How Insurers and PBMs Undermine the Patient-Physician Relationship
Americans of all ages are impacted by chronic illnesses, whether it is a child taking myriad pills to function with cystic fibrosis, or an older person struggling with arthritis. The Center for Disease Control and Prevention reports that 60% of adults in the United States are living with a chronic disease, with 40% of adults having multiple conditions. Many people with chronic illnesses, along with their doctors, have been through a long medical journey to diagnose their conditions and find the appropriate medications to best treat them. The lifesaving and life-changing medications that patients with serious and complex conditions are ultimately prescribed are specifically and carefully tailored to best meet their needs, at the determination of their doctors. Unfortunately, insurers and PBMs are restricting access to these lifesaving medications and undermining the financial support patients need to afford those medicines.
Copay assistance programs are supported by many drug manufacturers to help people pay for their medications. They allow under-insured patients to access and adhere to their doctor-prescribed medicines. Insurance plans increasingly shift more of the cost of prescription drugs to patients. Too many patients are burdened with high out-of-pocket costs for necessary lifesaving and life-enhancing treatments. The culprits are insurer and PBM formulary designs that leave patients on the hook for higher out-of-pocket costs. This interference creates a gap between what patients can afford and the price they must pay for their medicines. Copay assistance programs help to fill the affordability gap.
In recent years, insurers and PBMs have decided to stop counting patient assistance toward a patient’s out-of-pocket maximum or deductible when that assistance comes from a drug manufacturer. They keep the payments, but the patient is left with their full deductible and no credit toward their out-of-pocket limit. That means that when the copay assistance runs out, the patient is left once again with extremely high costs – and this time, no extra help to meet the financial need.
In some cases, these middlemen partner with private companies to market $0 yearly copays for patients, but in reality, they are siphoning away cash that should be used for patients to get their prescription medicines.
For example, PBM Express Scripts partners with a company called SaveOnSP, which markets a $0 out-of-pocket yearly copay for patients who enroll in the program. According to Drug Channels CEO Adam Fein, the company takes copay assistance money from the patient provided by the drug’s manufacturer and pockets a 25% fee, ultimately profiting from funds that are meant for patients. And since none of that copay assistance money was counted by the PBM toward the patient’s deductible or out-of-pocket maximum, they may never hit those limits.
Copay adjustment programs cause a slew of negative outcomes for patients. When a patient suddenly owes thousands of dollars for their medications – because their full deductible remains even after they receive copay assistance – he or she may not even have the money to refill that month’s prescription, let alone the months to come. These excessive costs contribute significantly to patients’ financial struggles and can even lead to medical bankruptcy. According to a survey conducted by Bankrate, less than 50% of Americans can afford a last-minute emergency expense of $1,000.
Additionally, patients often abandon their treatment prescribed by their doctor when out-of-pocket costs get too high, resulting in worse health outcomes for patients. According to an IQVIA study, in 2021, 61% of commercially insured patients did not fill their new prescription when their out-of-pocket costs exceeded $250. By delaying or stopping treatment, patients are susceptible to worsening health conditions and even death.
Policymakers across the country have taken notice. State lawmakers have increasingly taken up and signed into law legislation that bans the use of copay accumulator and maximizer programs. Fourteen states and Puerto Rico have enacted legislation banning copay adjustment programs. At the federal level, bipartisan legislation, H.R. 5801, titled the HELP Copays Act, that would prohibit copay accumulator and maximizer adjustment programs has been introduced and can serve as a model for bipartisan cooperation in the next Congress. Passing this legislation would protect millions of vulnerable Americans.
The doctor-patient relationship is sacrosanct. Insurance companies and industry middlemen should not be able to undermine this relationship to ensure greater profits. Copay assistance ‘adjustment’ policies need to end.
Jerry Rogers is the editor of RealClearHealth and the host of the 'Jerry Rogers Show' on WBAL NewsRadio. Follow him on Twitter @JerryRogersShow.
