In a video interview with Pharma Commerce, Kimberly Westrich, MD, chief strategy offer at the National Pharmaceutical Council, describes how in response to rising healthcare costs, employers have turned to high-deductible health plans and higher out-of-pocket (OOP) expenses, causing patients to pay more for healthcare. To help alleviate this financial burden, manufacturers offer copay assistance programs, which are aimed at improving medication adherence and preventing disease progression. However, insurers have introduced cost-shifting programs such as copay accumulators, maximizers, and alternative funding programs (AFPs) to manage these costs.
Copay accumulators redirect the value of copay assistance to the insurance plan instead of counting it toward the patient’s OOP max or deductible. This means that patients face surprise copay costs once the copay assistance runs out, essentially “double dipping” as the plan captures the benefit without applying it to the patient’s financial responsibility.
Copay maximizers also shift assistance from the patient to the plan but manipulate the patient’s copay to extract the maximum benefit from the copay assistance. While the copay assistance helps with a specific medication, it doesn’t count toward the patient’s deductible or OOP max for other expenses, leaving the patient responsible for other costs.
Alternative funding programs (AFPs) are more complex. In these programs, certain specialty medications are removed from insurance coverage, and patients must enroll in an AFP. They work with a third-party vendor to obtain the medication, often through manufacturer assistance, charity programs, or international pharmacies. While the AFP may provide the medication, it can be a slow and confusing process, and patients may not qualify, leaving them to pay out of pocket or forgo the medication. These cost-shifting strategies aim to manage healthcare expenses but can create additional financial and logistical challenges for patients.
Westrich also comments on how these accumulators, maximizers, and alternative AFPs are impacting patients, manufacturers, and healthcare ecosystems; sessions that have caught her eye; and much more.
A transcript of her conversation with PC can be found below.
PC: What other sessions have caught your eye at Hub and Specialty Pharmacy Models East?
Westrich: Unfortunately, I wasn’t able to be here for the entire conference. I really wish that I could have been, but I did have the fortune to attend the session—which was immediately before my session—and Dolores and Amanda from EMD Serono talked about their thriving culture.
This is the kind of session that you might not expect to sit in at a conference like this. I personally really enjoyed it. I have multiple hats at the National Pharmaceutical Council (NPC), and while one of my hats is looking at the employer-sponsored insurance world and doing policy relevant research, one of my other hats is related to culture, and I oversee our culture initiative at NPC.
Last year, we were chosen as a great place to work, and that’s been really important and exciting to me, so in this particular session with Dolores and Amanda, I was really interested in hearing about the things that they’ve been doing to deliberately have an open culture, a culture that has shared values and cultural curiosity. It was really interesting for me to hear how another organization approaches it, to have that overlaid with this particular conference, because they also wove in some information about their PAP program and how all of this fits together, so I really enjoyed hearing that.
NPC just celebrated our 70th anniversary last year, and I believe that one of the reasons that we are so successful—we have such longevity as an organization—is the focus that we put on our culture. I’m excited to take some of what I heard from Amanda and Dolores back to the office with me, and share some of their ideas with my colleagues and see how we continue to raise the bar—as Amanda and Dolores said today—on excellence.