Patient-forward copay solutions: Three considerations for building effective support

A patient's financial health can be one of the most significant barriers to accessing therapy. In fact, 72% of Americans report being "financially unhealthy." And often, the fear of the surprise bill and significant financial obligations of healthcare cause patients to forego treatment rather than risk an unmanageable cost.

Breaking down these barriers with copay support solutions is an effective way manufacturers can assist patients. But where do you begin? How do you design a copay solution that accounts for the changing landscape and, most of all, works for patients and your program? Here's what to keep in mind as you look for the copay solution to best fit your — and most importantly, your patients' — specific needs.

1. Affordability is evolving

Traditional pharmacy copay has been a well-established standard in the industry to date and has been primarily focused on managing the eligibility and value of each transaction. While familiar to manufacturers and industry stakeholders, traditional copay solutions like discount coupons may also be more vulnerable to threats like accumulator and maximizer programs. They may not be able to support changing market conditions like value-based plans, risk-sharing models, and other emerging payer and PBM strategies.

"We believe there needs to be a financial service offering that provides more than just a coupon," says Bob Raffo, President at FirstView Financial,* a healthcare fintech with expertise in enabling programs that address prescription abandonment issues in the pharmaceutical industry. "Comprehensive financial services help provide a holistic view of a patient's financial wellness."

Compared to traditional copay, newly designed solutions with integrated financial services are positioned to better help patients manage their healthcare costs. New copay solutions can also help optimize the patient experience and are highly adaptable to market requirements and changes. They can also capture more complete data earlier in the patient journey. In turn, this approach helps avoid threats like accumulators and maximizers.

Many manufacturers are already noticing this evolution in the market. They are looking to find the best copay solution for their program, which could mean transitioning from traditional point-of-sale coupons to full patient financial services solutions.

2. Manufacturers must prepare for accumulators and maximizers

Since accumulators and maximizers were first introduced in 2018, the industry has seen swift adoption of these programs by PBMs, with an estimated 60% of plans including a copay accumulator program in 2020. These programs reduce the overall financial impact and value of copay assistance to the patient and, instead, redirect a large portion of the benefit to the PBM itself.

The CMS Final Rule may make copay accumulators and maximizers even more complicated. The rule is scheduled to go into effect on January 1, 2023, and states that manufacturers must ensure the full benefit of their copay assistance goes to the patient. Because accumulator policies prevent the funds provided by a manufacturer from being applied to the patient's out-of-pocket cost and/or deductible, the coupon's full value is not realized by the patient under these plan policies. This means that copay accumulator programs result in manufacturer funds being more akin to a discount to the PBM's drug purchase price and must, therefore, be considered in the manufacturer's Medicaid best price calculation.

Manufacturers with pharmacy adjudicated products are currently challenged with actively reviewing present-day copay program structures and analyzing the financial impacts of including copay assistance in their Medicaid best price calculations. "We are rethinking copay program designs to ensure the financial assistance provided by the manufacturer is directed to the patient and is not 'caught up' in accumulator policy calculation," says Colleen Cummins, Lash Group Product Director. "To best ensure that the copay full benefit is going to the patient today, Lash Group offers an end-to-end, turnkey solution for our copay services."

3. Patients want simplicity

At the end of the day, simpler isn't just better — it's best. To gain access to specialty medications, patients may be navigating multiple barriers to care, including high out-of-pocket costs. As a result, patients may abandon critical medications at the pharmacy if they cannot cover their deductible. That's where patient support services can help. Patient support services are designed to speed access to therapy and help patients stay on therapy by supporting them through an often complex and challenging journey.

Traditional patient support services need to continue to evolve. An essential blend of technology and automation with human intervention is important to provide empathetic support when patients need it most.

From growing industry demand for end-to-end automation of foundational tasks to the fundamental need to meet patients where they are, patient support providers like Lash Group have been leading the way with new digital automation-focused strategies that help to simplify the process for patients. "Lash Group is the pioneer of the patient services industry," says Tommy Bramley, Lash Group President. "It is fitting that we lead the market again and cast the vision for the hub of the future. Digital automation and simple, accessible approaches for patients will be the foundation for that."

*“FirstView Financial" is the trade name of Firstview, LLC (a Delaware limited liability company)