
Source: Weiyi Zhu, Getty Images
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