An Upcoming White House Decision May Jeopardize Americans’ Access to Life-Saving Drugs
I have been picking up more healthcare commentary which depicts the difficulty in providing healthcare at a sustainable cost. This brief commentary depicts one of the problematic issues for people. I believe this sentence makes the issue very clear. Copay accumulators are programs health plans use to prevent copay assistance from counting toward patients’ deductibles or out-of-pocket maximums. They do not count towards a deductible which the patient is still left with once the copay accumulator is maxed.
An Upcoming White House Decision May Jeopardize Americans’ Access to Life-Saving Drugs
By Katie Adams
The rule concerns the use of“copay accumulators.” Copay accumulators are programs health plans use to prevent copay assistance from counting toward patients’ deductibles or out-of-pocket maximums.
Typically, when patients receive copay assistance from pharmaceutical companies, the amount paid by the manufacturer helps reduce the patient’s out-of-pocket costs. But with copay accumulators, the assistance from the drugmaker is not counted toward the patient’s maximum limit on out-of-pocket expenses.
The White House could soon finalize a rule that will either save or cost patients billions of dollars in prescription drug costs.
In September of last year, Judge John D. Bates of the U.S. District Court for the District of Columbia overturned a 2021 rule allowing the use of copay accumulators. The decision came as a result of patient advocacy groups challenging the Trump administration rule. It says that payers will now only be able to use the programs for brand-name medications that have generic equivalents.
HHS, along with CMS, appealed the decision in November. A month later, a bipartisan group of 19 U.S. senators sent a letter to HHS asking it to rethink its appeal. They were urging the department to drop the appeal to ensure Americans receive cost-sharing protections for their expensive medications.
Copay assistance is critical for many patients in order to afford their high copays. Copay assitance includes. those with cancer, arthritis, hemophilia, multiple sclerosis, HIV and hepatitis. Carl Schmid, executive director of the HIV+Hepatitis Policy Institute explains . . .
“Once the copay assistance runs out, the patient goes to pick up their drug and they are slapped with a several thousand-dollar bill. This is a surprise to them as they thought they were picking up their drug with no problem. They later learn that the copay assistance the insurer was collecting was not counting towards their deductible. In order to pick up their drug, they need to come up with the funds.”
This usually forces patients to make the decision of either going into significant debt or skipping their medication, Schmid noted.
He also pointed out that about half of all employer plans use copay accumulators or similar schemes — adding that these programs took nearly $5 billion in assistance away from patients last year. Schmid . . .
“We don’t understand why [insurers] are instituting these harmful schemes. We understand they are concerned about the high cost of drugs and they are trying to milk the drug companies, but at the same time they are harming patients.”
He said it’s unclear when the White House is expected to reach a decision on the rule, noting that it could be “any day now or several weeks.”
I scratch my head a little here. Aren’t these assistances essentially discounts from providers? Wouldn’t other policyholders be harmed in the underwriting of policies if discounts also were booked as satisfying deductible for some policyholders? Insurance is shared risk pools and the pool should benefit out of having lower aggregate claims. If the drug or treatment is a valid claim, the actual cost should be what is underwritten when establishing premiums for all policyholders. Again, when you are insured, you are not really accountable as an individual, but a participant in a pool.