Copay assistance is a lifeline for patients. So why are insurers blocking it?

In today’s broken insurance system, patients too often pay more for a medicine than what their insurance company pays.

Stephen J. UblJune 29, 2022

Copay assistance is a lifeline for patients. So why are insurers blocking it?.

In today’s broken insurance system, patients too often pay more for a medicine than what their insurance company pays.

While the prices insurers pay for brand medicines increased just 1.0% last year, too many patients still face unaffordable costs for life-saving treatments. In fact, commercially insured patients with a deductible have seen their out-of-pocket costs for brand medicines increase 50% since 2014.

This erosion in insurance coverage may be discouraging patients from using the medicines prescribed by their doctors, and the consequences can be devastating. In 2021, 61% of commercially insured patients did not fill their new prescription when their out-of-pocket costs exceeded $250.

That is why PhRMA supports a holistic solution to lower drug costs for patients. Until we address the roles insurers and pharmacy benefit managers play in deciding how much people pay at the pharmacy, there will still be individuals who struggle to afford their medicines.

In the absence of these broader reforms, many drug manufacturers offer help through patient assistance programs. When insurance falls short, this assistance aims to help patients take their medicines as prescribed by their doctors.

Research has found that those who use patient assistance were up to 47% more likely to stick with their treatment for a year. This lifeline is especially critical for individuals with chronic conditions. In 2019, they helped patients taking brand HIV or oncology medicines save $1,600 on average. Patients taking multiple sclerosis medicines saved an average of $2,200.

How Insurers Are Actively Undermining Patient Assistance

Unfortunately, insurers are adopting tactics that can deny patients the benefit of this assistance. Not only are insurers reducing coverage, they are coming between patients who need help and the assistance available to them. For example, insurers use accumulator adjustment programs, which exclude patient assistance from counting toward a patient’s deductible and out-of-pocket maximum. This forces patient to pay more and more out of pocket before their insurance coverage begins.

The intent of insurers is clear. These programs attempt to steer patients towards medicines insurers prefer instead of those that doctors prescribe. Not surprisingly, steering patients away from their prescribed medicines can steer them toward worse health outcomes.

In a survey, more than half of insurance companies acknowledged that accumulator adjustment programs can negatively impact whether a patient uses their medication as prescribed. Evidence shows that patients impacted by accumulator adjustment programs are 13 times more likely to stop taking a treatment as compared to those with consistent copays.

In some ways, patient assistance is similar to the support hospitals provide when they waive a patient’s out-of-pocket expenses. Taxpayer-funded incentives encourage this kind of hospital assistance. Yet the patient assistance many rely on for life-saving medicines is under assault by insurers.

Pushing Forward Patient-Centered Solutions

In a win for patients, a federal district court judge recently struck down a rule that would have made it more difficult for manufacturers to offer patient assistance. The federal judge noted that patient assistance can help people “shoulder high out-of-pocket costs and obtain needed medications that their doctors have prescribed.” The judge also described accumulator adjustment programs as “schemes” devised by health insurers to “pocket for themselves at least some of the assistance” that’s meant for patients.

Fortunately for patients, lawmakers are also taking notice. Since 2019, 15 states have banned accumulator adjustment tactics in state-regulated markets. At the federal level, a bipartisan bill was introduced to ban accumulator adjustment programs in many commercial health plans. Congress should build on the recent federal judge’s decision and rein in the use of accumulator programs.

Patient assistance offers a lifeline, but if insurance worked like insurance – covering the sick when they need care – patients wouldn’t have to rely on this assistance to afford the out-of-pocket costs for their medicines.

We need to solve systemic flaws that are driving up costs for patients in the first place. For example, insurers and PBMs pocket billions of dollars in rebates and discounts that are provided by drug manufacturers. These savings should be shared with patients at the pharmacy, but instead, many patients are forced to pay more for medicines than their insurance company pays.

Whether it’s through high out-of-pocket costs or accumulator adjustment policies, insurers are getting in between patients and their medicines. We should be doing everything we can to remove these barriers so people can access the health care they need. And until then, let’s remove barriers to patient assistance to help make medicines more affordable for those in need.

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