Hubs East 2025: Pushing Back Against Cost-Shifting Programs

In a video interview with Pharma Commerce, Kimberly Westrich, MD, chief strategy offer at the National Pharmaceutical Council, describes how in response to rising healthcare costs, employers have turned to high-deductible health plans and higher out-of-pocket (OOP) expenses, causing patients to pay more for healthcare. To help alleviate this financial burden, manufacturers offer copay assistance programs, which are aimed at improving medication adherence and preventing disease progression. However, insurers have introduced cost-shifting programs such as copay accumulators, maximizers, and alternative funding programs (AFPs) to manage these costs.

Copay accumulators redirect the value of copay assistance to the insurance plan instead of counting it toward the patient's OOP max or deductible. This means that patients face surprise copay costs once the copay assistance runs out, essentially "double dipping" as the plan captures the benefit without applying it to the patient's financial responsibility.

Copay maximizers also shift assistance from the patient to the plan but manipulate the patient's copay to extract the maximum benefit from the copay assistance. While the copay assistance helps with a specific medication, it doesn't count toward the patient's deductible or OOP max for other expenses, leaving the patient responsible for other costs.

Alternative funding programs (AFPs) are more complex. In these programs, certain specialty medications are removed from insurance coverage, and patients must enroll in an AFP. They work with a third-party vendor to obtain the medication, often through manufacturer assistance, charity programs, or international pharmacies. While the AFP may provide the medication, it can be a slow and confusing process, and patients may not qualify, leaving them to pay out of pocket or forgo the medication. These cost-shifting strategies aim to manage healthcare expenses but can create additional financial and logistical challenges for patients.

Westrich also comments on how these accumulators, maximizers, and alternative AFPs are impacting patients, manufacturers, and healthcare ecosystems; sessions that have caught her eye; and much more.

A transcript of her conversation with PC can be found below.

PC: What aspect of your presentation would you have wanted to dive further into?

Westrich: One thing that I really would have liked to have spent a little bit more time on is this idea of what can we all do to help push back against these programs. There's something that everyone can do, so for employers, I would call on employers to really assess the ethical and the legal considerations, and to really think about whether or not these cost-shifting programs are meeting their objectives, because I believe if they really take a careful look at the considerations, the research, the impact, they will land on the side of ‘no, these are not programs that we want to be implementing.’ That's what employers could be doing. In terms of health plans, I wish health plans wouldn't use these programs at all. If they are going to use them, they should be transparent, There should be a way for patients to know I'm enrolled in an accumulator program. I'm enrolled in a maximizer program. This is what that means. This is how it's going to impact me.

I call on health health plans to be transparent. Government regulators can issue that tri-agency guidance that we're waiting for, which I would hope would support the patient copay assistance, counting towards the patient cost sharing, that's been in limbo for a while. Patients need that rule to come out, and they need it to be enforced.

Then finally, researchers can continue to do the research to look at what the impact of these programs are. We do have some research showing the harm that can come to patients as the disease progresses, as they're waiting, along with the potential health inequities. The more research that we have that definitively shows to all of these stakeholders the harm that these programs can cause, then the more evidence and ammunition we all have to curtail or stop their use.