The following is a snippet of a 1/15/23 article written by Dr. Robert Popovian (American Council on Science and Health advisor) and Louis Tharp for Healthcare Business Today,
Although per capita patient out-of-pocket (OOP) spending on prescription medications has dropped, averages are deceiving. In the U.S., a modest percentage of patients are burdened with unsustainable OOP biopharmaceutical spending. These are the patients who depend on brand-name medicines that have no generic or biosimilar equivalents. The primary contributor to the OOP burden is the changing of pharmaceutical benefit design. Such evolution from fixed-cost co-payments to percentage-based coinsurance and the expansion of high-deductible plans has dramatically increased the OOP share of drug costs paid by those patients.
In addition, pharmacy benefit management companies (PBMs) and insurers have devised a payment model in which patients do not directly benefit from multi-billion-dollar concessions, rebates, and fees collected by PBMs and insurers from biopharmaceutical companies. In contrast to physician or dentist visits, where a patient’s coinsurance or deductible is based on lower prices negotiated by the insurer, patients’ shares of medication costs are based on the inflated list price. Subsequently, biopharmaceuticals are the only segment of the health system in which patients do not realize the benefit of lower prices negotiated on their behalf.
Over the past several years, biopharmaceutical companies have offered assistance to eligible patients to help offset OOP costs. The monetary value of these manufacturers’ patient assistance programs (PAPs) places the pharmaceutical companies among some of the largest U.S. charities. To devalue PAPs, PBMs and insurers have instituted accumulator and maximizer programs. These initiatives prohibit the patient assistance funds provided through pharmaceutical companies from counting toward the insured individual’s deductible or maximum OOP spending. Consequently, accumulator and maximizer programs force patients to double-pay. The insurer and PBM collect the patient assistance funds provided by the biopharmaceutical industry meant for the patient, while patients must continue making OOP payments until they meet their maximum requirements. Simply put, PBMs and insurers increase profitability on the backs of patients.
#Reprinted with permission. The entire article can be read on The Healthcare Business Today site.
