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Drug Affordability Challenges in the “Patient as Payer” Era
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Key Takeaways
- Prescription costs and coverage hurdles are increasing, leading patients to act as their own payers in a fragmented system.
- Despite $5 billion annual investment in patient assistance programs, less than 10% of eligible patients access them.
Experts urge for technology-driven, collaborative solutions as patients shoulder a growing burden of prescription costs.
As prescription costs continue to rise and coverage hurdles act as barriers, more Americans are finding themselves acting as their own payers in a complex and costly “patient-as-payer” health care system, according to a panel of experts at Asembia’s AXS25 Summit.1
The presenters called for coordinated, tech-enabled solutions to improve affordability and access and take advantage of underused patient assistance programs.
In the past 3 years alone, formulary exclusions have jumped 37%, out-of-pocket costs have surged, with 40% of prescriptions now costing patients $250 or more per fill, while the use of utilization management has risen 45%, explained panel moderator Dorothy Gemmell, chief commercial officer and president, GoodRx. Despite pharmaceutical companies investing $5 billion annually in patient assistance programs, fewer than 10% of eligible patients access them. With 9 in 10 brand-name prescriptions facing delays, switches, or denials at the pharmacy counter, it is crucial to explore how manufacturers, payers, and policy makers can better support patients in affording the medications they need.
“We know that the industry spends a lot of money and time trying to do the right thing, spending money on direct-to-consumer advertising [and] propositions on how to appropriately prescribe medications, but there's a big problem in affordability and at the counter as well,” said Gemmell.
Current State and Trends in Patient Affordability
The panelists highlighted the urgent need to redesign affordability solutions around the realities patients face at the pharmacy counter. As prescription costs continue to rise and coverage restrictions tighten, too many patients are left navigating a fragmented system with little support.
The health care system is built around access restrictions and margin extraction, favoring high-list, high-rebate products that ultimately harm patients, noted John O’Brien, PharmD, MPH, president and CEO, National Pharmaceutical Council. Instead, patients should be treated more like consumers with a seamless, 1-click experience similar to digital retail platforms, though this is complicated by the fragmented nature of health care, added Jennifer Norton, senior vice president of patient and market access, Takeda Pharmaceuticals. Moreover, about 50% of patients who discontinue therapy are not enrolled in co-pay programs, and many avoid filling prescriptions altogether due to cost concerns, added John Daly, head of North America patient support services, Sanofi. Therefore, helping patients gain and maintain access to medications requires an integrated, cross-functional approach that addresses affordability at every stage, according to Helmuth Fendel, vice president of market access account management and trade, AbbVie.
The panelists agreed that despite pharmaceutical companies investing billions in patient assistance programs, only a small percentage of eligible patients benefit, highlighting a critical need for more accessible and effective affordability solutions.
“I look around the room, I see so many colleagues I've worked with for decades, that have worked so hard so a patient wouldn't have to be the payer or think of themselves as the payer,” said Daly. “We know the greatest obstacle to patients starting on therapy and staying on therapy is out of pocket costs.”
Specialty Medications and Innovations
Specialty medications are becoming an increasingly critical, yet complex part of patient care, presenting unique challenges in affordability and access that demand innovative solutions, acknowledged the panelists. There also exists an emotional and financial burden on patients who are effectively becoming their own payers, making it vital to create solutions that span multiple channels and sources of information, noted Daly. Viewing the issue through a consumer lens, Norton emphasized the need to create a more seamless experience for patients, and stressed the importance of being able to anticipate and close gaps in care before they arise. Additionally, gaining access to specialty therapies, by advocating for a cross-functional, integrated approach to help patients afford and stay on their prescribed treatments, is crucial.
“I would like to see more of a focus on patient out-of-pocket cost when we start to think about how new drugs go to market, and if we can combine that with the value to the patient or the value to the purchaser, I think we'd be in a much better place,” said O’Brien.
In an interview with The American Journal of Managed Care® (AJMC®), O'Brien mentioned that there are also “a number of unanswered questions about whether or not patients will benefit from the Inflation Reduction Act’s effectuation at the pharmacy counter.”2 He also called on policy makers to reform the pharmacy benefit manager system and the 340B program.
The panelists agreed that addressing these challenges requires multiple solutions, including technology-driven support, multiple stakeholder collaboration, simplified patient experiences, and integrated workflows for providers, which ultimately should be centered around improving the patient journey.1
Patient Support Services and Technology
Patient support services are also needing to evolve to meet the demands of a more complex and costly health care environment, with panelists emphasizing the critical role of technology in bridging access and affordability gaps.
Simplifying hub enrollment and consent processes, particularly for office staff, is needed to create a seamless experience, emphasized Norton.
“We need to think of our partners across the ecosystem as an extension of ourselves, [as] true partners, and really figure out how we can create this seamless experience for the patient,” said Norton. “I feel like we're moving in the right direction across the ecosystem; that's a new emerging area that I see.”
Looking ahead, the panelists were optimistic about using artificial intelligence and other technologies to make patient support services more transparent, accessible, and tailored to individual needs, so that patients can receive the prescriptions they rely on, without having to bear such a costly burden.
“The whole reason we're in this room is we have patients who need our help,” said Fendel. “Our companies develop very strong and incredible, innovative medicines. We have great medicines in the market.”
References
1. Gemmell D, O’Brien J, Norton J, et al. How the ‘patient-as-payer’ era is transforming patient access & affordability. Presented at: AXS25; April 29, 2025; Las Vegas, NV.
2. Bonavitacola J, Mattina C, O'Brien JM. Trump administration should focus on fixing IRA, 340B: John M. O’Brien, PharmD, MPH. AJMC. April 30, 2025. Accessed May 1, 2025. https://www.ajmc.com/view/trump-administration-should-focus-on-fixing-ira-340b-john-m-o-brien-pharmd-mph
