Hubs East 2025: How Various Programs Affect Patient Care and Health Equity

In a video interview with Pharma Commerce, Kimberly Westrich, MD, chief strategy offer at the National Pharmaceutical Council, describes how in response to rising healthcare costs, employers have turned to high-deductible health plans and higher out-of-pocket (OOP) expenses, causing patients to pay more for healthcare. To help alleviate this financial burden, manufacturers offer copay assistance programs, which are aimed at improving medication adherence and preventing disease progression. However, insurers have introduced cost-shifting programs such as copay accumulators, maximizers, and alternative funding programs (AFPs) to manage these costs.

Copay accumulators redirect the value of copay assistance to the insurance plan instead of counting it toward the patient's OOP max or deductible. This means that patients face surprise copay costs once the copay assistance runs out, essentially "double dipping" as the plan captures the benefit without applying it to the patient's financial responsibility.

Copay maximizers also shift assistance from the patient to the plan but manipulate the patient's copay to extract the maximum benefit from the copay assistance. While the copay assistance helps with a specific medication, it doesn't count toward the patient's deductible or OOP max for other expenses, leaving the patient responsible for other costs.

Alternative funding programs (AFPs) are more complex. In these programs, certain specialty medications are removed from insurance coverage, and patients must enroll in an AFP. They work with a third-party vendor to obtain the medication, often through manufacturer assistance, charity programs, or international pharmacies. While the AFP may provide the medication, it can be a slow and confusing process, and patients may not qualify, leaving them to pay out of pocket or forgo the medication. These cost-shifting strategies aim to manage healthcare expenses but can create additional financial and logistical challenges for patients.

Westrich also comments on how these accumulators, maximizers, and alternative AFPs are impacting patients, manufacturers, and healthcare ecosystems; sessions that have caught her eye; and much more.

A transcript of her conversation with PC can be found below.

PC: How are these accumulators, maximizers, and alternative funding programs impacting patients, manufacturers, and healthcare ecosystems, and how does this all tie into your presentation that you participated in?

Westrich: These are having real impacts on patients, on employers, on the healthcare ecosystem. If we look at patients in particular, they are experiencing unexpected costs. They are experiencing negative health impacts when it comes to adherence and persistency concerns.

First of all, there's a huge lack of transparency surrounding these programs. Patients often do not even know that they're in one of these programs. They will be going to the pharmacy counter, and they will either get, in the case of an AFP, a surprise denial that they've got to navigate. With accumulators or maximizers, more often, they're getting their product covered, and all of a sudden, surprise, you have this financial obligation. And then what happens for many patients? There might be an adherence problem. They might not be able to afford their medication. They're confused. They're trying to navigate it. In a survey of patients who are enrolled in AFPs, they reported that there was a two-month delay in getting their medication, and during that two-month period, a quarter of those patients experienced worsening of their condition, disease progression. So that's real hardship that is occurring from these programs.

Another consideration that a lot of people aren't really thinking about is the impact on health equity. These programs have the potential to exacerbate already existing health inequities. Research has shown that non-white patients are more likely to be enrolled in a copay accumulator program than white patients, and these programs are often targeting specialty medications that are intended for chronic conditions that are very serious, and you're having situations where vulnerable populations are experiencing disruption in care, which then has ripple effects on their health.

Maybe they end up going to the hospital, and then there's costs elsewhere. So these programs are in a situation where they can be exacerbating the health inequities that are already existing in our program that we would really like to be focusing on and improving, and given the potential for the harm that these programs can bring to patients. one of the things that we also explored in our session is, what can you do if you've got a problem, you don't want to just talk about the problem, you want to bring some potential solutions to the problem.

There are several things that are being done at the policy level, and I'll talk about what's happening at the federal level and what's happening at the state level. We published a primer in Health Affairs Forefront earlier this week that looks at copay accumulators and maximizers, and goes into this more deeply than I'm about to here. I'm going oversimplify what's happening at the federal level and then at the state level. All of these programs are centering around not letting the copay assistance that comes from the manufacturer count towards the patient's out of pocket costs.