Co-pay Accumulator Programs: The Debate Continues

Co-pay accumulator programs are the latest cost management initiative resulting from the constant push and pull between payers, pharmacy benefit managers (PBMs), and manufacturers to reduce drug spend. However, despite intentions to mitigate the surging costs of care, these programs may also have unintended consequences that can negatively affect patients, according to a session held at the Asembia Specialty Pharmacy Summit 2019.

During the session, Bruce Feinberg, DO, vice president and chief medical officer of Cardinal Health Specialty Solutions, explored both sides of the debate regarding whether these tools are effective for managing costs or add barriers to access. “To understand the co-pay accumulator program, you really have to begin to understand the very delicate balance that has been going on now for 5 decades between those who pay for health care and those who provide the services and products that are being delivered to treat and provide health care,” Feinberg explained to the audience.

He noted that various iterations that have taken place in tweaking the health care system since the 1970s have had a huge impact on co-pay accumulator programs, especially the more recent shift toward high-deductible insurance plans. At the same time, drug prices have been markedly increasing, with costlier therapies in emerging areas of precision medicine and small molecule agents. “As the cost of care gets higher and higher, the employers who are sponsoring that care are looking for a gradual increase in responsibility,” Feinberg said.

The goal is to help patients and providers make different decisions for less costly interventions via patient responsibility, Feinberg explained. However, he added that these new methods from both payers/PBMs and manufacturers have elicited a constant battle between the 2 major industry players, often resulting in patients and providers getting stuck in the middle.

Co-pay accumulator programs seek to limit the use of manufacturer coupons by not counting the value of the coupon toward the patient’s deductible. From the payer/ PBM perspective, co-pay accumulators allow cost sharing for medications, increase provider awareness of the implications of high-priced drug alternatives, increase patient choice, and drive down drug prices. However, Feinberg described the potential unintended consequences of co-pay accumulators, which include increased nonadherence or discontinuation of therapies, added financial toxicity, and patient confusion.

According to a ConnectiveRx Patient Accumulator Survey, just 25% of patients reported being familiar with the term “accumulator adjustment” and 66% believe accumulator adjustments are unfair to patients. A 2019 Cardinal Health Specialty Solutions analysis found that 82% of medical oncologists and hematologists have not heard of co-pay accumulator programs before, and more than half of those surveyed expressed concerns that patients would face high out-of-pocket costs and ask for less expensive therapies.

Despite these concerns, is the program actually working? Feinberg said it looks like co-pay accumulators are here to stay, but whether they could drive down drug prices remains to be seen.

“It’s not clear yet how and if manufacturers can respond to this in an effective way to continue trends [that] in the past they have done with vouchers and rebates,” he said. For now, he noted that more needs to be done to reduce the unintended consequences.

“There is no happy ending here,” Feinberg concluded. “The saga continues.” 

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