The Copay Showdown

Anyone who doesn’t feel the healthcare terrain shifting under our feet hasn’t been paying attention. One of the many factors currently rocking the marketplace is the introduction of the copay accumulator (aka, copay aggregator, accumulator adjustment program, variable copay program, copay offset program). Increasingly adopted by payers, copay accumulators prohibit manufacturer-sponsored copay assistance from being applied to members’ deductibles, with important implications for patients and pharma brands.

Simply put, the advent of copay accumulators may mark an end to the days when pharma companies relied on copay assistance programs to make their products more affordable for patients. Payers have long viewed such programs, with frustration, as a deliberate effort to subvert their carefully structured formulary benefit design. That’s because copay assistance programs neutralize the financial incentives that payers have put in place to steer patients toward the drugs that those payers have deemed most cost effective. (As one payer told us, “We react vehemently against [pharma-sponsored] cost share support . . . because it absolutely destroys our formulary design.”) Some payers also postulate that copay assistance programs raise costs for the healthcare system at large by eliminating the incentive for patients to make financially responsible treatment decisions.

From the payer’s perspective, copay accumulators are a way of holding pharma companies accountable for their pricing and patients accountable for their treatment choices.

Of course, manufacturers see all this quite differently. By prohibiting their copay assistance from being applied to members’ deductibles, copay accumulators are dampening the intended effect of copay assistance and significantly altering the market access playing field. After all, the whole reason a manufacturer provides copay assistance is so that patients can afford (and therefore access) that manufacturer’s therapy. Which means, from pharma’s perspective, the trend toward copay accumulators can be a cause for significant concern.

According to a recent Xcenda survey of 46 national and regional commercial health plans, 39% of those payers are currently limiting the use of copay assistance programs and 72% of those are using the copay accumulator model to do it. In addition, a Zitter Health Insights study of 20 payers covering approximately 101 million lives found that in 2019, one-fourth of commercial lives are expected to be affected by a copay accumulator. Learn more about copay accumulators and their impact on market access strategy at CBI’s Copay Accumulator Summit.

The question for pharma is how to respond.

As the axiom says, the first step toward a solution is admitting you have a problem. We, at Cyan, are seeing pharma companies wake up to the challenge of copay accumulators. We are helping our clients explore a range of middle ground solutions, potentially including innovative contracting, that help to offset payers’ risk while supporting patient affordability.

Another productive role pharma can play is in helping medical practices understand and navigate the new normal. HCPs and their office staff have told us they don’t know much about copay accumulators because a) they are a relatively new development, b) payers don’t specifically call them out, and c) they are referred to by a variety of different names. An HCP’s first brush with a copay accumulator typically occurs when a patient complains that a copay card no longer works. Even in these cases, the HCP may think the copay card isn’t working for other reasons, such as a change by the manufacturer. Once informed about the accumulators, however, the HCPs we’ve spoken to have expressed interest in learning more about them and understanding how to identify which plans are using them.

Based on all these insights, we are actively encouraging clients to:

• Understand the impact of these programs on their pricing and contracting strategies

• Explore innovative contracting solutions with the potential to disarm payers’ concerns

• Educate physicians and their staff on the impact of these programs and how to help patients navigate them.

Copay accumulators are an effective (some would say aggressive) response by payers to what they regard as an unfair tactic on the part of pharma companies. Those payers who employ them are plainly drawing a line in the sand. However, considering that cost control is central to the payer’s mission, copay accumulators can also be seen as a cry for help. It’s up to pharma to answer that call.

Amber Gilbert is Managing Director at Cyan Health, LLC