Maintain an agile copay program in a changing policy environment

Copay support can mean the difference between a patient affording a lifesaving or life-enhancing therapy or not. But amid an evolving policy landscape, these legacy models may need a reimagined approach.

That's the takeaway biopharma companies are learning after a now-vacated Centers for Medicare & Medicaid (CMS) final rule that would have required copay assistance funds to factor into Medicaid's best price calculations.¹

Although it got struck down — a win for biopharma — the rule signals more challenges from health plans' newest strategy, accumulator/maximizer programs.

With these threats plus others ahead, biopharma companies would do well to make their patient financial programs more adaptive, responsive, and agile for the uncertainty to come.

The "uphill battle" of accumulators and maximizers

Introduced just a few years ago, accumulator and maximizer programs disallow copay discounts from applying toward patients' out-of-pocket costs. And even with the recent judicial ruling, they're still going strong.

Their fast uptake and continued existence create vulnerabilities in traditional copay solutions and open the door for payers to engage in similar tactics that further jeopardize access and affordability, says Colleen Cummins, Director, Customer Solutions, Biopharma Services at AmerisourceBergen.

"Accumulators and maximizers just make the uphill battle harder for patients who are struggling to cover their costs," she said, speaking at the 2022 Patient Assistance & Access Programs conference. "[And] with the rapidity of the change and the hyper-focus on copay assistance, I think we're safe to assume that we'll continue to see pressures and threats to copay assistance in the years to come."

Shifting the mindset from copay transactions to comprehensive patient financial wellness

Presenting the need for manufacturers to rethink patient financial assistance, Cummins encouraged biopharma companies to go beyond traditional copay discounts toward more comprehensive patient financial support. Not only could this promote affordability despite accumulator and maximizer programs, but it could also ready biopharma companies for new market trends such as value-based reimbursement and risk-sharing models.

"There needs to be a financial service offering that provides more than just a coupon," she said. "Compared to traditional copay, newly designed copay solutions with an integrated financial services solution can better help patients manage their healthcare costs."

As far as what those new solutions could or should become, consider a holistic approach instead of a transactional one. With an estimated 3 in 10 American adults not taking medications as prescribed because of their cost², opportunities to bolster financial wellness are far-reaching. It's not just what people pay, but the broader assistance they get from the patient support program — from flexible payment processing and automation to well-trained specialists.

Patient support programs are well positioned to provide that type of wraparound financial support, just as they do with other key functions such as clinical education. But if manufacturers are to use patient assistance programs in service of these new aims, they must use patient support programs to the fullest extent.

Supporting financial health with collaboration

In this changing environment, biopharma companies will need to react to changes flexibly as they shift copay programs toward a more comprehensive model. As always, engaging a strong network of biopharma service providers is key. But as financial health becomes a greater priority, so does the need to involve experienced financial partners in the ecosystem of patient support functions.

For example, AmerisourceBergen welcomed FirstView Financial into its family last year, building on its existing network with many other partners. With FirstView's ability to provide omni-channel affordability resources earlier in the patient journey, the relationship can help stem threats from accumulator and maximizer programs thanks to a greater degree of transparency. And, powered by an ethos of empowering financial wellness instead of just providing point-of-sale discounts, FirstView supports customized and comprehensive support — like flexible payment solutions — across patients' varying needs.

With this and similar partnerships, patient support programs can more readily deploy solutions to support patients' individual financial needs beyond discounts alone. These partnerships also provide the benefit of having someone else monitor for policy and market changes, just like the recently vacated CMS rule. When the network of expertise and solutions is more expansive, programs can react in real time for an optimized patient experience.

Creating value in more places

Copay programs have long helped people access medications they otherwise couldn't afford. Though threats like accumulator and maximizer programs jeopardize some of those gains, biopharma companies can offset those concerns with a comprehensive approach to financial wellness.

When organizations create value by factoring in patient wellness instead of financial transactions, they can make the most of patient support programs so that access prevails, even as policy comes and goes.

References

1. King, R. Judge strikes down CMS' Medicaid copay rule, handing PhRMA major win. FIERCE Healthcare. 19 May 2022. Accessed 20 Sept 2022. Available at https://www.fiercehealthcare.com/payers/judge-strikes-down-cms-medicaid-copay-rule-handing-phrma-major-win
2. Poll: Nearly 1 in 4 Americans Taking Prescription Drugs Say It’s Difficult to Afford Their Medicines, including Larger Shares Among Those with Health Issues, with Low Incomes and Nearing Medicare Age. Kaiser Family Foundation. 1 March 2019. Accessed 20 Setp 2022. Available at https://www.kff.org/health-costs/press-release/poll-nearly-1-in-4-americans-taking-prescription-drugs-say-its-difficult-to-afford-medicines-including-larger-shares-with-low-incomes/