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The Evolution of Patient Assistance Programs

By Seamus Cole

It’s no secret that copay maximizer and accumulator programs have come under fire since their inception, and for good reason: In theory, these programs aim to help manage costs, but oftentimes accumulators can end up shifting the cost of medications to patients while maximizers can shift the cost of care from the patient to the manufacturer.

Now, amid the relentless tug of war between payers and pharmaceutical manufacturers, a relatively new type of patient assistance program has emerged. These programs—such as Paydhealth and MedMonk—work like savings aggregators, finding the maximum amount of savings possible to help patients pay less for their medications. Also, like copay accumulators and maximizers, they’re often a built-in feature within an employee benefits plan.

In a recent interview with payers on this topic, one VP of Pharmacy described the programs like so: “They provide alternative funding services, coordination of benefit investigation, and find copay assistance programs and money from charitable foundations with the objective to reduce burden on patients and employers.”

Uninsured or Insured Patients: Who Benefits?

Typical manufacturer assistance programs are for patients who lack health insurance or whose insurance doesn’t cover a medication that they need. They must also have an existing prescription, must reside in the U.S. and must be under a specific income threshold, which varies by medication and family size.

One of the new aggregator programs, Paydhealth, gathers information from the member, including household size and income, to apply for funding programs. Therefore, it’s reasonable to conclude that Paydhealth is able to identify patients who have insurance but still qualify for a manufacturer’s patient assistance program if a health plan doesn’t cover the drug that they need.

While that seems like good news on the surface, what does this mean for patients without insurance?

Let’s look at a hypothetical example: Product X costs $10,000 per year. Ten commercially insured patients could afford the medication via their prescription plan benefits, but their plan does not cover it. All 10 patients are on the same commercial insurance plan and are a part of an aggregator program that’s similar to Paydhealth or MedMonk.

Another eight patients do not have insurance and wouldn’t be able to afford the medication out of pocket. The manufacturer has $100,000 set aside in a patient assistance program for those who can’t afford Product X without insurance.

In this example, since the commercial plan excludes coverage for Product X, all 18 patients will qualify for the manufacturer’s patient assistance program, including the 10 who have insurance. This would save that plan money for each of these patients. However, in this hypothetical example, the manufacturer’s patient assistance fund could dry up before some or all of the eight patients without insurance can reap the benefits. The assistance program would have been able to cover the uninsured patients if a program like Paydhealth or MedMonk hadn’t been put in place. The dynamic changes when these new savings aggregators allow patients with insurance to qualify for manufacturers’ assistance programs.

As these savings aggregators grow in popularity, situations like these could become common and result in confusion. Patients are told if they enroll in one of these aggregator programs, then they’ll get the maximum savings possible. While that’s true, enrolling might also result in the patient assistance program being depleted faster than it would otherwise.

Assessing the Future Impact

While these types of aggregator programs are fairly new and small in size, if they become more prevalent, they could help manufacturers use the funds in their patient assistance programs more efficiently. One payer that we interviewed believes the programs could become popular due to the cost savings: “They’re gaining in popularity. Because of the rising cost of pharmacy benefits, small employers especially are simply trying to figure out how to reduce their cost burden.”

However, the rise of savings aggregators could result in manufacturers being more reluctant to create patient assistance programs. This would likely have the biggest impact on manufacturers with large funds set aside in their patient assistance programs since there’s more money available to deplete. It could also lead to worse outcomes if it results in fewer patients being able to access medication.

Moreover, the implementation of the savings aggregators might also lead to more restrictive drug coverage for expensive agents, which would result in more patients needing to go through the medical exception process to get access to therapies. With more medical exceptions there would be a larger administrative burden and potential delays in patients getting lifesaving medications. It could also result in lower costs for plans if they save money via the manufacturers’ patient assistance funds, which would bring down premiums.

While nascent, savings aggregators are clearly an evolution of copay accumulators and maximizers, and they’re worth keeping an eye on as the industry makes room for them. Tracking these programs as they become more prevalent will become key if they’re able to help payers maximize all available savings for their plans.

MMIT recently fielded a special report to survey payers on the future of copay accumulators and maximizers. Learn more via MMIT’s Oncology Index or Biologics & Injectables Index for non-oncology products.

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© 2024 MMIT
Seamus Cole

Seamus Cole

Seamus Cole is a Consultant in Advisory Services at MMIT.

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