![]() In response, accumulator programs entered the arena. If patients on high-cost drug therapy know they are not assuming that financial risk because of being able to use PAP money to eliminate their deductible, one could argue that the system is being gamed to some extent. High-deductible plans often offer beneficiaries a lower contribution option by taking on some financial risk. Understandably, employers and payers do not appreciate that PAP dollars are being used by patients to pay down their deductible and maximum out-of-pocket expense while the plan experiences escalating pharmacy benefit costs because of these expensive agents. Things started getting ugly when “accumulators” and now “maximizers” entered the fray. That is the bad part of PAPs, but the reality is, you need to participate or you are subsidizing someone else’s drug costs. On a macro level, the use of PAP programs has the effect of increasing the cost of care for all. ![]() Given that the cost of PAPs is baked in, it is also a cost-shifting or subsidy strategy, where the expense of high-cost drugs is shared across all commercially insured beneficiaries. The intent is to promote newer, higher-cost treatment options. PAPs were primarily introduced to nullify the impact of benefit design on patient financial risk and assure providers that high-cost treatments will not be financially harmful to patients. Although the true success of these benefit design strategies is controversial, with some evidence that they may have detrimental effects on patient care and outcomes, they are intended to attempt to bend the curve on escalating costs of care. Through tiered co-pay and deductible structures, they are attempting to ensure that patients have inancifal skin in the game. For many years, employers, payers, and pharmacy benefit managers (PBMs) have been developing benefit designs to incentivize patients and providers to make cost-effective treatment decisions. So, what could be bad about PAPs? First, it is important to recognize that the funding of PAPs is a business strategy, a budgeted operating cost, and is essentially “baked in” to the overall pricing of pharmaceuticals. Of course, the exclusion of governmental insurance plans is unfortunate because these patients are often the ones in greatest need of financial assistance. In fact, to not participate in a PAP can be interpreted as overpaying for a drug, somewhat like paying the list price for a new car. Therefore, at the micro level, this is a good thing.Īccess to high-cost medications is increased, health care providers are insulated to some extent from unpaid bills, and patients reduce their out-of-pocket costs. At my organization, we have a new job category called medication access specialists, who, among other things, are responsible for connecting patients to PAPs and helping families and patients navigate the sometimes confusing process. This is also potentially beneficial for the institution because it reduces bad debt. ![]() Many health care systems have gone so far as to develop organized programs to connect patients with PAPs as a means of enhancing access to medications and reducing their financial burden. We are all familiar with the patient assistance programs (PAPs) primarily sponsored by drug manufacturers or a partner organization and generally consider them a good thing for assisting patients with high out-of-pocket costs for expensive specialty drugs, especially in this era of high-deductible insurance plans. ![]()
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