PITTSFIELD, Mass. -- Imagine you’re undergoing chemotherapy as part of your cancer treatment. But when you arrive at your local oncologist’s office, you’re told that the practice can no longer directly provide you with some of the medications you need.
Rather, you must contact your health insurance provider to learn how to get the drugs. Once the medications are obtained, you bring them to your cancer doctor, who then prepares them for your treatment.
This process, in which the patient -- not the doctor -- is responsible for purchasing the medications directly from predetermined venues, is known in the health care field as "brown bagging." And local cancer specialists say it’s a lousy, potentially dangerous way to treat ill patients, which is why Berkshire Hematology Oncology -- the county’s largest private medical oncology practice -- is refusing to go along with the plan.
"It’s a slang term because, basically, patients come in with a brown bag with their drugs in it," said Fred Harrison, the practice administrator at BHO, the third-largest community oncology group in Massachusetts.
As of Jan. 1, Blue Cross Blue Shield of Massachusetts now requires customers to purchase some cancer-related medications directly from predetermined retail or specialty pharmacies, because the company will no longer cover the costs of physicians who procure these medications on behalf of their patients.
The unilateral move -- doctors claim Blue Cross has declined to discuss its decision -- has sparked outrage among oncologists whose patients are insured by Blue Cross, which serves about 70 percent of non-Medicare patients in Massachusetts.
The Massachusetts Hospital Association and the Massachusetts Society of Clinical Oncology are also opposed to the move, which is only expected to affect Blue Cross customers in Massachusetts and Rhode Island -- both high-density Blue Cross states.
Harrison said he learned of the proposed changes in late August, but multiple attempts to discuss the matter with Blue Cross since then have been unsuccessful.
"They ignored our first two letters," he said.
A third letter was sent via FedEx to Cleve Killingsworth Jr., the chairman, president and chief executive officer of Blue Cross in Massachusetts, who should have received it the day before the changes took effect, according to Harrison.
"The two biggest issues here are safety and reliability. It’s a two-prong thing," said Harrison, adding that both prongs are compromised by the new policy.
BHO has long purchased cancer medications directly from the same, reliable drug wholesaler, which "buys directly from a manufacturer," Harrison said.
A list of some 60 drugs -- including a half-dozen common cancer medications -- are no longer directly available from physician practices, but instead must be procured through specific retail or specialty pharmacies, according to the new Blue Cross policy.
"We were confident with our chain of custody in obtaining the drug," Harrison said. "We have no confidence in Blue Cross Blue Shield’s chain of custody."
The scheduled changes have backed BHO doctors into a corner. And when you back oncologists into a corner, they tend to get angry.
"I am furious," said Dr. Harvey Zimbler, a BHO partner.
Zimbler and his physician colleagues Michael DeLeo, Paul Rosenthal and Spyros Triantos recently issued a letter warning patients about the changes, which are causing consternation for many commonwealth oncologists.
"We strongly disagree with this new policy; we believe it is a short-sighted measure designed to cut costs at the potential expense of patient safety and convenience," the local doctors stated in their Dec. 16 letter to patients. "And because we cannot assume responsibility for medications over whose quality and storage conditions we have no control, we can no longer administer those drugs to our patients."
Blue Cross "has elected to implement its new policy regardless of strong opposition from physicians and patients," according to the BHO doctors.
"There wasn’t a dialogue about this," said Zimbler, calling the new policy "unconscionable."
"It’s pretty much beyond belief," said the doctor, who received his cancer training at the National Cancer Institute in Bethesda, Md., and his hematology training at the National Institutes of Health, also in Bethesda.
"You can’t do this to doctors who care about patients," said Zimbler, "and you can’t do this to patients."
A Blue Cross spokesman couldn’t immediately be reached for comment.
Harrison noted that insurance companies are obviously hoping to "save some money" in this poor economy. But BHO is unwilling to handle sensitive cancer medications -- many of which require mixing and special preparation -- that come from outside sources because they can’t trust the conditions under which the drugs were stored.
"Doctors won’t know where this stuff is coming from," Harrison said. "We don’t know if it was in patients’ cars all afternoon while they were shopping. We don’t know how this was handled, or where it was stored."
A fundamental change
Traditionally, outpatient chemotherapy has been administered in physician offices or hospital outpatient departments using drugs prepared by a doctor’s staff or a hospital pharmacy, according to the American Society of Clinical Oncology, which encourages in-house dispensation of cancer drugs to reduce the possibility of medication errors and other mishaps.
The term "brown bagging" was coined to describe a variety of scenarios, including situations in which insurance companies require customers to pick up their medications themselves, then bring the drugs to their oncologist’s office in a "brown bag" for infusion. Other common scenarios include insurance companies switching to cheaper wholesale suppliers of oncology drugs, or requiring drug suppliers to ship medications to pharmacies near the insurance company’s customers.
"No insurance company will sign a waiver saying, ‘OK, we’ll take the onus on this,’" said Harrison, which is why BHO is resisting the move.
If Blue Cross fails to reconsider the policy switch, Harrison said, "we may have to reconsider our provider relationship with Blue Cross. They’re basically backing us into a corner."
For Zimbler, it all comes down to quality control and patient safety.
"We have superb facilities and I think we do a high-quality job, and we’re not going to let Blue Cross dictate the quality of care that we provide to our patients," Zimbler said.