Massachusetts Study Highlights Co-Pay Assistance as Positively Impacting Patient Access & Adherence

On July 6, 2020, the Massachusetts Health Policy Commission released its study examining the use and impact of prescription drug coupons in Massachusetts. This study was required as part of the extension to the Massachusetts law permitting manufacturer drug coupons (co-pay assistance offers) or vouchers to reduce patients’ cost-sharing obligation that was previously due to expire at the end of 2019. The purpose of the study was to evaluate the effect of drug coupons and product vouchers for prescription drugs on pharmaceutical spending and health care costs in Massachusetts to aid in determining future legislative positions on manufacturer cost-sharing support.

The report is very comprehensive and evaluates the impact of coupons and vouchers in the context of several considerations including patient access, affordability, overall healthcare spending, medication adherence, and health outcomes. Below are some notable ideas expressed in the report.

Eliminating coupons would likely be detrimental to patients

The report makes several well-supported points on both sides of the coupon issue and cites data that shows their use does, in some cases, contribute to increased drug spending. Several data points also illustrate their criticality in enabling patients to access much-needed therapies that do not have generic alternatives. These same therapies would be cost-prohibitive without manufacturer co-pay assistance. However, the report concludes that coupons are a critical tool that enables patients to afford medications, stating:

“Eliminating the availability of coupons at this time – without substantial protections for patient affordability – would likely create serious challenges for many patients in the Commonwealth. (p.25)”

Coupons increase adherence, which can decrease long-term healthcare spending and drive better health outcomes

The report makes several points regarding the impact manufacturer coupons have on medication adherence, and the corresponding positive health outcomes that result from patients remaining adherent to therapy:

“Coupons may also help patients initiate or continue a clinically necessary therapy that otherwise would be cost-prohibitive, resulting in higher adherence to needed medications. While higher adherence would increase prescription drug spending, this increased drug spending may be potentially offset by lower spending on other medical services and improved patient health.” (p.2)

“Research indicates that increasing medication adherence has the potential to reduce emergency department visits,17 hospitalizations, 18 and overall health care costs for patients managing chronic conditions.19, 20, 21 Prohibitive out-of-pocket drug costs are one factor contributing to poor medication adherence,22 and the relationship between patient drug cost and adherence is well documented in the literature.23, 24, 25, 26, 27, 28, 29, 30” (p.14)

“…studies suggest that coupons may have larger effects on adherence for higher-cost drugs. Using a large sample of specialty prescriptions, a 2014 Health Affairs study by Starner et al. found that drug coupons were associated with 44.3% of these prescriptions in 2013 and saved patients an average of $1,069 per year, reducing the proportion of prescriptions for which patient cost-sharing was more than the key threshold for abandonment of $250 from 12% to 1%.37” (p.15)

Co-pay accumulators and maximizers present additional challenges

The report also explored the impact of copay accumulators and maximizers. It cited data around the increased prevalence of each in recent years and noted that these benefit designs effectively restore the affordability hurdles for patients that coupon programs are designed to help overcome. Another notable statement in the report is that the complexity of accumulators may cause them to not be effective in steering patients to lower-cost generic medications, which the Centers for Medicare and Medicaid Services (CMS) outlines in the Notice of Benefit and Payment Parameters Rule as a key reason for granting health plans the flexibility to implement them in benefit designs.

Due to the complexity of copay accumulator programs, they are unlikely to encourage patients to use lower-cost alternatives. Copay accumulators shift costs from the payer to the manufacturer and patient, potentially resulting in lower premiums. However, copay accumulators may preserve the affordability challenges that patients originally faced in their plan design, which could lead to lower access and adherence. (p.24)

“However, some legal analysts question the legality of copay accumulator programs: depending on the specific design, these programs could implicate privacy rules under the Health Insurance Portability and Accountability Act (HIPPA), consumer protection laws, and nondiscrimination rules under state laws.54” (p.24)

While it remains to be seen how the Massachusetts legislature will ultimately react to this report in determining the future of manufacturer coupon use, the report makes a strong statement recognizing their importance in the healthcare economic system. Its timing is even more significant given a recent proposal by CMS that, if implemented, would require manufacturers to include the value of copay assistance offers in best price calculations. This would be necessary if they are unable to ensure the benefit of the offer goes solely to patients and not health plans, as in accumulator scenarios. Many patient advocacy groups are cautioning that if such a requirement were adopted, it could make several specialty drug co-pay programs financially untenable for manufacturers. The potential discontinuation could render patients unable to access much-needed and in many cases life-sustaining, therapies that do not have lower-cost generic alternatives.

Mercalis (formerly TrialCard) is actively engaged in these topics and prepared to offer alternative solutions to pharmaceutical manufacturers. Our programs ensure that patients can access and afford specialty therapies regardless of the outcomes of multiple pending legislative matters that could impact copay assistance programs.

For more information about co-pay accumulator programs, please visit our co-pay accumulator resources. To speak with a member of our team, please contact sales@mercalis.com.

Jason Zemcik, Sr. Director, Product Management at Mercalis (formerly TrialCard)