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Medical and pharmacy care for patients with autoimmune conditions is often costly. For many, innovative, high-touch medicines may represent the only option for meaningful disease control. While the prevalence of these disorders is low compared to other chronic conditions, affected individuals may face higher pharmacy out-of-pocket costs. Individuals in high-deductible health plans (HDHPs) with health savings accounts (HSAs) are particularly likely to face higher cost sharing because these health plans operate under Internal Revenue Service guidance that limits what can be covered pre-deductible and, therefore, leaves patients paying a deductible of at least $1,350 before most prescription drugs can be covered. As a result, they may not be able to afford to continue treatment, which may result in worsening health status and the potential for increased health care expenditures.
Biopharmaceutical companies provide copay assistance to help patients manage out-of-pocket expenses and improve treatment adherence. Until recently, health plans tended to include this assistance with other cost sharing assigned to the patient and credited toward a patient’s deductible and annual out-of-pocket cap. But recently, pharmacy benefit managers (PBMs) started implementing copay accumulator adjustment programs for some health plans. These programs carve out copay support provided by biopharmaceutical companies so that it does not count toward a patient’s deductible or maximum annual out-of-pocket cap. As a result, these new programs may leave patients to face several thousand dollars of additional out-of-pocket costs before employer contributions are provided.
The results of a recent study were presented at AMCP Nexus that compared adherence to autoimmune specialty drugs among commercially-insured patients receiving coverage from an employer before and after a copay accumulator adjustment programs were implemented. The research included patients who were subject to a deductible for their medicines (HDHP/HSA) and those not subject to a pharmacy deductible (PPO plan). After these programs were implemented, commercially-insured patients in a HDHP had a significantly greater risk of treatment discontinuation and lower refill adherence in comparison to patients in the PPO plan.
Prior to copay accumulator adjustment programs, these metrics were not statistically different between groups. Ten months after these programs started, compared to patients with PPO plans, patients in HDHP/HSA plans had:
- 233 fewer autoimmune prescription fills per 1,000 patients
- Four times higher treatment discontinuation
- 12 percent lower refill adherence
With accumulator programs limiting the effectiveness of biopharmaceutical company copay assistance, patients enrolled in HDHPs may face a “cost-sharing surprise” where they have to pay unexpected out-of-pocket expenses before having enough money in their HSAs to cover those costs. In this scenario, patients may be presented with a retail pharmacy bill which may be thousands of dollars. Given that according to a recent Federal Reserve study, 44 percent of Americans would have trouble paying an unexpected $400 emergency expense and would need to borrow or sell something to come up with the money, the implications of copay accumulator adjustment programs on medication adherence could be significant. Research has shown that low adherence to medicines, such as those treating autoimmune diseases, can lead to increased disease progression, higher medical costs and productivity losses.
This study provides groundbreaking findings on the dangerous impact of copay accumulator adjustment programs on medication adherence and disease control in patients with autoimmune disorders.
Bruce Sherman, MD, FCCP, FACOEM, is the Chief Medical Officer for the National Alliance of Healthcare Purchaser Coalitions, where he provides guidance for clinically-related organizational activities. He also serves as Medical Director, Population Health Management for the RightOpt private exchange offering at Conduent HR Services. His primary areas of responsibility include health/well-being strategy and data analytics, with the goal of implementing integrated, data-driven approaches to optimize workforce health, productivity and performance for employer clients. Dr. Sherman has research interests in the areas of employer health benefits strategies and the business value of workforce health. Previously, he has served as the consulting corporate medical director for Wal-Mart Stores, Inc., Whirlpool Corporation and The Goodyear Tire & Rubber Company.
A frequent speaker, Dr. Sherman has presented on a broad array of workforce health, productivity and human resources practice-related topics to diverse audiences, and has published numerous related, peer-reviewed articles. He received his MD from NYU School of Medicine, his MA from Harvard and his ScB from Brown and continues as a member of the clinical faculty at Case Western Reserve University School of Medicine.
