Friday, May 12, 2023

Adapt or Fall Behind: The Need for Agile Copay Programs in Today's Shifting Payer Landscape

Today’s guest post comes from Nasir Ali, Chief Product Officer at CareMetx

Nasir discusses manufacturers’ strategies for mitigating the patient impact of copay accumulators and maximizers. He then outlines two key tactics that manufacturers should include in hub programs.

To learn more how digitally-enabled hub programs help patients, download CareMetx’s report: The Evolving Landscape of Digital Healthcare Hubs.

Read on for Nasir’s insights. .

Adapt or Fall Behind: The Need for Agile Copay Programs in Today's Shifting Payer Landscape
By Nasir Ali, Chief Product Officer, CareMetx

Today, nearly one-third of US adult patients don’t take their medication as prescribed because they can’t afford to. With high deductible health plans driving up out-of-pocket (OOP) costs, and budgets strained by inflation, many patients are forced to make decisions that may threaten their health and quality of life: skipping doses, cutting pills in half, foregoing paying for other essentials to cover their drug costs, or discontinuing treatment.

Copay programs can provide a lifeline for patients who face drug affordability challenges, but those programs are under tremendous pressure amidst today’s evolving payer landscape. Manufacturers and their digital hub providers are responding with increasingly agile copay programs that continually adjust to combat changing market conditions.


Manufacturer copay programs were designed to help patients afford their therapies, but market forces and plan design changes can hinder their use and reduce their ability to assist patients as intended. For example, copay accumulators and maximizers are shifting more of the financial responsibility to the patient (through higher OOP costs) and the manufacturer (who incurs higher expenses if a maximizer sets the patient’s OOP obligation to match the annual maximum copay value, instead of the drug’s price.) Today, an estimated 80% of patients are enrolled in a health plan that supports copay accumulator use, and 61% are exposed to a maximizer.

The shifting policy landscape also has an impact, as payers are continually responding to legal challenges by introducing new iterations of maximizers and accumulators. Recent developments include a US District Court ruling that vacated the Centers for Medicare & Medicaid final rule, and the introduction of a bipartisan House of Representatives bill that would require health insurance plans to apply copay assistance to the patient’s deductible and OOP maximum, essentially banning copay accumulator programs for plans regulated at the federal level.


With the patient assistance environment constantly changing as payers seek new ways to reduce financial exposure to copay programs, manufacturers and their hub partners need to stay agile when designing and managing copay programs that deliver the greatest benefit to patients.

A “set it and forget it” approach won’t work; instead, manufacturers need nimble copay programs that adapt to ever-changing conditions. To ensure their copay programs stay responsive to evolving plan designs and keep patients from experiencing undue financial hardship, manufacturers should build two key elements into their hub programs:
  1. Claims monitoring. A hub provider should monitor and analyze the brand’s claims data and identify patient populations most affected by copay accumulators or maximizer formulary lists. Since usage trends vary across drug types and therapeutic areas, manufacturers rely on their hub providers for sophisticated analytics—powered by AI and machine learning—to delve into the brand’s claims and identify where an accumulator or maximizer is creating patient financial challenges or increasing manufacturer costs.

  2. As one manufacturer shared during a recent CareMetx study, “From the manufacturer end, it's very difficult to find the individual claims that are falling into a maximizer program. That’s an important area where if the hub provider or the copay provider has strong technology, and offers that level of specificity in their reports, that's a gold mine. If a vendor tells us that they can identify, with 90% accuracy, every claim that falls into a maximizer or an accumulator program, everyone’s ears would perk up in the room at that point.

    Hear what other leading manufacturers have to say about today’s evolving patient services landscape by downloading the full report.

  3. Mitigation measures. Digital hubs must design and implement measures to counteract the latest version of accumulators and maximizers, reducing the impact on patients and manufacturers. That might involve changing the copay benefit design and payment protocol, altering the system’s business rules, using split adjudication, or adding a direct-to-consumer prepaid debit card. By staying nimble, the hub can help protect copay dollars, avoid patient disruption, and limit the manufacturer’s exposure.
The most effective, agile copay programs are part of a broader, holistic approach that considers the patient’s total affordability profile and all the social determinants of health that may impact their ability and propensity to initiate, adhere to, and persist on therapy. By keeping their copay programs agile and viewing them through the broader lens of total affordability, manufacturers and their digital hubs can engage with patients effectively, respond to their needs on a personalized basis, and identify all the options that can mitigate affordability as an obstacle to life-changing therapies.

For more insights on the trends impacting patient services programs and best practices to ensure success, be sure to download the Evolving Landscape of Digital Healthcare Hubs report from CareMetx!

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