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The copay accumulator bans
passed in 15 states affect about 15 million people, or 11% of U.S. commercial
plan members, according to research by consulting firm Avalere Health. Experts say the drug
manufacturer-backed bans pick winners between payers and patients, but don't
come close to solving the persistent problem of sky-high prices for
life-saving drugs.
PBMs, manufacturers face
zero-sum fight
- State lawmakers
have moved to ban copay accumulators and maximizers in order to reduce
out-of-pocket costs for patients. But there is a cost to doing so,
explains Ge Bai, Ph.D., a professor at Johns Hopkins University’s
schools of business and public health.
- "This
reflects different political environments and the focus on different
constituencies, because in these programs, there's no right or wrong,”
she tells AIS Health. “It's all about who's getting a bigger pie, who's
getting prioritized in the process. The difference is whether they want
to prioritize patients' interest over the overall pool.”
- "These
states' regulatory decisions are the outcome of a very complex political
game," Bai adds. "It involves industries and advocacy groups
funded by special interests. Sometimes the payers have the upper hand,
sometimes the drug companies have the upper hand.”
Pharma companies sue
regulators
- On Aug. 30,
three patient advocacy groups — the HIV + Hepatitis Policy Institute,
the Diabetes Leadership Council and the Diabetes Patient Advocacy
Coalition — filed suit against
HHS, HHS Secretary Xavier Becerra and CMS Administrator Chiquita
Brooks-LaSure, challenging the federal regulations that allow copay
accumulator programs. In addition, Johnson & Johnson in May filed suit against
Cigna Corp.'s Express Scripts subsidiary in the hopes of getting a judge
to block the PBM's copay maximizer program.
- Katie Keith, a
Georgetown University researcher and law professor who writes Health
Affairs’ "Following the ACA” article series, wrote in a Sept. 28 article that the
plaintiffs are arguing that "CMS 'sided' with insurers and PBMs by
allowing these companies to disregard copay assistance programs from
drug manufacturers in patient deductibles and out-of-pocket
maximums," and overstepped its authority under the Affordable Care
Act to restrict cost sharing.
- "'Cost-sharing,'
[the plaintiffs] argue, is defined solely on whether an enrollee owes
for a medical expense — rather than the source of the payment,"
Keith adds. "Thus, CMS cannot limit the sources or types of support
that enrollees use to fund their cost-sharing requirements. On this
point, the plaintiffs try to compare support from drug manufacturers to
other types of copay assistance (e.g., support from a family member or
contributions from a GoFundMe page). The plaintiffs also raise concerns
about the fact that many plans do not clearly disclose whether the
insurer has an accumulator program."
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