Sticker shock at the pharmacy counter is becoming increasingly more common for patients across the nation. But with leading pharmacy benefit managers (PBMs) showing incredibly stable drug prices for many commercial health plans in 2017, it’s important to consider the other players in the health care supply chain that ultimately determine what patients pay for their medicines. Hint: it’s not the drug manufactures.
As the media has covered widely in recent weeks, tactics used by health plans to shift costs to patients in the form of higher out-of-pocket costs are helping to keep the health insurance industry’s costs down, and profit margins up – all at the expense of the consumer.
In recent years, insurers have tried to guide patients toward less expensive treatments by making them pay a higher portion of a drug’s costs,” Reuters reports. “Drugmakers responded by dramatically raising the financial aid they offer, in the form of “copay assistance” cards – similar to a debit card – that reduce what consumers need to pay when they place their pharmacy order.
This year, Express Scripts and others introduced a new ‘copay accumulator’ approach for its corporate customers. The programs prevent copay card funds from counting toward a patient’s required out-of-pocket spending before insurance kicks in on expensive specialty drugs, such as arthritis and HIV treatments.
These newly instated copay accumulator programs are often being implemented with almost no consumer notice and can leave patients on the hook for thousands of dollars out of pocket. Writing for The Hill in June, David Balto, a former policy director of the Federal Trade Commission’s Bureau of Competition and a former antitrust lawyer at the U.S. Department of Justice who now represents independent specialty pharmacies, makes this point clear:
These copay accumulator programs, often implemented without a patient’s knowledge or full understanding, force patients to pay more out-of-pocket costs in the long run, potentially endangering the most vulnerable patients who need their prescriptions the most.
If out-of-pocket costs become too high, patients may stop taking their prescribed medication as recommended for treatment. And falling behind on a prescription, or stopping it completely, may lead these patients to incur more serious health problems, costing them even more in the long run. Balto adds:
The side effects of these programs are … problematic. Because patients will now have to pay more out-of-pocket over the course of the year, it will be harder for them to afford the care they need and less likely to adhere to their treatment program.
BIO, along with a growing number of organizations, opposes copay accumulator programs and will continue to advocate against any measures that would shift greater drug costs to patients. Kaiser Health News reported in May that “the AIDS Institute was among 60 HIV organizations that sent letters to state attorneys general and insurance commissioners across the country asking them to investigate this practice, which has emerged in employer and marketplace plans this year.”
Smart policy would help lower what patients pay for the medicines they need, but stakeholders across all health care sectors must work together. That’s why we’ve teamed up with the Council for Affordable Health Coverage – a group of pharmacy benefit managers, drugmakers, insurers, patients, consumers and employers – to promote market-based policies and help ensure patients have access to affordable, innovative cures and treatments that they need and deserve.