New copay rule worries patients, providers
https://www.pharmacytoday.org/article/S1042-0991(21)00844-6/fulltext#relatedArticles
Patients may be unpleasantly surprised by a new rule finalized by CMS in July 2020—potentially forcing them to abandon their prescriptions due to unaffordable drug costs.
Sanjeev Seenath, PharmD, MBA, a managed care pharmacy specialist at State of Hawaii MedQUEST division, worries that patients will be even more concerned about their out-of-pocket expenses when they find out that the manufacturers’ copay assistance programs contributions, including copay cards, are being excluded from their out-of-pocket maximums. He said this will cause a ‘trickle down’ effect, resulting in poor patient adherence to medications and negative health effects.
The CMS rule allows commercial health insurers to permit these programs even when a brand name medication does not have a generic or appropriate alternative, while not requiring transparency from insurers about these programs existing, even though it will severely affect their health care spending, according to Bryan S. Walsh, JD, and Aaron S. Kesselheim, MD, JD, MPH, writing in the American Journal of Managed Care August 2021 issue.
“If pharmaceutical companies are able to incentivize their brand-name drug products through their copayment assistance programs, this only fattens their pockets and adds to economic waste in the health care system, which will drive up health plan premiums and health care costs for patients,” said Seenath.
Financial burden on patients
Ever since drug manufacturers started offering copay assistance programs to help cover a portion or the full cost of brand-name medications, patients have been able to afford—for the most part—these medications. However, insurers, both public and private, have lost out on these manufacturer reimbursements which have, up until this point, been automatically applied to their beneficiaries’ out-of-pocket maximums.
With this realization in mind, insurers have put in place copay accumulator adjustment programs (CAAPs) to keep health care costs low by encouraging the use of lower-priced generic alternatives, which in turn places the financial burden on patients.
“The CAAPs program makes it very unfair for patients in cases where there are no generic alternatives available for the patient or in the case where there is a generic drug available, but the brand- name drug appears to be superior due to its therapeutic equivalence,” said Seenath. When manufacturer assistance limits are met, patients will feel the high financial burden of these brand name medications.
Changes in prescribing
“From a CMS standpoint working for the State of Hawaii, discussions about the CAAPs are changing the landscape of how physicians are prescribing drugs because they are concerned about their patients’ health and whether or not they will be able to afford brand name drugs if they aren’t able to take advantage of the manufacturers’ copayment assistance programs,” said Seenath. “This is inadvertently leading to more systemic issues of increased health care costs, higher hospital readmission rates here in the islands, and economic waste.”
Health care providers could be more cautious about prescribing certain medications.
“Clinical outcomes and the quality of care is of utmost importance,” said Seenath. “So, unless there are generic equivalents that are in the same drug class with same therapeutic equivalence and clinical benefit, then the copay adjustment accumulator program is really doing an injustice to the patient and affecting the quality of care.”
To truly help patients, he said, insurance plans need to be transparent with their beneficiaries about these new rules and how it impacts their copayments in order for patients to make well-informed decisions on their health care spending.
Filed under: General Problems
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