The Pioneer Institute recently released a white paper that examines the impact of pharmacy benefit managers (PBMs) and copay accumulator and maximizer programs have on the ability of patients living with specific conditions to access treatment they need to manage their conditions. Copay accumulator adjustment programs prevent manufacturer-provided copay assistance from counting toward a patient’s deductible or out-of-pocket cost maximum. This can unfortunately result in large and unexpected costs for patients, as well as interrupted treatment regiments. Copay maximizers are similar, but instead set a patient’s cost-sharing amount to the maximum value of the copay assistance, spread throughout the year.
Dr. Bill Smith, Senior Fellow and Director of the Life Sciences Initiative at Pioneer Institute, Dr. Robert Popovian, Senior Visiting Health Fellow at Pioneer Institute, and Wayne Winegarden, Senior Fellow and Director of the Center for Medical Economics and Innovation at Pacific Research Institute, came together to write the white paper that examines real cost data and the average benefit design for an Affordable Care Act-compliant plan to demonstrate the patient health and economic consequences of implementing copay accumulator and maximizer programs.
The authors note that patients sometimes delay or forgo care because of their overall higher out-of-pocket obligations. They estimate that delayed or forgone health care due to maximizers could increase health care costs by anywhere between $1.3 billion and $2.5 billion annually.
The white paper cites the Drug Channels Institute figures that 80% of commercial insurance plans offered accumulator programs in their plan design in 2021, while 61% offered maximiser programs. Of those 61% that offered maximizer program, 45% of plans implement maximizer programs as part of the plan’s benefit design (not just an offering). Additionally, a January 2023 Avalere report found that 83% of commercial market enrollees were part of health plans with accumulator programs and 73% part of a plan with a maximizer program.
The paper identifies three specific trends that show that copay accumulators and maximizers are not a financial necessity for payers. Those three trends are: the relatively small role the cost of prescription drugs plays in determining health care premiums, the modest rate of growth in the cost of prescription drugs, and the declining average price of prescription drugs.
Additionally, the report finds that maximizer programs “do not reduce patients’ overall healthcare costs once other medical care costs are considered” but tend to only alleviate costs for specific drugs for patients with certain conditions.
“Copay accumulator and maximizer programs interrupt the relationship and trust between patients and their healthcare providers, all while driving up costs for those seeking treatment,” said Dr. Popovian. “Insurance programs must primarily focus on protecting patients if they fall ill, not burdening low- and middle-income populations with large out-of-pocket costs while commercial insurers profit.”