Prioritize patients over insurer profits
Managing a chronic complex disease is just that, chronic and complex. Accessing medication to treat the disease should be simple. Increasingly, patients are experiencing challenges accessing medications prescribed by their physician due to a health insurer practice called “copay accumulators.”
When patients are prescribed expensive treatments, they often receive financial assistance, termed “copay assistance,” to offset out-of-pocket patient costs. These are called “copay assistance programs” and are typically offered by pharmaceutical companies, but also by charitable organizations and advocacy groups. They can cover thousands of dollars on infusion, oral, and injectable therapies, making medications that would otherwise be unaffordable for many patients very accessible.
As the executive director of The Elliot Lewis Center, a comprehensive care center for patients with multiple sclerosis, the majority of our commercially insured patients use copay programs. Disease modifying therapies, or medications, can slow the disease from progressing. The medications approved for
An increasing number of insurers (80 percent of commercially insured plans) are implementing copay accumulators, diverting that assistance to themselves instead of patients.
multiple sclerosis cost an average of $94,000 per year; copay assistance programs make the drugs accessible and affordable.
In the past, insurers counted copay assistance toward the patient’s deductible and maximum out-of-pocket costs. For example, if a patient with a $2,000 deductible received a bill for $1,500 for their medication, the copay assistance program might pay the entire amount of $1,500 and the remaining deductible for the patient would be reduced to $500. But now an increasing number of insurers (80 percent of commercially insured plans) are implementing copay accumulators, diverting that assistance to themselves instead of patients. In this case, the copay program would pay $1,500 but the patient responsibility for the deductible would remain $2,000. Under the “copay accumulator” practice, the insurer is collecting from both the copay program and the patient. They are getting paid twice.
This practice of double-dipping via copay accumulators is why Massachusetts lawmakers should pass legislation that would ensure that copay assistance is counted toward meeting the patient out-of-pocket costs.
If a medication is perceived as expensive and unaffordable, patients may decide not to take it. Copay assistance allows patients access to medications as prescribed by their doctor without worrying about the financial impact of treatment. Treatment adherence reduces health care costs in the long run. When patients do not adhere to their medications, they may have symptom flares, relapses, or hospitalization; this can lead to a long-term increase in disability.
If patients with multiple sclerosis can no longer have copay assistance count toward their out-of-pocket costs, their current medications may become unaffordable. They will probably be forced to pursue less effective generic treatment options.
Medication decisions should be between the physician and the patient, not dictated by an insurance company. Removing the benefit of copay programs would make many medications unaffordable and drive patients to less effective products and treatments.
For our patients with MS, we are lucky to have many medication options, because MS is not one size fits all. Different patients are better suited to different therapies. The physician and patient are best suited to make this decision. Unfortunately, the more effective therapies are newer to market and more expensive for insurers in the short term. The use of less effective products is shortsighted both financially and in terms of overall patient health. Less effective products drive health care costs up, leading to more doctor visits, expensive tests, ER visits, hospitalizations, and increased disability.
When Oregon’s governor signs the bill, as is expected, that will make 20 states as well as Washington, D.C., and Puerto Rico that have already passed accumulator ban laws. Massachusetts lawmakers should prioritize patients over insurer profits. In doing so, they will secure more just and equitable health care delivery for their most vulnerable constituents.