Drawing on conversations with pharmaceutical market access leaders, Anurati examines whether traditional copay assistance programs are delivering sufficient value. She argues that automatic point-of-sale discounts often subsidize prescriptions that patients would have filled anyway. She makes the case for a more targeted, data-driven approach that aligns affordability spending with patient behavior to improve adherence and gross-to-net (GTN) performance.
To learn more about Sempre Health’s approach to patient affordability, visit Sempre Health..
Read on for Anurati's insights.
"How Do I Know I'm Not Just Giving Money Away?" The Question Every Market Access Leader Is Asking
By Anurati Mathur, Co-Founder & CEO, Sempre Health
The tool everyone uses and nobody likes
The tool everyone leans on most is the automatic point-of-sale buydown: a discount that runs on every claim that exceeds a specified cost-share threshold, for every patient, invisibly, regardless of what they would have done anyway.
The leaders who buy these programs were candid. "The exposure for certain programs is really, really high." It is invisible to the patient, prescriber, payer, and often the pharmacist, so the brand gets little recognition, and it is the most expensive tool to administer per fill. Asked what it actually changes, more than one leader gave the same answer: one, maybe two, incremental fills a year.
It persists because it is effortless for the manufacturer, though for patients it often adds confusion, since they rarely know what they'll pay until they fill. It may keep some from walking away out of sticker shock, but no one can claim it changes behavior long-term.
Buying down the patient who is already at the counter
A discount's job is to bring a patient to the pharmacy counter. Rebates already ensure a preferred formulary tier. Then, an automatic buydown often pays again. One market access leader put it this way, "If we already have a $30 preferred copay and we're paying significantly for that, do I want to automatically buy it down even further across the board?"
An automatic buydown can only act at the moment a patient fills, so it only reaches patients who have already shown up. It does not remind anyone a refill is due, notice when one is missed, or reach the patient who quietly stopped three months ago. It might reward arrival, but it does not cause it.
To the people who develop medicines, every patient matters, and I am not suggesting the patient at the counter should pay more or benefit any less from the discount. The question is whether the same dollars could pull through both the likely fill and the unlikely one, so more patients benefit from their medicines more often. That second group is where unmet need lives, and reaching it is what improves health and lowers total cost of care.
In Sempre's programs, nine in ten enrolled patients had never used a copay card. With payer opt-in, we reach net new patients without added promotional spend.
So while automatic buydowns may make sense at launch, where volume at all costs is a defensible, albeit blunt, strategy. The problem is that it keeps running long after coverage arrives, when it stops onboarding patients and starts subsidizing the ones a brand has already earned.
Why this question goes unanswered
I expected to hear about hurdle rates. Mostly I did not. "We're not that sophisticated. We probably should be, but we're not," one leader told me. Success is measured against forecast, not a control arm.
Nobody in these rooms lacked good intentions. They lacked data and control. And, they lacked a real alternative.
Gross-to-net discipline has arrived everywhere except the pharmacy counter
Manufacturers now manage rebates, 340B exposure, and Medicaid liability with real rigor, but those are set in bulk and in advance, for whole populations. Patient affordability is the one GTN line spent one claim at a time, on a specific patient, the only line that could be managed with precision, and the one that gets the least.
Precision GTN spend does not mean inviting fewer patients. It means broad adoption with carefully managed parameters underneath. Payer claims reveal distinct cohorts before anyone is invited: the active filler with a high cost-share, the active filler already in a low tier, the lapsed patient, and the one whose prescription was abandoned. Discounts are tailored to each, designed to bridge the deductible phase, and grow with on-time fills, so spend follows behavior. One universally available program, better performance in every cohort. And, of course, some lines, like clinical severity, protected characteristics, and federal beneficiaries, are never crossed.
What we have measured
This is how Sempre configures programs today, from inside the pharmacy benefit, knowing each eligible patient before any outreach. Against the one to two incremental fills attributed to automatic buydowns, our programs deliver roughly four incremental fills per enrolled patient, measured against matched non-enrolled cohorts. The outcomes are published: a UPMC-funded study in the Journal of Managed Care & Specialty Pharmacy (2024) and a Blue Shield of California study presented at AMCP (2024).
The next playbook
The ESI settlement and the CAA of 2026 are changing rebates while the industry quietly admits the incumbent affordability tools don't sustainably change patient behavior. The next affordability playbook is not a bigger discount. It is a discount that knows its recipient before it is used.
Click here to learn more about Sempre Health's patient affordability programs.
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