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The American Journal of Managed Care July 2019
Changing Demographics Among Populations Prescribed HCV Treatment, 2013-2017
Naoky Tsai, MD; Bruce Bacon, MD; Michael Curry, MD; Steven L. Flamm, MD; Scott Milligan, PhD; Nicole Wick, AS; Zobair Younossi, MD; and Nezam Afdhal, MD
Precision Medicines Need Precision Patient Assistance Programs
A. Mark Fendrick, MD; and Jason D. Buxbaum, MHSA
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Robert W. Dubois, MD, PhD
Real-Time Video Detection of Falls in Dementia Care Facility and Reduced Emergency Care
Glen L. Xiong, MD; Eleonore Bayen, MD, PhD; Shirley Nickels, BS; Raghav Subramaniam, MS, BS; Pulkit Agrawal, PhD; Julien Jacquemot, MSc, BSc; Alexandre M. Bayen, PhD; Bruce Miller, MD; and George Netscher, MS, BS
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Impact of a Co-pay Accumulator Adjustment Program on Specialty Drug Adherence
Bruce W. Sherman, MD; Andrew J. Epstein, PhD; Brian Meissner, PharmD, PhD; and Manish Mittal, PhD
Medicare’s Bundled Payment Model Did Not Change Skilled Nursing Facility Discharge Patterns
Jane M. Zhu, MD, MPP; Amol Navathe, MD, PhD; Yihao Yuan, MSc; Sarah Dykstra, BA; and Rachel M. Werner, MD, PhD
Number of Manufacturers and Generic Drug Pricing From 2005 to 2017
Inmaculada Hernandez, PharmD, PhD; Chester B. Good, MD, MPH; Walid F. Gellad, MD, MPH; Natasha Parekh, MD, MS; Meiqi He, MS; and William H. Shrank, MD, MSHS
Insurers’ Perspectives on MA Value-Based Insurance Design Model
Dmitry Khodyakov, PhD; Christine Buttorff, PhD; Kathryn Bouskill, PhD; Courtney Armstrong, MPH; Sai Ma, PhD; Erin Audrey Taylor, PhD; and Christine Eibner, PhD
Healthcare Network Analysis of Patients With Diabetes and Their Physicians
James Davis, PhD; Eunjung Lim, PhD; Deborah A. Taira, ScD; and John Chen, PhD
What Are the Potential Savings From Steering Patients to Lower-Priced Providers? A Static Analysis
Sunita M. Desai, PhD; Laura A. Hatfield, PhD; Andrew L. Hicks, MS; Michael E. Chernew, PhD; Ateev Mehrotra, MD, MPH; and Anna D. Sinaiko, PhD, MPP
Physician Satisfaction With Health Plans: Results From a National Survey
Natasha Parekh, MD, MS; Sheryl Savage; Amy Helwig, MD, MS; Patrick Alger, BS; Ilinca D. Metes, BS; Sandra McAnallen, MA, BSN; and William H. Shrank, MD, MSHS
Evaluation of Interdisciplinary Geriatric Transitions of Care on Readmission Rates
Nada M. Farhat, PharmD; Sarah E. Vordenberg, PharmD, MPH; Vincent D. Marshall, MS; Theodore T. Suh, MD, PhD, MHS; and Tami L. Remington, PharmD

Impact of a Co-pay Accumulator Adjustment Program on Specialty Drug Adherence

Bruce W. Sherman, MD; Andrew J. Epstein, PhD; Brian Meissner, PharmD, PhD; and Manish Mittal, PhD
Commercial health plan initiation of a co-pay accumulator adjustment program for specialty medications treating autoimmune diseases was associated with significant reductions in medication adherence and persistence.

Objectives: To assess the impact of a co-pay accumulator adjustment program (CAAP) on usage patterns of autoimmune specialty drugs, comparing health savings account (HSA) or preferred provider organization (PPO) plan enrollees before and after implementation of the CAAP.

Study Design: Retrospective cohort analysis.

Methods: Data on HSA and PPO patients with autoimmune specialty drug use were drawn from the Conduent pharmacy benefit manager for January 2016 to October 2017 from 15 self-insured employers initiating a CAAP in January 2017. Outcomes included monthly mean fills per person, therapy discontinuation, and proportion of days covered (PDC). Linear regressions, Kaplan-Meier survival curves, and Cox proportional hazards models assessed differences while adjusting for patient characteristics.

Results: There were 365 HSA and 238 PPO patients. After the CAAP implementation, for HSA versus PPO patients, adjusted trends in monthly fills per person decreased more rapidly, the risk of treatment discontinuation was significantly higher, and PDC was significantly lower. Prior to the CAAP, these metrics were not statistically different between groups except in 1 case. To help place the post-CAAP adjusted differences in trends in context, by the end of October 2017, 10 months after the CAAP start, HSA patients had 233 fewer autoimmune drug fills per 1000 patients, 20 percentage points higher treatment discontinuation, and 12 percentage points lower PDC.

Conclusions: After the CAAP, HSA patients on autoimmune drugs had significantly lower monthly fill rates, higher risk of discontinuation, and lower PDC than did PPO patients, suggesting that CAAPs have the potential to negatively affect specialty drug use.

Am J Manag Care. 2019;25(7):335-340
Takeaway Points

Pharmacy benefit managers are offering co-pay accumulator adjustment programs (CAAPs) to counter pharmaceutical company co-pay assistance subsidies for enrollees receiving specialty medications, although the impact of these programs on medication adherence is unknown.
  • In this analysis, implementation of a CAAP was associated with significant reductions in autoimmune specialty drug adherence.
  • Risk of treatment discontinuation was significantly higher following CAAP implementation.
  • Use of specialty drugs included on the preventive drug list, which eliminates co-payments, was not affected by the CAAP.
  • Further analysis is needed to evaluate the implications for subsequent healthcare utilization and costs.
Employers are concerned about the rapid growth of specialty pharmaceutical (SpRx) expenditures. In a 2018 survey of large employers, 80% identified SpRx costs as a top 3 driver of healthcare costs, and 26% said it was their greatest healthcare cost driver, up substantially from 6% in 2014.1

Employers have acted to constrain SpRx expenditures. Those offering high-deductible health plans (HDHPs) have combined medical and pharmacy plan deductibles into one, thereby shifting initial payment for prescriptions to enrollees until they reach the deductible limit.2 Some employers have added pharmacy benefit management features, including utilization management, use of a SpRx vendor, and the addition of a SpRx tier in formularies.1 Others have excluded many SpRx products from medical plan coverage, thereby shifting greater oversight of SpRx use to pharmacy benefits.3

For enrollees, the financial implications of these cost-sharing tactics may be significant, particularly for lower-wage earners.4 Combined with premiums, out-of-pocket (OOP) costs for healthcare may represent one-fifth or more of an employee’s wages,4 forcing enrollees to make challenging resource allocation decisions between medical care and other basic needs.

Pharmaceutical manufacturers have sought to improve patients’ access to treatment by reducing their OOP costs via co-pay assistance cards, which have become widespread among branded therapies. Nearly 70% of the 132 highest-spend branded drugs in 2014 offered co-pay assistance cards.5 Employers are concerned that by lowering OOP costs with co-pay assistance cards, enrollees may increase medication use and associated expenditures,6,7 despite formulary design and step edits.

Until recently, co-pay assistance funds counted toward the overall patient payment for medications because no accounting process existed to distinguish patient OOP payments from manufacturer subsidies. With co-pay assistance cards, HDHP enrollees could reach their deductible limit after only nominal OOP expenditure, resulting in more patients reaching their deductible thresholds sooner and exacerbating employers’ concerns around increasing medical spending.

To mitigate this issue, pharmacy benefit managers (PBMs) have started co-pay accumulator adjustment programs (CAAPs), which ensure that any pharmaceutical manufacturer subsidy toward patients’ OOP medication cost is not credited toward their deductible. Under a CAAP, HDHP enrollees may experience an abrupt spike in OOP medication costs during treatment when manufacturer subsidy limits are reached but before patients have reached their deductible. This potentially unanticipated OOP expense may lower medication adherence and persistence. To date, however, no studies have examined this issue empirically.

Even without outcomes data, CAAPs have become popular among employers. In a recent survey of large employers, nearly 30% implemented a CAAP for 2019 and 21% were contemplating one for 2020 or 2021.1 In another recent employer survey, 54% of respondents did not credit third-party co-pay assistance toward patient deductibles.8

We sought to assess the impact of a CAAP on autoimmune SpRx use in a commercially insured population. Autoimmune drugs provide a salient setting for CAAPs, as there are multiple branded drugs with high patient co-pays. Roughly 2% of the US adult population have either gastrointestinal or arthritis-related autoimmune disorders possibly treated with SpRx.9,10 The large number of affected individuals and the chronicity of autoimmune illness generate a sizable study population. In contrast, SpRx treatments for other conditions have therapeutic or benefit design attributes limiting the relevance of adherence. For example, adherence rates for HIV medications among employed individuals are typically high.11 SpRx for multiple sclerosis (MS) may be included on PBMs’ preventive drug lists and thus not subject to the deductible. Other SpRx (eg, for hepatitis C virus or cancer) have brief or unpredictable courses.

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