Prescription Back-Door Discounts
Wojcik and Alexander discuss how prescription co-pay discounts lower patients' costs but can negatively impact pharmaceutical pricing in the long run. The say insurers' approaches to co-pays offer only a short-term solution for a systemic problem.
Are there downsides to these co-pay discount cards and programs?
Alexander: These types of approaches propagate a healthcare system where enormous costs are charged for prescription drugs that are borne by consumers and by all of us. The short-term implication is clear—if you have a co-pay offset, it will let someone pay a $5 co-pay instead of a $50 one.
But the long-term effect is trickier to know and understand. Years ago, we did a study looking at free samples offered by physicians, which is slightly different. We found that, paradoxically, people receiving free samples had higher prescription drug costs during, and well after, they received their samples.
It seems counterintuitive until you stop to figure it out. If someone receives a free sample for a drug, even a high-priced one, they may go on to fill a prescription for that same drug. You can imagine the same sort of factor at play with offsets. They are allowing patients, for a time, to fill prescriptions for more expensive medications.
Wojcik: There are some cases when high-priced medications like specialty pharmaceuticals offer manufacturers’ discount coupons that are helpful to both the patient and the plan. If there is no alternative, this can help the patient. But that is the minority of cases. Discounting their co-pays is potentially discouraging them from seeking lower-cost medications that might be appropriate. It saves the patient money at the time they are buying the medicine, but, over time, it costs the plan—and therefore the participants—more if there is a lower-cost alternative medication that they could be using. Driving the use of more expensive medications when lower-cost ones are available drives up the cost for everyone.
The use of these has grown a lot in the last few years. For example, in 2009 there were 75 medications that had co-pay cards associated with them, and by 2015 there were 700. So there’s a big growth in recent years along with the growth in specialty pharmaceuticals and an increasing number of high-priced medications. Eighty percent of specialty drugs have co-pay discount card programs associated with them today.
Maximizers are even more recent to the market. When a pharmacy benefit manager is aware there is a coupon out there (and they have good information about ones available), they will encourage a member to seek out the maximum in terms of coupons and deductibles and will add that on to raise the deductible or out-of-pocket maximum to include the total amount of aid coming from the manufacturer.
Alexander: One wonders why it took so long for insurers to do this. Accumulators and maximizers are short-term and imperfect fixes for a long-term problem. As time goes on, more will be revealed about how they impact the market. Now, there is relatively little information on what effects they are having. Like, there are some questions about what effect they will have on drug utilization and adherence.
Wojcik: It’s not the ideal situation in the first place to have a need for a discount card and coupon and then on the back end adjusting for that as an accumulator and maximizer. It just adds confusion to the plan. Our response is, if it is causing so much of a workaround and administrative burden, why don’t they just reduce the price for everyone at the outset instead of just making it less for the lucky people that get these cards.
The plan owes it to patients to explain why they are implementing these: to ensure patients are getting the best value for their medications; that there may be a lower-cost alternative out there that is appropriate instead of the expensive name brand. In terms of a plan, they do, in written documentation, disclose when they are using maximizers or accumulators. But participants probably don’t read it, and then they have to call the insurer, who has to tell them their discount card doesn’t help reduce their deductible. It’s not an ideal situation all around.
Employers should reach out and say, “Why we have these is to reduce costs and improve value and spending on pharmaceuticals. And what we are trying to do is for the benefit of all of the members and the plan as a whole.” Otherwise, members will not understand how cards and coupons can be detrimental overall.
Wojcik: Most employers feel the way pharmaceuticals are priced and the way the supply chain works isn’t optimal and would like another way. This involves payers coming together with manufacturers and figuring out a better way. But that’s a bigger change in the system.
We need more transparency in the pharmaceutical market and more information about how pricing occurs. This might obviate the need for things like co-pay discount cards and ways to counter them. The ideal scenario would be for patients to check with their plans and be fully knowledgeable about alternatives. Another important piece of communication and education which is increasingly happening is informing physicians about the prices of medications and alternatives. Often, they have no idea what the price in the system is. They can be more educated on pricing and the impact of discount cards and coupons when they are prescribing medication to patients.