The webinar focused on the trend of payers and pharmacy benefit managers (PBMs) increasingly adopting accumulator and maximizer programs, and how these programs negatively impact patients by not allowing manufacturer copay assistance to count towards deductibles and out-of-pocket maximums.
Chris Dowd's Opening Remarks
Chris Dowd, SVP of Market Development at ConnectiveRx, opened the webinar by explaining the “specialty drug out-of-pocket cascade,” in which 3 factors compound each other to place a heavy financial burden on patients:
- High out-of-pocket costs on patients through premiums, deductibles, and copays.
- Restrictions from payers like prior authorizations and step therapy.
- Adoption of accumulator and maximizer programs, which directly prevent copay cards from counting towards deductibles and out-of-pocket maximums.
Dowd presented data showing aggregate out-of-pocket spending by patients reached $83 billion in 2022, up from $75 billion in 2020. Additional ConnectiveRx data indicates abandonment rates for specialty prescriptions begin rising dramatically when copays exceed $50. Prevalence data on accumulator and maximizer adoption indicates broad implementation, with 89% of surveyed employers having accumulators available and 61% having maximizers available.
Katie Verb's insights
Katie Verb, Senior Director, Executive Branch Strategy, U.S. Policy & Government Affairs at Bristol Myers Squibb, provided a pharmaceutical manufacturer perspective. She characterized the situation as an ongoing “whack-a-mole” problem, where each legislative or legal solution leads payers and PBMs to find workarounds to restrict patient assistance programs. She advocated for comprehensive reforms of the system rather than piecemeal solutions. Verb warned against complacency, suggesting that manufacturers, patients, and providers all need to remain vigilant through legislation, regulation, and litigation to maintain patient access.
Carl Schmid's insights
Carl Schmid, Executive Director, HIV+Hepatitis Policy Institute, reviewed their recent court victory striking down a 2021 HHS rule allowing the broad use of copay accumulators. However, Schmid remains concerned that guidance and enforcement is still needed to ensure that payers comply with the prior HHS rule from 2020, which required counting copay assistance towards deductibles and out-of-pocket maximums for brand drugs without generic equivalents.
Bill Sarraille's insights
Bill Sarraille, senior partner at Sidley Austin LLP, provided a sobering assessment about the potential response from payers. He warned that payers may argue that the recent court decision was too unclear to force immediate changes, allowing business as usual operation of accumulator programs until more definitive legal clarification emerges. Bill indicated that additional litigation initiated by patients may be necessary to force payers into compliance. He also cautioned that HHS may now have latitude to delay issuing further guidance given the court's finding that the statute was ambiguous. He expects HHS to punt on making any clear policy changes until after the upcoming 2024 elections, to avoid exposure on this issue.
With those concerns in mind, he went on to focus on a footnote at the very end of the judge's decision, which stated that if further clarification is needed on what prior rule is now in effect, the agencies can seek guidance “from the court.” Sarraille interpreted this as a reference reinstating the prior 2020 regulation which required copay assistance to count towards deductibles and out-of-pocket maximums for brand drugs without generic equivalents. However, he remains concerned that payers will argue the overall decision was too unclear, allowing them to continue accumulator programs by claiming the statute itself is ambiguous. He advised that additional litigation may be necessary to force payer compliance until definitive regulatory guidance emerges.
Q&A Session with Panelists
In the question and answer portion, panelists noted accumulator and maximizer programs are also increasingly affecting drugs covered under medical benefits as more specialty medications shift to pharmacy claims. The panel sees a need for continued vigilance through legislation, regulation, and litigation to restrict these programs. When asked about the core motivation for payers adopting these programs, Schmid suggested a mix of high plan deductibles, a desire to control costs, and maximizing insurer revenue by pushing more cost to manufacturers.
The panel also discussed how the programs are more prevalent in certain therapeutic areas like MS, oncology, rheumatoid arthritis, HIV/hepatitis, asthma/COPD, and diabetes. Katie additionally commented that upcoming PBM reforms at the state level could potentially influence the use of accumulators and maximizers.
When asked what brand teams should be doing looking ahead to 2024, the panelists advised that brands should not be relaxing their efforts but should instead continue pushing ahead with strategies against accumulators and maximizers. The panel made clear that continued pressure is essential, and brands cannot let up in fighting against these harmful programs and pushing for systemic reforms.