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5 ways providers need to respond to payers' new patient assistance program approach

January 30, 2018

    As drug prices rise, a growing portion of infusion center patients have come to rely on drug manufacturers' patient assistance programs (PAPs). The aim of these programs is to ensure that patients can afford their drugs, regardless of their out-of-pocket cost. While PAPs take many forms, most offset or completely cover patients' copay, coinsurance, or deductible for drugs. 

    In recent years, PAPs have come under fire from multiple sources. Critics assert that these programs effectively remove market pressure on drug prices and therefore enable drug manufacturers to continue to raise prices without limit.

    The 340B drug pricing controversy, explained

    Perhaps in response to this criticism, payers are beginning to change their policies regarding PAPs. Specifically, some insurers will no longer count funds from drug manufacturers' PAPs toward a patient's deductible. As a result, patients who were previously able to cover their out-of-pocket expenses with financial assistance may now face considerable costs. (For a sample analysis, see Drug Channel's "Copay Accumulators: Costly Consequences of a New Cost-Shifting Pharmacy Benefit.")

    Steps for providers

    These policies are likely to have significant consequences for patients and providers. Here are five ways to mitigate the financial implications:

    1. Understand your local health plans' policies

    To start, these policies are most likely to affect commercially insured patients who purchase their insurance on the individual market or through an employer that offers fully-funded health plans. Over time, payers are likely to encourage self-insured employers to incorporate the policies as a cost control strategy. The California Rheumatology Alliance has prepared a briefing to discourage employers from adopting this approach.

    These policies go by various names, including "accumulator adjuster programs" and "copay adjustment programs," which make them difficult to research. To date, most health plans and pharmacy benefit managers (PBMs) have made little information available on their public websites, so providers and patients may have the best results by calling them directly.

    2. Alert patients who may be affected by the changes

    Patients are unlikely to be aware of changes in their insurers' policies or to research the issue when purchasing coverage. Consequently, patient financial assistance staff should educate patients who will be affected by the policies and alert them to the impact on their out-of-pocket expenses. This is especially important for patients continuing treatment who have been reliant on PAP funds in the past.

    3. Partner with prescribers to consider alternative drug therapies

    Although rare in cancer care, there may be instances in which patients are eligible for an alternative, less expensive drug. In the event that patients are unable to afford their out-of-pocket expenses, financial counselors should work with prescribers to explore different options.

    4. Talk with patients about where they fill their prescriptions

    Much about the new policies is still unclear. Some patient advocates have pointed out that unless patients are filling their prescriptions at a pharmacy owned by their health plan or PBM, the insurer has no way of tracking whether the patient used a PAP to cover out-of-pocket expenses. However, some insurers have indicated that they have arrangements with pharmacies to report this information.

    5. Provide patients with out-of-pocket cost estimates and help them plan for their expenses

    The Oncology Roundtable has done extensive research on how to improve financial navigation for cancer patients and others on high-cost drug therapies. These new policies only increase the importance of strong financial navigation, both to protect patients from unanticipated and potentially crippling bills and to safeguard providers’ bottom line.

    In light of the many changes to health care coverage across the past year, financial navigation will again be a focus for at our 2018 Oncology Roundtable national meeting.


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