The copay adjustment landscape is constantly evolving, leaving many brand managers and patient support teams questioning how to stay one step ahead of cost shifting strategies that are affecting their patients. We recently provided a comprehensive update on the state of Accumulators and Maximizers in the specialty space at Informa Connect’s Hub and Specialty Pharmacy Models East Conference. Among other things, the ongoing legal battles over accumulators was covered, and we gave our predictions how some of those situations will play out.
Stay tuned to this space as we update our predictions as the stories play out. You can also watch our webinar on demand as it was recorded at Hub East.
24 in ‘24
During the conference, we discussed our first prediction, stating that the trend of state enacted anti-Accumulator laws would continue, with 24 States banning Accumulators by 2024 (up from just 5 in 2020). Per NCSL, as of summer 2023, laws in 20 states and Puerto Rico have been passed to address the use of copay adjustment programs by insurers or PBMs by requiring any payment or discount made by or on behalf of the patient be applied to a consumer’s annual out-of-pocket cost-sharing. If the 24 in’24 prediction is right, that means around 30 million patients will be shielded from ever having to face an accumulator when purchasing their medication.
For context, take a look at Drug Channels, where Adam Fein has been tracking the rise of adjustment programs for more than six years. In 2020, he reported that four states had “passed laws that ban or restrict the use of accumulators in individual and small group healthcare plans”. The number of states banning accumulators in some way has quadrupled in just three years, and with that kind of momentum, it’s likely we will see more states continue to adopt these policies in the coming years.
Bipartisan Support
In the US, systemic change often starts at the state level, but it takes federal efforts to ensure all residents receive equal treatment on any issue. When it comes to accumulators, the demand on the state level has made it almost inevitable that the federal government will get involved, and the first of two bills is H.R. 830, the Help Ensure Lower Payment Copays Act, or the HELP Copays Act. Simply stated, the bill:
… requires health insurance plans to apply certain payments made by, or on behalf of, a plan enrollee toward a plan's cost-sharing requirements. Specifically, plans must apply third-party payments, financial assistance, discounts, product vouchers, and other reductions in out-of-pocket expenses toward the requirements.
The February bipartisan house bill entered the Senate in May, and while plenty of patient support advocates are supporting the bill, there is still a long way to go. In our second prediction, our experts place this bill at a 25% chance of passing through to become law, given how early we are in the process. We will be watching this situation closely as it unfolds.
Involving the Federal Court
Comparatively speaking, the case of HIV and Hepatitis Policy Institute et al. v. U.S. Department of Health and Human Services et al. is much further along in its efforts to ban accumulators in the US. Filed in August, 2022, the plaintiffs allege that accumulators violate the Affordable Care Act and Administrative Procedure Act, while defendants believe eliminating accumulators will “encourage patients to use more expensive medications over less costly treatments, and also contribute to higher drug and health care spending and thus higher premiums”.
Soon after the filing, HHS appealed to the court asking for the case to be dismissed on the grounds that the plaintiffs failed to allege concrete damages as a result of the accumulator policies. The judge, however, disagreed and declared the case can continue. Overcoming this hurdle was a big win for anti-accumulator advocates, and because of this, our third prediction believes there is a positive trending chance of this case ruling for the plaintiffs. In fact, the government's reply in support of the cross-motion for summary judgment is due July 7th; we will share those results when they are available.
The ongoing legal battle is sure to change the accumulator landscape, and maximizers for that matter, regardless of the outcomes of our predictions. Stay up to date as we watch the results unfold, and don’t forget to watch our exclusive webinar on demand for all things copay adjustment programs.