Choosing Drug-related Routes of Administration

The panel discusses routes of drug administration with the example of oral, infused, and self-injectable disease-modifying therapies in MS as well as the difference between brown bagging and white bagging.


Neil B. Minkoff, MD: Hello. Welcome to the American Journal of Managed Care® program entitled, “Supporting Cross-Benefit Management of Infused Drugs.” I’m Dr Neil Minkoff. Joining me today in this virtual discussion are some of my colleagues: Dr Michael Fine, medical director of Health Net of California; Dr Eric Cannon, chief pharmacy officer from SelectHealth; Cheryl Larson, the president and CEO of the Midwest Business Group on Health; and Dr Kevin Stephens, a CMO [chief medical officer] from UnitedHealth. Today, our panel of experts will discuss how to optimize disease management, both clinically and financially, when covering an infused product under the pharmacy and medical benefit. With that, I’ll dive right in.

One of the things we’ve been trying to understand is looking at the differences between health care provided-administered drugs or self-administered drugs and what the clinical and cost considerations are while you’re looking at the administration or site of care. There are many therapeutic areas where there are different options. You’re looking at something like an MS [multiple sclerosis] or psoriasis for which there are multiple routes of administration for some of the different therapeutic options and different therapies with the same mechanism of action, and some emerging agents can be quite expensive.

Using MS as an example, we see that disease-modifying therapies can be oral, infused, or self-injected. How do you figure that out? How do you look at this affecting your budget, or how does it drill down to your overall cost of care? Eric, do you want to take a stab at that?

Eric Cannon, PharmD, FAMCP: Yes, I appreciate that, Neil. Thank you. When it comes to how we look at these therapies, the key question we always ask ourselves is, “What’s the appropriate therapy for the particular patient?” Looking at a patient and saying, “You’re a patient for an infusion, or you’re a patient for a self-injection or oral therapy” without understanding the patient, their social determinants of health, and what is going to drive and optimize therapy for them is a real mistake on our part. We always try and take that first look at what the appropriate therapy is for the patient. The next step, though, is looking at what the key cost drivers are behind that therapy and how aligned the incentives are between us and that particular provider or that particular facility. We want to make sure that we’re delivering the right care for the patient, but we also want to make sure we’re delivering the most cost-effective care. We break that down, we look at what the costs of each of those therapies are, and we have an open discussion with the provider, making sure in that process that we’ve worked hard to align all of the incentives. What are the costs to administer that drug in a facility versus if the patient was able to administer at home? That’s where we start as an organization [at SelectHealth].

Neil B. Minkoff, MD: Cheryl, you have an interesting perspective on this, right? You’re representing the employer community, and you’re probably less involved in different routes of administration than you are in the overall care and the cost of care. How do you look at this when you’re talking to those who are administrating your benefit?

Cheryl Larson: Thanks, Neil. For self-insured employers, and in my world, employers are the real payers of health care and pharmacy benefits, as well as the government, there’s a big range in pricing for these drugs. Employers need to consider which benefit to run the drug through. For example, if you run it through the medical benefit, the cost of treatment is significantly more, and there are no rebates to the plan. We’re not big fans of rebates because it’s like getting a tax return: you get the money after the fact, or it’s fake money. But they still exist, and some employers still want to use them.

Eric talked about misaligned incentives, that’s the big reason we’re not fans of rebates: the average employer in the United States does not get their rebate returned to them; it gets kept by one of the intermediaries. Since you’re not getting rebates through the medical plan, but you are through the pharmacy benefit, but you may not be getting all of the rebate back, it’s a mess out there. There are other factors, but it matters which benefit a drug and a treatment is running through.

In terms of the mode of administration, employers recognize that hospital outpatient site-of-care facilities can increase costs the most, and we continue to see growth of physician groups and outpatient facilities being owned by the hospitals. The cost of this continues to grow, and it’s of concern to us.

Neil B. Minkoff, MD: Do others want to weigh in on this? The breakdown between the different routes of administration is something that’s relevant to all of us.

Kevin U. Stephens, Sr, MD: I can comment. There’s another variable that we have to consider, and that’s the capabilities of the patient and the capabilities of the provider. Sometimes, when you have a brown bag versus a white bag scenario, the providers’ offices may not be equipped to handle some of the patients because of the time it takes and even complications. Sometimes, some medications can have a drastic and dramatic adverse effect like allergic reactions and so forth, and the providers have to be ready and able to handle that. Even if it’s self-administered at home, they’re all not the same. Some people have different capabilities. It’s a complicated picture when you put it all together to try to make it work. You have to think about what’s best for the patient.

Neil B. Minkoff, MD: Can you take one second to make sure everybody is level set and spend a sentence or two explaining how you see the difference between brown bagging and white bagging, so that, for the people who are watching, we make sure that we’re all speaking the same language?

Kevin U. Stephens, Sr, MD: I’d be happy to. Brown bagging would be if the prescription goes to the pharmacist, and then the patient will get the medication from the pharmacy and brown bag it, as in take it to the provider. A white bag would be if the prescription goes to the provider’s office, and then the patient goes to the provider’s office, and it’s already wrapped. The patient has less interaction; that’s the major difference.

Eric Cannon, PharmD, FAMCP: Neil, let me jump in on that a bit. In terms of a health system, this is one of the key concepts that we struggle with: brown bagging is difficult for a health system to understand and determine the pedigree of that product. What was the handling of that product up until the point that it was delivered to the office for administration for the patient? We’ve even, to some degree, looked at it and said we’re not completely comfortable with white bagging even though the white bag may come from our own specialty pharmacy. It is critical to be able to track and understand the pedigree of the product and make sure that what is being delivered to the patient is the right drug and that it’s been handled appropriately at each step along the way.

We’ve made great steps from where we were 10 to 15 years ago when we were looking at a lot of brown bagging. But even today with white bagging, we know that there’s a host of issues that are created. I even had the opportunity to go into the rheumatology clinic in one of our major facilities [with SelectHealth], and in the back room, they had a huge set of shelves that had product that had been white-bagged in. You look at that, and you see all the product that’s come in, and that may be for patients who are coming in for a visit who don’t show up. I don’t want to take a position one way or the other as to what’s right or what’s appropriate because we ultimately need to look at how we deliver the appropriate product for the lowest possible cost for a patient. As we talk about brown bagging and white bagging, there’s a whole host of costs and operational issues that come along with that.

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