By Dr. Brett Smith
As a rheumatologist, I’ve seen firsthand how my patients’ quality of life has been improved by prescription medications. Unfortunately, in Tennessee and across the country, rising out-of-pocket costs are putting treatments and medications out of reach for many people battling complex, chronic conditions. And when patients face high prices at the pharmacy counter, it can push them to forgo or alter their treatment regimen, which can ultimately lead to poorer health outcomes.
Many patients who are suffering from rheumatoid arthritis and other rheumatic illnesses, depend on co-pay assistance programs that help cover the cost of the specialty medications they need to manage these painful and sometimes debilitating diseases. Co-pay assistance works by allowing patients to use pharmaceutical coupons toward specialty medications or by allowing a third party to make payments toward a patient’s overall deductible.
Co-pay assistance gives patients the ability to access the medications prescribed by their doctors without having to shoulder significant costs. And it leads to improved health outcomes down the road because patients are more likely to follow their recommended treatment regimen, keeping them healthier and out of the hospital.
Unsurprisingly, health insurers have found a loophole to get around this patient lifeline, making it more difficult for Tennesseans to access critical care. Last year, the Department of Health and Human Services issued a rule allowing health insurers to implement “accumulator adjustment programs.” Under this rule, insurance plans do not have to count pharmaceutical coupons or third-party assistance toward a patient’s deductible or out-of-pocket maximum.
What does this mean for patients? Let’s break it down. Imagine you need a new, innovative medication to manage your arthritis and it costs $3,000 each month to refill. Your insurance has no deductible and will cover 50 percent of that cost. But without financial help, you cannot afford $1,500 out-of-pocket at the pharmacy counter each month. Graciously, the pharmaceutical company offers a coupon that covers 90 percent of your out-of-pocket costs, so you only have to spend $150 of your own money to manage your health.
Now, here’s the loophole. If your health plan has implemented a co-pay accumulator program, it can accept the coupon while refusing to apply it to your overall deductible and maximum out-of-pocket costs. Unknowingly, you will continue to pay $150 each month and never hit your maximum out-of-pocket costs.
The same concept applies if someone in front of you in the drive-thru line pays for your meal, but the restaurant decides to charge you anyway. In both scenarios, the patient and the customer are being double charged. This practice is becoming more prevalent in the health care space, as health insurers use co-pay accumulator programs to profit at the patient’s expense.
More and more health plans are adopting this practice as a way to shift more costs to patients and increase their company bottom lines. To get in front of this concerning trend, two bills have been filed in the Tennessee legislature that will stop this unfair, costly and discriminatory program from continuing in our state. If passed, these bills will ensure that all payments made by patients, or on their behalf, will count toward patients’ out-of-pocket costs and overall deductibles.
The COVID-19 pandemic has proved that we cannot put health care problems on the backburner. We must remove this barrier now, so Tennesseans can continue to benefit from co-pay assistance programs and access the medications they need to lead healthy lives.
Rising out-of-pocket costs are already forcing patients to choose between refilling their medication or feeding their family. That’s not a decision any Tennessean should be forced to make. After one health insurer imposed an accumulator adjustment program for autoimmune medications, refill rates dropped 12 percent in just one year, and the number of patients who stopped the drug entirely increased 400 percent, according to a 2019 AMCP Nexus study. That’s why we need to get in front of this issue now and pass legislation to address this problem in our state.
Legislators must act now so that Tennessee patients can continue accessing important, life-saving care, without enduring major out-of-pocket costs. Let’s not wait any longer to end harmful co-pay accumulator adjustment programs and ensure Tennessee patients come before insurance company profits.
Dr. Brett Smith is a rheumatologist and has been practicing medicine since 2015. He currently works at Blount Memorial Hospital and East Tennessee Children’s Hospital.