Earlier this month, hundreds of health care professionals, including providers, payers, pharmacists and manufacturers, descended on Las Vegas for the 2019 Asembia Specialty Pharmacy Summit. In addition to abundant networking opportunities, client meetings and vendor exhibits, the conference offered a chance to hear thought leaders share insights and weigh in on key trends shaping the industry.
Potential Impact of Drug Rebate Reform
An underlying theme resonating through several talks was uncertainty surrounding how removing safe harbor protections under the Anti-Kickback Statute for prescription drug rebates by the U.S. Department of Health and Human Services could impact health care. During a featured session and an Industry Insights Dinner hosted by CoverMyMeds, Dr. Adam Fein from Drug Channels Institute offered his expert opinion on the topic.
Within our current health care system, list price for a medication does not typically reflect final net price. The list price is often set artificially high and is then offset to the net price through considerable prescription drug rebates. These rebates are offered to pharmacy benefit managers (PBMs), health plans and managed care organizations by pharmaceutical manufactures in exchange for preferred formulary placement. Under proposed new rules, such rebates would become illegal for drugs covered by government entities (e.g. Medicare Part D and Medicaid).
As prescription drug rebates have been a fundamental part of our health care system since the 1990s,1 a change to this model could have profound effects industry-wide. Dr. Fein forecasted narrower formularies with “winner-take-all” bidding for placement in drug classes with therapeutically comparable medications, among several other predictions (e.g. decline in brand-name list prices, slower growth in drug prices, broader formularies for certain drug classes to encourage indication-based price competition, etc.).2,3 He also predicted that if the federal government were to implement such regulations, the commercial market would likely follow suit in three to four years.
If such reform does take effect, patients could experience potential fallout as the industry seeks a new normal. Solving access challenges through all of this change will be more important than ever for getting patients the medications they need to live healthy lives.
Understanding Copay Accumulators
Another topic sparking interest was copay accumulators – specifically, what they are and what they mean for patients. As drug prices have steadily increased through the years,4 payers and PBMs have implemented utilization management strategies to help mitigate drug spend. Some of these involve increasing patient responsibility through greater cost sharing. By making patients more financially responsible for their own health care, it’s thought that providers and patients will be more mindful of lower-cost therapeutic alternatives when making health care decisions.
As a result of cost-sharing efforts, the number of Americans covered under high-deductible health plans reached 43.4% in 2018, a 17.9% increase from 2011.5 While in the deductible phase of such plans, patients are exposed to high out-of-pocket costs, which can lead to prescription abandonment and medication non-adherence.6,7 To offset these unintended consequences, manufacturers offer patients financial assistance in the form of copay cards, coupons or vouchers that cover the copay amount for a prescribed medication and apply to the patient’s deductible. In some instances, the deductible is reached, and insurance coverage begins without the patient having to contribute.
This complete transfer of financial responsibility away from the patient led to the development of copay accumulators. Within these programs, financial assistance from manufacturers can still be used to cover a patient’s copay at the pharmacy, but it no longer counts towards the deductible. In this way, patients get some copay relief but are ultimately responsible for meeting the deductible on their own.
While acknowledging the sentiment behind copay accumulators to curb increasing drug prices and promote sensible prescribing, one Asembia speaker noted that providers and patients are unaware of and do not understand copay accumulators.8 As a result, patients faced with unexpected medication costs can become non-adherent or discontinue therapy altogether.8,9
As 44% of commercial health plans representing ~147 million covered lives had a copay accumulator in 2018, and another 27% intend to implement such a program during or after 2019, this industry trend continues to gain traction among payers.10,11 Moving forward, prescription decision support technologies and price transparency tools, like RxBenefit Clarity™, can help support patients and providers with options for selecting and affording therapy.
Growth in Specialty Therapeutics
In 2018, a record 39 specialty therapies were approved by the FDA and it is projected that from 2019 – 2023, 65% of newly launched medications (~54) worldwide will be considered specialty.4,12 For many patients, these innovative medications offer a chance to be well. Due to their complexity and high-cost, access to specialty therapies can be complicated and adherence can be difficult.
Many Asembia attendees were concerned with providing optimal support for patients who are prescribed specialty medications. Supporting such patients at the start of their journeys can help facilitate medication access, affordability and adherence. CoverMyMeds has developed a new end-to-end electronic solution that can help – to learn more, visit go.covermymeds.com/specialty.
While the 2019 Asembia Specialty Pharmacy Summit exposed many challenges on the health care horizon, it was clear that all stakeholders are resolved to do their best to help patients.
- The History of Rebates in the Drug Supply Chain and HHS’ Proposed Rule to Change Safe Harbor Protection for Manufacturer Rebates, Foley Hoag LLP, 2019
- A World Without Rebates: Predictions for How the Channel Will Evolve and Why Drug Prices Will Go Down, Drug Channels Institute, 2019
- The Road to 2020: Understanding the Regulatory Timeline for Part D Rebate Reform
- The Global Use of Medicine in 2019 and Outlook to 2023, IQVIA Institute, 2019
- High-deductible Health Plan Enrollment, National Center for Health Statistics, 2018
- Patient Affordability Part Two, IQVIA Institute, 2018
- 2018 Real-time Benefit Check National Adoption Scorecard, CoverMyMeds, 2018
- Co-pay Accumulator Programs: The Debate Continues, Specialty Pharmacy Times, 2019
- The Impact of Accumulators on Co-Pay Programs, RxCrossroads by McKesson, 2019
- Copay Accumulator Programs, Zitter Health Insights, 2018
- Copay Accumulator Update, Drug Channels Institute, 2018
- 2019 Specialty Pipeline Highlights, Specialty Pharmacy Times, 2019