Vanderbilt’s Stacie Dusetzina and colleagues explain how the ‘copay adjustment’ programs work in this week’s JAMA Internal Medicine and also shed light on third strategy used by insurers and pharmaceutical benefit managers, the alternative payment program.
It wasn't that long ago that only a few drug industry insiders knew about accumulators and maximizers, and fewer still understood them.
That is changing, though, as the programs have become more common and patient groups and the pharmaceutical companies have raised objections and filed lawsuits against them. Journalists have also put a spotlight on accumulators and maximizers, including our colleague, Denise Myshko, who wrote an in-depth story posted earlier this month about accumulators and maximizers for Formulary Watch, a website affiliated with Managed Healthcare Executive. This week, Stacie B. Dusetzina, Ph.D., a prolific healthcare policy professor at Vanderbilt University Medical Center and an expert on drug costs and coverage, and two of her Vanderbilt colleagues, Autumn D. Zuckerman, Pharm.D., and Megan Schneider, Pharm.D., added to the growing of number of articles, surveys and reports about accumulators and maximizers with an opinion piece published yesterday in JAMA Internal Medicine. Dusetzina, Zuckerman and Schneider also explained alternative funding programs, a third type of program used by pharmacy benefit managers (PBMs) to blunt the effect of the patient assistance programs provided by pharmaceutical companies. According to their explanation, payers exclude specialty drugs from their coverage and then refer patients to third-party organizations that contracts with the plan’s PBM. These third-party organizations then seek other ways of getting the excluded drugs covered that may include tapping into the drug company’s patient assistance program or other charities.
Adam Fein, a well-known drug industry expert, wrote posted an article (full text is available) critical of the alternative payment programs in October 2022 titled, “The Shady Business of Specialty Carve-Outs, a.k.a., Alternative Funding Programs.”
Dusetzina and her colleagues, writing in the cautious style of a medical journal, said that use of “copay adjustment” — an umbrella term for accumulators and maximizers — and alternative funding programs may make it difficult for patients with commercial insurance to get insurance coverage for specialty drugs or “to obtain them at all.” The exclusion of specialty drugs from coverage and the lack of insurance transparency about coverage “may impede the ability of patients to receive timely care or to understand the amount they owe for drugs their clinicians prescribe.” They also note, though, that patience assistance programs can boost healthcare spending if patients overuse expensive drugs because they are shielded from out-of-pocket costs. The programs are expense for drugmakers, but the Vanderbilt researchers note that they make let them raise prices without reducing patient use because “patients are not sensitive to increased pries if their out-of-pocket costs do not change.”
Copay accumulators tally up the amount of money a patient receives in patience assistance and keeps that money from counting toward the patient’s deductible. As the Vanderbilt researchers explain, this can mean that patients, after experiencing no out-of-pocket costs, are caught by surprise and suddenly face full-cost sharing. The result, they say, are “financial challenges” for patients or they stop taking the medication as prescribed — or some combination of both. Dusetzina, Schneider and Zuckerman make the interesting observation that copay accumulators were developed for patients in high-deductible plans with health savings account to make sure they paid their deductible without manufacturer assistance because doing so was required by federal law. Now, though, insurers have started to apply them to other types of insurance. Maximizers also involve excluding manufacturer patient assistance payment from counting toward the deductible. But instead of facing a sudden cost, the programs even out the cost sharing and set it to match the amount available from the patient assistance program. Dusetzina and her colleagues give the hypothetical example of a manufacturer’s patient assistance program totaling $12,000. Under a maximizer program, the insurer or its PBM might then set the copayment requirement at $1,000 a month. As a result, the patient would have no out-of-pocket costs. The Vanderbilt researchers say that the manufacturers’ have responded by slashing their patient assistance programs. They gave AbbVie’s copayment program for Humira (adalimumab) as example. The patience assistance program’s maximum for a patient is $14,000 example. For plans with a maximizer, AbbVie cuts the assistance to $4,000, according to Dusetzina, Schneider and Zuckerman.
MHE Reporter: Peter Wehrwein, Managing Editor