Backlash Against Copay Accumulators

Physicians and patient groups say the latest tactic for shifting costs to consumers will affect adherence—and public health.

Ed Silverman

Copay accumulators may be providing some payers and employers with relief from rising drug prices, but this new cost-shifting tool is also accumulating its share of controversies.

Since emerging last year, accumulators have caught on quickly. With accumulators, the value of copay assistance cards or coupons do not count toward out-of-pocket costs that are applied toward deductibles. As a result, more upfront costs are shifted to consumers and away from employers and other payers.

Currently, 17% of employers are using them, but 29% will do so in 2019, according to a recent survey of 170 employers that was conducted by the National Business Group on Health. “They are not universal yet,” says Steve Wojcik, vice president of public policy, “but they will probably continue to be one tool that employers use to keep costs down.”

The pushback, however, is increasing. In July, a few dozen groups representing patients, providers, and consumers launched a campaign to convince policymakers that copay accumulators will hurt public health. Their first step involved asking all 50 state insurance commissioners to investigate the growing use of the tool because accumulators target specialty medicines that are often injected or infused—and typically are more expensive in the first place. Among the groups that signed the letters are the American College of Rheumatology, the National Viral Hepatitis Roundtable, the AIDS Institute, the Infectious Diseases Society of America, the Patient Access Network Foundation, and the National Organization for Rare Disorders.

A key concern of physicians and patient groups is that many people will forgo their medicines because they have grown to rely on copay cards or coupons to afford their prescriptions. Another gripe is that plans are using accumulators with little or no notification, which may mislead patients about their coverage.

“Accumulators are seen as a way to keep manufacturers in line and force them to negotiate better deals,” explained Randy Vogenberg, who heads the Institute for Integrated Healthcare, a research and education advisory firm, and who is a member of the Managed Care editorial advisory board.

“But the Achilles heel for the pharmacy benefits manager is that you’re hurting the patient, who is stuck in the middle,” says Vogenberg. Patients “may end up not taking or getting a drug, which is not good for anyone. And it’s not really affecting pricing because patients are still hurting. Unfortunately, it makes the third party payer look like a crook.”

So far, though, there is no “definitive evidence” that accumulators improve or detract from adherence, says Jonathan Gavras, MD, the chief medical officer at Prime Therapeutics, the pharmacy benefit manager.

“It’s a relatively blunt instrument,” he concedes. “But when we look at the economics from our side, even with coupon programs, these drugs are very expensive. So I think they’ll have to stay until someone figures out a way to do a better benefit design. But it’s in no one’s interest for a patient not to get a drug.”

There is little question, though, that many drugmakers are chafing. In the first quarter of 2018, net prices (prices after rebates and discount concessions) charged by drugmakers declined 5.6%, compared with a 1.7% drop in the corresponding quarter a year ago, according to Sector & Sovereign. This occurred even though increases in list prices mostly held steady.

Moreover, the products that were identified as most likely to be targeted with accumulators accounted for about 48% of net brand sales. These included drugs used to treat multiple sclerosis and HIV for which net prices fell 5% and 12%, respectively. Drugmakers are sorting out what their next steps might be, including developing payment options to avoid detection by payers, even as patients continue to benefit from copayment assistance. “This is a dynamic space in the market,” says Michael Carlin of Trial Card, which operates copay cards for the pharmaceutical industry and is reportedly working with drug companies to blunt accumulators.

Meanwhile, it’s uncertain whether accumulators are going to generate savings for payers. But they don’t seem to be going away any time soon. “There’s no guarantee,” says Benjamin Slen, vice president of product development at Express Scripts. “We can do some reporting on it and show value, but not a guarantee of specific savings…. But demand [among employers] is growing. I think these are here to stay.”

Ed Silverman founded the Pharmalot blog and has covered the pharmaceutical industry for 20 years.

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