by Dr. Gerald Felando
There is no debate that Americans spend more on prescription drugs than the citizens of any other country in the world.
As a former state lawmaker who sat on key policy committees thirty years ago, I would have hoped that policymakers on both sides of the table would have found an equitable and effective solution to addressing healthcare costs.
But in the absence of a legislative solution, charitable foundations, patient advocacy groups and pharmaceutical manufacturers have developed assistance programs to help reduce patients’ out-of-pocket payments for medication and treatment.
The funds provided by these programs are supposed to go towards a patient’s deductible, allowing them to hit their deductible maximum, and have insurance cover the rest of the cost. But insurers and Pharmacy Benefit Managers (PBMs) who help to negotiate drug prices, took umbrage with patients participating in cost sharing programs. So, they developed a new mechanism that allowed them to take the assistance funds and continue to make patients pay.
They have done this by inserting “copay accumulator” language into health plans, which says that if a drug is classified “non-essential,” they do not have to count third party assistance in payment for the treatment towards a patient’s deductible. And wouldn’t you know it, a lot of the newest and most effective drugs for chronic diseases have been classified as “non-essential.”
To hear PBM’s explain it, the financial assistance programs were simply about pushing the newest drug vs. a generic alternative. And I would accept that claim, were it not for the fact that a USC study found that 79% of drugs affected by the new program had no branded or generic alternative.
This new scheme is simply unfair and unjust. But it has not received the attention it deserves because most people affected don’t know that their health plan has a co-pay accumulator or maximizer language included until they get hit with an unexpected bill.
Many of my former constituents experienced chronic diseases like diabetes, heart disease, and cystic fibrosis. Fortunately, they are living longer and more comfortably thanks to innovative therapeutic medicines created within the past few years.
For example, in addition to being key to development of COVID vaccines, mRNA technology is now being developed to treat patients with amyloidosis and cystic fibrosis. And we have seen scientists discover new treatments for Alzheimer’s, ALS and even find a cure for Hepatitis C.
As a cancer survivor twice, I recognize how lucky I am to be alive due to these remarkable scientific breakthroughs as well as passionate and skilled doctors and nurses. Which could only lead one to believe that there is hope for patients suffering from chronic disease in our country.
The good news is that lawmakers in Congress have taken notice of this issue – and state lawmakers here in California are now considering fixes to this imperfect policy.
Sixteen state legislatures from around the country have come up with a solution; by banning this practice and ensuring financial assistance meant to help pay for medication and reduce the financial burden on patients accomplishes both of those goals.
We need to raise awareness to give Congressional leaders the support to continue their efforts and speak out in California about reducing the cost of living with a chronic illness and ending copay accumulator programs. We owe it to our families, friends, and neighbors who have been harmed by this unfair and unjust practice.
About the Author: Dr. Gerald Felando is a former State Legislator and Member of the Assembly Health & Aging Committees (1978-1992). Retired from public office, Felando now spends time advocating for patient rights and access to affordable prescription medicines.