Congress should seize the opportunity to reduce drug costs for consumers
Prices are rising for just about every category of goods and services: food, housing and health care. Consumers could enjoy a break. And while we rarely see simple, bipartisan solutions moving forward, right now Washington has a vehicle that would bring immediate relief to American patients dependent on co-pay assistance when they arrive at the counter of the pharmacy. Congress can do something significant to ease the financial burden on ordinary Americans trying to pay for their lifesaving drugs.
Over the past decade, health insurance intermediaries have found new ways to pass the cost of drugs on to patients by increase in deductibles and coinsurance, saving billions as costs pile up for patients struggling to make ends meet. Meanwhile, insurers and pharmacy benefit managers (PBMs) pocket the savings on brand name drugs with an insider game of negotiated rebates, rebates and other payments from manufacturers they fail to match. impact on patients.
Increasingly, insurers and PBMs are also refusing to factor the value of copayment assistance into the patient’s deductible or out-of-pocket for the plan year. Many of these patients, especially those with rare diseases for which there is no generic alternative to the brand name drug, depend on these drugs to stay alive. They cannot afford the drugs without co-payment assistance. But when insurers refuse to include this aid in the personal expenses of a patient, these patients encounter a double problem.
The process of blocking patients’ access to co-pay assistance, called “co-pay accumulator adjustment programs”, means that patients simply cannot afford to pay for drugs that often save Lives. Too often, once a patient sees this higher price, they end up abandoning the drug over the counter, disrupting their treatment and thus becoming sicker.
PBMs say co-payment assistance steers patients to more expensive brand-name drugs and increases overall spending. But the Data show that this argument is simply false. For starters, co-pay assistance isn’t readily available to anyone who wants it. An insured patient must meet certain criteria before they can even apply for co-payment assistance. A patient must be privately insured under a program without any federal or state funding, and they must meet with their provider to determine appropriate treatment and obtain a written prescription. In some cases, patients must go through utilization management procedures, such as step therapy, before they can receive assistance. In other words, there are many checks and balances to ensure co-payment assistance is not abusive.
Even after patients have jumped through all these hoops, the Data show that they are not using co-payment assistance on more expensive brand name drugs by choice. The vast majority of the co-pay is used in cases where there is no generic alternative. In fact, copayment use on brand name drugs when there is a cheaper generic option is only 0.4% of the entire commercial market.
There is a remedy for this untenable and dangerous situation for patients: HR 5801, the HELP Act (Help Ensure Lower Patient Copays Act), would require health insurers to account for the value of co-payment assistance in the annual deductible or personal liability of patients. More than 40 members of Congress in both aisles have signed on to co-sponsor the legislation, which mirrors policy more than a dozen states have already adopted.
As ordinary Americans struggle to afford gas, groceries and a roof over their heads, Congress can help stop insurers from exploiting their patients. The co-pay is a vital resource for consumers struggling to make ends meet and manage a serious, often fatal illness. Congress should act quickly to provide this relief by protecting co-pay assistance at the pharmacy.
Sally Greenberg is Executive Director of the National Consumers League (NCL), a leading consumer advocacy organization representing consumers and workers on marketplace and workplace issues. NCL provides transparent annual reports on donor contributions — including those in the pharmaceutical industry.