What the Data Shows on Copay Accumulator Adjustment Programs
by Kollet Koulianos, MBA, Hemophilia Alliance Payer Consultant
By now, there is no doubt that our HTC’s are not only well versed on what Copay Accumulator Adjustment Programs (CAAP’s) are, but likely most, if not all, of you have had patients reach out seeking help, given the most recent data published by Avalere suggests that 83% of commercial enrollees are on a plan that has copay accumulator language. If you consider that the first CAAP was implemented by a self-funded employer in January of 2017, the uptake has been unprecedented.
From the beginning, we have expressed concern for the unintended consequences that could result for the approx. 55% of chronic disease patients on a high deductible health plan (HDHP) given that enrollees must satisfy his/her entire deductible before the plan contributes the first penny; and the fact that deductibles can be as high as $9,100 individual / $18,200 family in 2023. Manufacturers state that they offer patient copay assistance programs to commercially insured patients to reduce a patient’s out-of-pocket cost burden, because frankly they are untenable.
Research conducted by the National Pharmaceutical Council and Xcenda, found that increased patient cost-sharing was associated with worse medication adherence (84% of studies), persistence (79%) and discontinuation of medicine use (58%). In addition, six of nine (67%) studies found that increased cost-sharing was associated with decreased medication initiation.
The greater the magnitude of patient cost-sharing, the worse the adherence outcomes regardless of the condition, patient population, or type of cost-sharing. This evidence indicates that patients fail to start and continue needed medicines because of the cost burden.
Some evidence also suggests that higher patient cost-sharing for medications was associated with increased hospitalizations and decreased use of outpatient services. Four of six studies showed a significant increase in inpatient hospital utilization associated with higher cost-sharing.
As of today, 19 states (map below) have banned payer and pharmacy benefit manager (PBM) copay accumulator programs. These laws apply to state-regulated health plans, including the individual, fully insured large group, and small-group markets. It is possible additional states could join the growing number to pass accumulator laws as several states have yet to wrap up their 2023 legislative sessions.
A poster just presented at the end of June 2023 at the Academy Health ARM2023 conference, suggests that States that have banned the use of copay accumulators saw a decrease in patient out-of-pocket liability and an increase in treatment adherence and persistence. For those of you who may still be working to pass legislation in your state, these findings should be beneficial to share with your state legislators looking to reign in PBM games.
Current states with accumulator bans
Because states do not have authority over ERISA plans, federal work is also being done in parallel to the state efforts. H.R. 830 The HELP Copays Act has been introduced by Representative Buddy Carter (R-GA) and currently has 61 bi-partisan cosponsors; and the Senate companion bill S.1375, led by Senator Roger Marshall, MD (R-KS) has also been introduced and currently has 13 bi-partisan co-sponsors.
This article focuses on copay accumulators, not copay maximizers. We will dive into copay maximizers in the coming months. Any questions can be directed to the payer team at the Hemophilia Alliance and for additional resources focused on both accumulators and maximizers visit www.allcopayscount.org
Washington, DC’s HOT July – Advocacy Update
~ Artemis Policy Group
Congress has returned from its July 4th Recess with a full plate for the remainder of the month. In healthcare, bills on PBMs and pandemic-related issues seem to have the greatest chance of moving forward but the House and Senate Committees of jurisdiction are far apart on many policies. The future of 340B continues to play out mostly in press releases of new organizations forming, several related to a split among Community Health Centers. There is the potential for the introduction and movement of bills impacting 340B related to contract pharmacy and hospital reporting. Below is a recap of what we have seen in the last month.
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