Copay adjustment programs may worsen racial disparities in health outcomes

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Non-white patients who used copay cards were significantly more likely to encounter copay adjustment programs, such copay accumulators and maximizers, compared with their White counterparts.

The affordability of prescription medications remains a critical concern for patients across the United States. A recent study sheds light on the implications of copay adjustment programs and how they may affect different racial groups. The research, published in the Journal of Managed Care + Specialty Pharmacy, suggests there are potential disparities in access to vital medications, highlighting an unintended consequence of these programs.

Over the past five years, patients have faced a significant increase in cost sharing for prescription medications. These escalating out-of-pocket costs have been linked to poor medication adherence and thus can exacerbate existing health disparities. In response to this growing issue, patient assistance programs, often in the form of copay cards, have been introduced to help offset the financial burden by reducing patients' out-of-pocket expenses. Previous studies have demonstrated that these programs effectively improve medication adherence and clinical outcomes.

However, many pharmacy benefit managers (PBMs) and insurers have recently introduced copay adjustment programs (CAPs), which alter the impact of copay assistance. There are generally two types of CAPs: copay accumulators and maximizers. With accumulators, the money from copay cards does not count toward patients’ annual deductible or out-of-pocket limit, which can lead to patients’ out-of-pocket costs jumping up later in the year, often unexpectedly.

With maximizers, the copay assistance is evenly spread over the year but still doesn't count toward the deductible or out-of-pocket limit and accordingly delays a patient’s ability to reach these benefit thresholds. Generally, after patients reach these thresholds, their out-of-pocket costs will be reduced.

The new research, conducted as a retrospective, cross-sectional study, examined the utilization of copay assistance and CAP exposure within a commercially insured patient population. The study analyzed data from a sample of more than 4 million patients, representing about 5.6% of the total database population. The study included people under the age of 65 years who were covered by commercial insurance and had at least one pharmacy claim in certain therapeutic areas between Jan. 1, 2019, and Sept. 30, 2021.

One key finding of the study was that there were no statistically significant differences in copay card use between non-white patients and white patients. However, when looking specifically at copay card users, non-white patients who used copay cards were significantly more likely to encounter copay adjustment programs compared with their white counterparts. Non-white patients had a higher likelihood of being exposed to maximizer programs, with an odds ratio of 1.27. Similarly, non-white patients had a higher likelihood of being exposed to accumulator programs, with an odds ratio of 1.31.

“Health care disparities are well described, leading to disproportionately worse clinical outcomes in underserved communities, such as Black and Brown patient populations. Our finding that the use of copay cards did not differ by patients' race and ethnicity was a pleasant surprise,” said study author A. Mark Fendrick, M.D., director of the University of Michigan Center for Value-Based Insurance Design. “However, the fact that non-White patients were more likely than White patients to be included in a copay adjustment program is worrisome, in that the loss of financial assistance may lead to reduced access to essential medications, potentially resulting in diminished clinical patient-centered outcomes and worsening of health care disparities.”

The study’s findings may have significant implications for managed care organizations and payers. As the cost of prescription medications continues to rise, the role of copay assistance programs becomes increasingly important in ensuring patients’ access to treatments. While these programs have the potential to mitigate financial barriers, the emergence of CAPs introduces new challenges. Given the unintended consequence of CAPs and their possibility of exacerbating health care disparities, the study authors suggest that payers may need to reconsider using these programs. It is crucial to ensure fair access to health care resources.