Lawmakers Seek Easier Access to Injections and IVs for Chronic Illness, Cancer Patients

Colorado legislators want to make it easier for people with chronic or severe illnesses to access specialty drugs and treatment from their nearest doctor's office or clinic instead of relying on mail orders or specialty pharmacies in their health insurance networks, but insurers worry doctors and hospitals will increase prices as a result.

Specialty drugs are used to treat complex or chronic conditions like cancer, HIV/AIDS, multiple sclerosis and rare genetic disorders. Often they require a special dosage, handling, administration and storage, and may need to be injected or infused into a vein through an IV and given at a hospital or doctor's office instead of at home. They also generally require special follow-up care from a health care professional.

House Bill 24-1010 would require health insurance companies to cover the cost of specialty drugs purchased from doctor's offices or clinics chosen by the patient, the same way they would if the drugs were bought through specialty pharmacies in their health insurance network.

Specialty pharmacies are state-licensed locations that mail specialty drugs to doctor's offices and clinics, where the drugs are prepped and administered, or have medical professionals on site who administer them. Locations like Walgreens and CVS can be licensed as specialty pharmacies, but health insurance policies often require that doctors order from specialty pharmacies in their patient's network to have it covered by insurance.

Those health insurance policy requirements are known as white-bagging mandates. The bill would allow doctors to administer the specialty drugs they have on site and have that treatment covered by insurance. While opponents of the bill say white-bagging is meant to reduce health care costs, supporters of the bill say white-bagging causes delays in treatment that can be life-threatening.

"House Bill 1010 leaves decision-making in the hands of the physician and patient, letting them decide what's best for the patient care," the bill's state Senate sponsor, Dafna Michaelson Jenet, said during a hearing. "In summary, this bill would prohibit plans from interfering with the physician-and-patient relationship and deciding what's best for their care."

The Senate Health and Human Services Committee considered the bill on April 17 — but at Jenet's request, the committee voted to lay over the bill to give the sponsors time to work on amendments. Jenet didn't specify what the amendments would do, but the bill is scheduled for another committee hearing on Wednesday, April 24.

Patrick Boyle of the Pharmaceutical Care Management Association, which manages drug benefits for health insurers, spoke in opposition to the bill at the hearing. He said that health insurers started mandating white-bagging to save their customers money, because doctors and hospitals mark up the price of drugs.

"It arose as a defensive mechanism for health plans who were being gouged by hospital systems who were providing the drugs to patients in the facility for care and were marking them up dramatically," Boyle says. "In order to protect themselves, health plans asked the pharmacy benefit manager to provide the drugs through specialty pharmacies."

With white-bagging, health insurance providers are able to order the cheapest drugs for treatment through specialty pharmacies, which have larger inventories. Boyle says that hospitals and doctors have smaller inventories of more expensive drugs on site or charge more for the same drugs if they have to order them.

Saskia Young is executive director of the Colorado Association of Health Plans, which advocates for high-quality and affordable health care. During the hearing, she said that doctors often mark up drugs as much as 33 percent — or as much as $1,500 per treatment — and add that to a bill for administering the drugs. HB24-1010 would give doctors and clinics "free rein to mark up drugs," she says.

Faster Medication Access

Supporters of the bill argue that the issue isn't drug prices, but patient safety, as ordering drugs can create life-threatening delays. Leslie Busby, an oncologist from Rocky Mountain Cancer Centers, said that white-bagging "often leads to delays and damaged products" and "unnecessary infrastructure costs" for storing ordered specialty drugs.

"I recently treated a patient with HPV-related tonsil cancer. Cure rates are good, but the treatment requires intense, difficult-to-tolerate radiation and chemotherapy given on schedule," Busby said. "If required to accept white-bagging, I would have had to send him home without treatment."

Busby adds that "the unused white-bag drug cannot be used later or for another patient, so it is wasted" when it can't be used. "This exacerbates the already challenging nationwide drug shortages," he says.

Speaking for people who don't rely on white-bagging but go directly to the specialty pharmacy, Amelia Schachter, a retired nurse and cancer survivor who is now a volunteer with the AARP advocacy team, tells Westword that the bill will help "people who live in rural communities or have difficulty getting to a specific pharmacy to get their injections or to get their IVs," she says.

"Some people don't live close to a hospital or a specific Walgreens. They have to travel fifty, sixty miles. If they could just get it at their local doctor's office, it would make a lot more sense," she says. "It's mostly looking at people who are disabled, who are elderly and have transportation issues. The insurance company may say a medication has to be given at a specific location to get it covered by insurance — Medicare, especially."

An amendment to the bill made in March excludes hospitals. If it passes, the measure will only protect patients who go to doctor's offices and clinics from having to pay for specialty drugs without insurance.

AARP, formerly the American Association of Retired Persons, is one of the few national groups supporting the bill. Bristol Myers Squibb, one of the world's largest pharmaceutical companies, is also lobbying in support of the bill.

Locally, the bill has support from the state's largest organizations advocating for cancer patients, people with chronic illnesses and those who need mental and behavioral health services. This includes the Colorado Medical Society, Mental Health Colorado, the Center for Health Progress, Colorado Behavioral Healthcare Council, Chronic Care Collaborative, Rocky Mountain Cancer Centers, Advent Health and WellPower.

Mental health care relies on provider-administered specialty drugs for some schizophrenia and substance abuse treatments. People with those illnesses are often homeless, and injections and IVs are more reliable than carrying around their medications, explains Stephanie Johnston, the director of community relations and public policy for WellPower, formerly the Mental Health Center of Denver.

The number of opponents lobbying against the bill is small, but most are large health care companies.

Along with Optum, a $200 billion health care company that provides tech and pharmacy services, three other opponents lobbying against the bill are large health insurance providers: Cigna, Elevence Health (formerly Anthem) and United Health Care. None of the three insurance agencies responded to requests for comment.

Other groups are opposing only certain parts of the bill. Young says CAHP supports the bill but wants it amended to prevent doctor markups on drugs, which could also lead insurance companies to raise premiums.

"Carriers in the current system can say, 'This isn't reasonable; we're going to require you use the drugs we procure.' What this legislation is doing is taking away that leverage," Young says. "That raises premiums for everyone, and that raises the out-of-pocket costs for your patients and your members."