Middlemen Threaten Patient Access With Accumulator Adjustment Programs

Navigating our complex health care system with a chronic or rare illness can be a daunting task for patients — full of bureaucratic barriers and a web of intersecting costs. It’s estimated that 191 million people live with at least one chronic disease, and 75 million live with two or more. The prevalence of chronic disease increases as an individual ages, and consequently, out-of-pocket health care costs also go up.

Aging individuals need all the help they can get. Most can’t afford to pay thousands of dollars at the pharmacy counter, or even a $50 co-pay for a doctor’s visit, prescription medicine or tests. Cost sharing for medicine can be expensive, so manufacturers offer patient assistance to lower out-of-pocket costs and ensure these medications are affordable. At our organization, we see the benefit of this form of assistance every day. Unfortunately, as individuals age and go on to Medicare, they are no longer eligible for much of this assistance.

Studies show that some patients forgo treatment or abandon their drug regimens as prices increase. If patients stop managing their conditions, complications due to lack of treatment will harm their health and ultimately increase health care costs across the system. Making matters worse, pharmacy middlemen are encouraging employers to adopt new insurance policies that significantly jeopardize patient assistance for individuals with private health insurance.

Created by pharmacy benefit managers, accumulator adjustment programs are gaining traction in the health insurance marketplace. Where these tactics are used, AAPs essentially block the coupon from counting toward patients’ deductibles. Patients affected by these policies may face a surprise at the pharmacy counter and be asked to pay thousands of dollars in higher out-of-pocket costs for medicines before they reach their deductibles.

Unfortunately, by substantially increasing out-of-pocket costs for patients, these programs risk putting medicines for chronic and rare diseases out of reach – particularly for some low- or moderate-income Americans.

With patient access to medications jeopardized, once-managed conditions could intensify. The long-term consequences of these programs could potentially mean more hospitalizations and health complications due to a lack of adherence to reliable and once-affordable treatment regimens.

Put simply, AAPs not only increase out-of-pocket costs for many patients, they increase the likelihood that Americans who rely on medicines will have to stop taking them. This is dangerous and unacceptable.

The complicated nature of our health insurance system too often results in an unfair deal for consumers who have no other choice. But the potentially detrimental effects AAPs may have on patient health demand action. Americans should reach out to their health insurance providers to check whether their individual plan is making this structural change to payments. If so, they should speak up about how harmful accumulator adjustment programs can be.

Additionally, organizations that work with patients and health care consumers must continue to push back against these dangerous programs. Speaking out against these unacceptable changes that will increase patient out-of-pocket expenses can help ensure that at-risk patients continue to have access to the necessary treatments that they rely on.

Americans, and our aging population, deserve no less.


Dr. Yanira Cruz is the president and CEO of the National Hispanic Council on Aging and also serves on the boards of the Consumer Health Foundation and the American Society on Aging.

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