Understanding Both Sides of the Copay Accumulator Debate

Bruce A. Feinberg

Just a few weeks ago, CMS finalized a new rule in its 2020 Payment Notice permitting payer organizations to implement copay accumulator programs, which will no longer count any manner of manufacturer discounts towards a patient’s healthcare deductible.

While CMS argues this ruling will help encourage patients to use less-expensive generic drugs when available, the decision flies in the face of states like Virginia and West Virginia, which have recently passed legislation banning such programs, citing patient protection concerns.

The idea of copay accumulation is simple. Under such a program, health plans no longer need count copay assistance programs, copay cards, manufacturer coupons, or other copay assistance that patients may use to help them afford brand name medications toward a patient’s deductible.

With so many pharmacy benefit managers (PBMs) assigning specialty drugs to the highest copayment tier, some, like CMS, argue that copay accumulator programs will help inspire patients to use lower costing drugs.

Others hold that they will result in skyrocketing out-of-pocket costs for patients, particularly patients who are living with chronic medical conditions-as well as limiting access to patients using the most medically appropriate medications. Bruce A. Feinberg, vice president and chief medical officer at Cardinal Health Specialty Solutions, led a session at the 2019 Asembia Specialty Pharmacy Summit, in Las Vegas, Nevada, to break down the debate-and help attendees understand the nuances of this ongoing controversy.

Related: How Payers Are Keeping Specialty Drug Costs Down

“Copay accumulator programs have been rapidly deployed in the market, and further adoption is expected in 2019 despite the ongoing debate about their benefits,” he said. “However, their effectiveness has not been demonstrated-and the potential risk to patients if access to some of these therapies is restrict is still unknown.”

Feinberg said that if accumulator programs worked as intended-by persuading providers to write prescriptions for less expensive medicines-payers and PBMs would definitely benefit by not having to cover the greater costs of such brand name drugs. Yet, he stated, the unintended consequences may be that patients are unable to manage the additional financial burdens without those drug manufacturer discounts, leading them to use less-effective drugs, potentially worsening their condition, or discontinuing drug therapies altogether because they can’t afford them.

Copay accumulator programs are gaining in popularity with payer organizations and PBMs-and Feinberg believes we will see wider adoption in the years to come. And while the jury is still out on just what the outcomes of such programs will be, Feinberg stated that healthcare executives should monitor those results carefully, understanding the implications for actual healthcare costs over time and patient access to treatments.

“If these programs result in increased non-adherence rates among patients, it could lead to declining patient outcomes for health systems,” he argued. “The goal of accumulator programs is to increase patient financial responsibility and, in doing so, make patients more accountable and engaged in shared-decision making, choosing more cost-effective treatment options. In theory, this might lower the cost of care if the savings from less costly drugs were passed through to patients and plan members. But it only works if lower cost treatment options exist-and if patients are able to influence their doctor’s prescription decisions.”

Kayt Sukel is a science and health writer based outside Houston.