The pharmacy team at Lifespan in Rhode Island is celebrating a legislative win against white bagging, thanks to a new state law requiring insurers and pharmacy benefit managers (PBMs) that cover infusion medications to pay for them when dispensed from any in-network hospital or clinic.
The new law goes into effect in January.
White bagging arrangements generally require healthcare facilities to obtain clinician-administered outpatient medications from a payer’s designated pharmacy, which ships the products directly to the site of care. Clinic staff are responsible for receiving, storing, preparing, and administering the products — activities that bypass the site’s established medication-use process and may not be reimbursed by the payer.
Christine M. Collins, senior vice president and chief pharmacy officer for Lifespan, called white bagging a dysfunctional barrier to the coordination of care and a threat to patient safety.
“It’s just incredibly wrong,” she said.
Lifespan drafted a policy paper in 2021 that described how white bagging has affected specific patients.
In one case, clinicians had to scramble because a white-bagged medication dose wasn’t sufficient for a child who had gained weight during the course of treatment.
State of the States
Every year, state legislatures make thousands of health policy decisions, including ones that affect pharmacy practice. In a new series, State of the States, ASHP News Center will profile ASHP state members and affiliates as they help shape decisions and policies important to the pharmacy workforce.
Another child’s treatment was delayed for a month because the dispensing pharmacy hadn’t communicated its administrative requirements to the patient’s family or the hospital. A third case involved an adult whose medication was shipped to the hospital’s infusion center over a holiday weekend, when the facility was closed. The medication was left outdoors and had to be destroyed, and the patient’s treatment had to be rescheduled.
Collins said those examples still ring true and reflect the problems Lifespan’s patients face today.
The new law owes its existence, in part, to Lifespan pharmacist Michael Poirier’s decision to speak with his state representative, Justine Caldwell, about the problems caused by white bagging.
“I could see there was an unmet need and an opportunity to improve patient care,” said Poirier, who is system director of ambulatory care pharmacy services for Lifespan. “I was somewhat surprised when, after a very brief conversation, she said, ‘Yeah, I’ll support you with this.’”
The bill earned little attention during the 2022 legislative session. In 2023, it gained momentum and passed the Senate Health and Human Services Committee. When Caldwell reintroduced the bill this year, it was favorably received, moved quickly through the legislative process, and was signed into law in June.
Poirier credited Lifespan’s government relations staff with forging collaborations that helped get the bill passed.
“We partnered with the Hospital Association of Rhode Island, who really took it from there and drove the engagement,” Poirier said. Other advocacy allies included the Rhode Island Society of Health-System Pharmacists, the Rhode Island Pharmacists Association, the Hematology/Oncology Pharmacy Association, the New England Hemophilia Association, Care New England, and ASHP.
“We had a ton of support, whether it was through letters of support sent into the Senate or House, or even testifying, which was critical to our success,” added Poirier, who was among those who testified in favor of the bill. “When the legislators hear from the patients who are impacted, and when they hear from the providers doing the work, that’s what really helps them understand the complexity and the challenges with white bagging mandates.”
Poirier said the advocacy team used ASHP’s white bagging model legislation to develop the initial draft of the bill. He said the version that was enacted reflects consensus and compromise among stakeholders.
Although the initial draft applied to all clinician-administered drugs, the final legislation excluded non-infused medications from the white-bagging restrictions. Collins said that change wasn’t a concern for Lifespan.
“What we were really concentrating on, and what was most impactful to us, was the infusions,” she said.
Collins said Lifespan’s pharmacy, contracting department, and infusion center staff are examining their processes to identify potential snags as the health system prepares for the law’s implementation in January.
Although the number of states that prohibit mandatory white bagging is growing, not all advocacy efforts have been successful.
Natalie Nguyen, medication safety pharmacy manager at Virginia Commonwealth University Medical Center and VSHP’s president during the legislative session, said white bagging has been on VSHP’s advocacy radar for several years.
The Virginia Society of Health-System Pharmacists (VSHP), in partnership with the Community Oncology Alliance, advocated this year for a bill that would have eliminated mandatory white bagging in the state.
The bill stalled after steep opposition from PBM lobbyists. But the legislative experience highlighted the value of building coalitions that can aid future advocacy efforts.
“This was kind of the year where we were trying to find the right stakeholders,” she said. “With the Community Oncology Alliance coming out with that bill, this seemed a very opportune time to join forces with them and try to move this initiative forward.”
Brad McDaniel, medication utilization strategy pharmacist at Carilion Clinic in Roanoke and VSHP legislative committee co-chair, said VSHP developed talking points and other materials related to white bagging for pharmacists to use during the society’s annual statehouse visit, held in conjunction with the Virginia Pharmacy Association.
Joshua P. Crawford, system director of clinical pharmacy services for Bon Secours Mercy Health and VSHP legislative committee co-chair, said VSHP recently stepped up its outreach to legislators.
“We’ve started inviting delegates — especially people we think that could be champions — to [our] Commonwealth Leadership Forum,” Crawford explained. He said the twice-yearly event allows potential bill sponsors to interact with “passionate and knowledgeable” state pharmacy leaders about important patient-care issues.
Despite the lack of success with this year’s white-bagging bill, Crawford said he’s gained valuable insights from his overall advocacy work for VSHP.
“I’m realizing that you don’t have to just react. You can be proactive. And if there’s something that you think is detrimental to patient care or pharmacy practice, there are avenues to get those things changed,” he said.
