By Karen Blum
GRAPEVINE, Texas—Over the past few years, some employers have opted to lower their healthcare spending on high-cost medications by removing those drugs from the formulary and forcing beneficiaries to apply for charitable care to cover drug costs and copays. It’s a trend that puts people who are truly needy and rely on charitable care at risk for not having their medications covered if funds run out, adds to patient stress levels, and leads to fragmented medication records, among other concerns cited by an expert panel during the NASP 2023 Annual Meeting & Expo.
Patient affordability needs have given rise to several types of financial assistance organizations to cover high-cost medications, said Michael Einodshofer, RPh, MBA, the chief pharmacy officer for Optum Rx, a pharmacy benefits manager. Remedies include copay assistance and copay cards from pharmaceutical manufacturers for insured patients who need help covering out-of-pocket costs, which apply to everyone regardless of income, and patient assistance programs (PAPs) run by both manufacturers and independent charities and foundations. The PAPs offer free drug programs for uninsured or underinsured patients, and financial assistance to help with related costs. Eligibility is generally based on income and drug costs.
Alternative funding programs, in contrast, sell a service that makes otherwise insured members appear to lack coverage for certain high-cost drugs, Mr. Einodshofer said. The vendors operating the programs then help members seek “free” medications from PAP programs that were established to help underinsured and uninsured patients. Optum Rx does not allow alternative funding, he said.
“If you’re an employer, you’re putting yourself at risk in a lot of different ways and you’re putting your employees in harm’s way if you say yes to these programs,” Mr. Einodshofer said. The organizations tend to lack transparency, not listing their corporate addresses or executives on their websites.
Here’s how the strategy works: A specialty claim carveout or exclusion is put in place, removing certain products from the health plan’s formulary. The patient then receives a denied claim for their prescription and is rendered uninsured. To get their medication, they are required to enroll in a PAP, a process that could take two to four weeks. Such programs undermine the intent of PAPs and divert assistance away from patients in need, Mr. Einodshofer said.
Over the past five years, both the number of employers using alternative funding programs and the number of organizations pitching them has grown. In a 2022 survey from the Pharmaceutical Strategies Group, some 12% of plan sponsors said they currently use an alternate funding program and many others are considering them, Mr. Einodshofer noted.
Alternative funding models may pose significant risks to individual patient access and the health system, said Mr. Einodshofer and co-panelists Corey Belken, PharmD, a national account manager for Genentech, and John Michael O’Brien, PharmD, MPH, the president and CEO of the National Pharmaceutical Council, a health policy research organization. Disadvantages include the following:
• They may interfere with patients receiving timely treatment since delays in care could lead to disease progression or a decline in health status.
• Patients with complex health needs may not have access to the right level of specialty support through the alternative funding vendor.
• There could be safety risks if third-party vendors are sourcing medications from unlicensed overseas pharmacies.
• Patients may be burdened with undue stress during this process.
• Funding sources such as PAPs and charity organizations may close if they become overburdened.
• Use of third-party alternative funding vendors may add complexity and risk to the patient access process, including the potential for inappropriate handling of protected health information.
The speakers reported no relevant financial disclosures other than their stated employment.
