Tuesday, June 3, 2014

Patient Advocacy: Healthcare on your Side

Patient Advocacy: Healthcare on your side

   by Martine G. Brousse
Healthcare Specialist, Patient Advocate, Certified Mediator

Brown/White Bagging: A disturbing trend

Over the last few years, a disturbing trend on how insurance companies manage infused or injected medications has been spreading within the healthcare industry. Aimed at saving costs (theirs, not yours!), it is affecting patients undergoing treatments as easy and inexpensive as B12 injections to pricey, complex chemotherapy infusions, and anything in between. 

The American Medical Association and various patient-centered organizations has decried this business move, and are sounding the alarm. Some of the main concerns include patients' access to treatments, safety, legal liability and costs. 

1. What is this trend?

Insurance companies are now shifting the financial burden of many infused or injected medications from the "medical" benefit portion of policies onto their "pharmacy" benefits. While access is usually still available, it is more complicated, expensive and possibly unsafe for patients to obtain office-based treatments. 

Until recently, any medication which the nurse injected or infused in an office (or outpatient) setting was purchased by that medical practice and billed, along with the clinical services, to your insurance under your "medical" benefits. Reimbursed to the clinic or office, these medications were bought from a few reputable companies, and were shipped under appropriate conditions, guaranteeing safety and provenance. 

Now, more and more insurance companies are forcing medical offices to stop this practice, and obtain drugs through specific mail-order companies they contract with ("white-bagging"). In some cases, patients must receive these drugs at home ("brown-bagging") then deliver them to their doctors. 

2. What is the big deal?

There are many unsettling aspects to this new business model. 
  • Administrative hurdles: instead of requesting one authorization for one course of treatment, offices now are required to do so for the general treatment aspect (from the "medical" utilization management unit) and one for each individual drugs (from the mail-order company or "Pharmacy" authorization unit). This creates delays, chances of errors, or potential denials.
  • Pay up now! Before a shipment is sent out, the mail order pharmacy will require the approval and full co-pay remittance from the patient. Whereas your doctor allows monthly payments on expensive treatments, and bills you after the facts, the pharmacy will not extend such niceties. No can pay? no delivery!
  • Complicated scheduling: your next treatment may not occur on the scheduled date if the shipment your doctor is waiting for has not been made. Coordinating the ordering, receiving and administration of your prescribed drugs may test the staff's (and your) patience. 
  • Provenance: a big issue with the AMA, the origin of drugs cannot be traced further back than the mail-order company. Where, when and from whom were the drugs purchased? Neither you nor your doctor will know. 
  • Source of Manufacture: your doctor may choose a certain manufacturer for a certain generic drug, based on experience or preference. In this scenario, he will not have any word in the matter, and may have to use drugs manufactured abroad rather than ones made and inspected in the US. 
  • Shortages: a serious and growing issue, certain drugs of limited or focused use are in short supply. Offices are on alert for such instances, and either "stockpile" whenever possible or purchase more expensive alternatives to avoid delaying or canceling treatments. With mail order companies, any backorder will take as long as it takes to get filled, with obvious disregard to patients' needs
  • Labeling: even if you are not required to play this game by your insurance, nothing can assure you that your personal treatment is done being given using drugs which were meant for another patient, but, for scheduling purposes or due to improper labeling, are now given to you. Many offices don't have the manpower or workflow to track every delivery. Similar drugs (office-bought and insurance-delivered) are stored together, and given "as needed" not "as assigned". 
  • Safety: any shipment delivered to your home wile you are not there can be stolen, delaying your next treatment. What about a box full of sensitive drugs sitting on your front porch, in a warm day? Any ice will have melted, potentially compromising the contents...and your health. And how about storing it? Whereas your doctor's drug storage unit is at the appropriate temperature, and sounds an alarm if it is not, your fridge might be too cold or not enough, questioning drug stability and effectiveness.
  • Handling: transporting any shipment from your home to the office also requires appropriate and safe conditions. Did you leave the package in your car while running errands? Is it packed in dry ice or just in the original package? 
  • Liability: your Doctor is legally responsible for any procedure rendered in  the office, and for any product injected into you. In such cases, where does his responsibility start or end? Having lost control of the process, will he be covered by his malpractice insurance in case of a problem? Who can now determine whose fault is responsible for a negative outcome?
  • Costs: even if you already have met your deductible and/or out of pocket liability for the year, you may have to pay additional fees for those "pharmacy" products. Your share of cost might be higher too, as many of these drugs are brand and therefore reimbursed at the lowest level. 
3. What can you do? 

Your options might be limited. Based on your policy, you may be required to use a mail-order pharmacy to cover certain treatments or drugs. Appeals can be filed, and in case of a negative response, you may request a review by an outside medical doctor. 

If you are being asked to receive and handle very sensitive or unstable drugs (such as chemotherapy agents) without training or proper knowledge, this could negatively affect your health and safety. Ask if a shipment can be sent directly to the office, that is better than a home delivery. Threatening to hold your insurance liable may help. 

The medical office may also request a waiver due to specific circumstances. Drug manufacturers can often help in this process, as legal liability might ultimately be traced back to them. So might your HR department.

In some cases, paying cash might be the way to go. A B12 injection, for example, costs less than $ 1.00. Paying the office for it will save time and efforts, and will be gladly accepted by the grateful staff. 

In conclusion:

Be aware when your doctor prescribes a infusion or injection. Call your insurance to find out what are the requirements when using specific drugs, and whether the office can use their own stock. 
Talk to the staff about any authorization requirement, or if they will even accept any brown or white bagging. Many office do not, citing legal liability and malpractice insurance guidelines. An alternative administration arrangement, at home or at an infusion center for example, will need to be made.

* As seen on NerdWallet

©  [2016] Advimedpro.
©  [2016] Martine G. Brousse.
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