Inequities in exposure to copay accumulator programs – Healthcare Economist

Copay cards are somewhat controversial. These cards or coupons are used to help patients pay the co-pays and deductibles they are required to pay when using pharmaceuticals. On the one hand, these programs are very beneficial for patients. Out-of-pocket costs for patients have increased dramatically in recent years, even among the insured. For example, whereas in 2009 only 7% of workers had a deductible of $2,000 or more, now 32% have a deductible just as high. Additionally, nearly half of small business workers have a deductible of $2,000 or more. On the other hand, payers claim that copay cards increase healthcare costs by increasing the use of pharmaceuticals due to moral hazard.

https://www.kff.org/report-section/ehbs-2022-summary-of-findings/attachment/figure-f-33/

To address the problem, payers have begun to implement the Copayment Adjustment Program (CAP), as
copay accumulators and copay maximizers.

In accumulator programs, payments made with copay cards do not count toward patient deductibles or OOP. [out-of-pocket] cost maximums. Therefore, these programs can increase the total cost-sharing burden of patients and potentially result in unexpected and substantial mid-year expenses.

In maximizer programs, the total annual benefit is allowed to increase up to the maximum amount that a manufacturer is willing to reimburse patients for their copay expense. This amount is distributed throughout the patient’s benefit year to match the use of these available funds. These maximizer programs do not yet count toward a patient’s deductible or maximum out-of-pocket cost within a given year and may delay a patient’s ability to reach this benefit threshold, leaving the patient exposed to additional costs related to other medicines or diseases.

An important question is whether (i) copay card use varies by racial and ethnic group and (ii) whether CAP programs vary by racial and ethnic group. This is exactly the research question. Ingham et al. (2023) aim to answer. The authors use 2019-2021 data from IQVIA Longitudinal Access and Adjudication Data (LAAD) compared 1:1 with consumer data from Experian Marketing Solutions, LLC. The first is a claims data source, the second is a consumer data source. Using these data files, the authors find that:

…there were no significant differences in copayment card use between non-white and white patients (odds ratio [OR] =0.995; 95% CI = 0.99-1.00; P = 0.0964). However, among copay card users, non-white patients were significantly more likely to be exposed to CAPs, either as maximizers (OR = 1.27, 95% CI = 1.22-1.33; P < 0.0001) or accumulators (OR = 1.31, 95% CI = 1.26-1.36; P < 0.0001), compared with white patients.

In other words, non-white patients are approximately 30% more likely to be exposed to a CAP program than whites. The full article is available. here.

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