Pharmaceutical manufacturers continue to sponsor copay programs to help patients afford life-saving medications, while payers continue to respond with new varieties of copay accumulators and maximizers that shift the financial burden to patients and manufacturers. It’s a vicious cycle that jeopardizes health outcomes.
Unraveling these challenges was the focus of an episode of the Prescription for Better Access podcast, hosted by Mark Hansan and Dr. Scott Howell, two industry leaders who’ve dedicated their careers to improving patient access.
Two industry experts joined this podcast episode to share their views on the copay landscape: Lauren Crawford Shaver, head of Healthcare and Life Sciences for the Americas and senior managing director at FTI Consulting, and Carl Schmid, executive director at the HIV + Hepatitis Policy Institute.
Understanding the Origins
As Shaver pointed out, accumulators and maximizers emerged about five years ago in response to the rise in manufacturer copay assistance programs.
Depending on the structure of a patient's benefit plan and the copay assistance program they have access to, a patient could satisfy their drug deductible for the year after one or two months. In that case, the medication would be fully covered by the patient's insurance for the balance of the year.
To get around that possibility, payers began incorporating copay accumulators into their plans. “The payer says that since the assistance comes from the manufacturer, it doesn’t count toward the patient’s deductible,” Shaver said. “It’s about who is helping that patient reach their deductible, how we’re moving the payment, and who is ultimately keeping it.”
Copay maximizers soon followed as an additional mechanism to shift drug costs away from the payer. Maximizers typically set the patient’s OOP cost to equal the total value of the manufacturer’s copay assistance, and apply that amount evenly throughout the year. “By dividing the assistance into equal monthly increments, the individual doesn’t hit the maximum early in the year, and insurers can take the maximum amount from the manufacturer,” Shaver said.
Understanding Impact on the Patient
Schmid shared his views on how these programs shift the burden to patients. “First the copay assistance is paid for by the manufacturer. Once it runs out, the payer goes to the patient to finish covering the cost,” he said. “They (the payers) are ripping off the patient.”
When asked if maximizers are more patient friendly than accumulators, Schmid disagreed. “It means insurers are collecting more money than they are legally able to,” he said, with the payer sometimes collecting even more than the patient’s total OOP expense.
Schmid believes one of the greatest challenges is that most patients don’t realize they’re subject to these limitations. “It’s not in the summary of benefits you get when you buy the policy,” he said. “It’s buried deep in lengthy documents you probably don’t see.”
This lack of awareness eventually impacts how patients approach their healthcare. They might pick up their prescription every month under the assumption the copay assistance is contributing to the cost. Months later, they learn they owe $1,000 or more because the copay assistance didn’t count toward their deductible.
“When that happens, many patients just don’t pick up the drug,” Schmid said. “At a time of high inflation, they can’t afford the unplanned expense.” He noted some studies have shown that patients with copay accumulators often delay their treatments, causing their health outcomes to suffer.
Solving the Copay Dilemma
Several efforts are underway to reduce the impact of copay accumulators and maximizers. Schmid reported that 17 states and Puerto Rico have banned accumulators (as of this writing), and organizations like his are working to expand that number. However, he said the state-by-state approach is time consuming and not the ideal solution since it only touches state-regulated plans.
Separately, the HIV + Hepatitis Policy Institute filed litigation against the Department of Health & Human Services for promulgating a rule that opens the door for payers not to count copay assistance programs toward the patient’s OOP responsibility.
“There was also an administrative procedures act filed which claims that leaving the definition of cost-sharing up to PBMs and insurers violates the Affordable Care Act,” Schmid said. “And both the House and Senate have introduced bills to get copay assistance to count toward the patient’s OOP cost.”
Shaver views the potential solution as a four-lane approach:
“I think the most important lane will be the storytelling approach,” she said. “We’re here talking about policy and the idea of moving dollars from a manufacturer to an insurer vs a patient. But patients need drugs that help them live their lives, day in and day out.”
The guests and hosts agreed that ultimately, benefit design needs an overhaul. “We have to make sure benefit plans are designed with the patient at the center,” Shaver said. “Plans need to focus on value-based care, so patients get the best preventive care and the payment model incentivizes that.”
Howell pointed out the irony of the origins of copays, which began as an incentive to move patients from branded drugs to generics. “Now they’re used for single-source drugs where patients have no alternative,” he said. “To have those copay costs increase is outrageous.”
Hansan agreed, harking back to the days when pre-existing conditions precluded patients from securing coverage. “Better access was the whole point of the Affordable Care Act,” he said. “Now, copays have gone off the rails from their intended use.” Both hosts believe benefit plan design reform could go a long way toward relieving the cost burden that so many patients face today.
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