Collaboration in copay: a new era for patient affordability in healthcare

In the past five years, copay accumulators and maximizers have exploded as a model to curb copay programs, introduced by pharmaceutical manufacturers to help patients afford their medications. While these programs have helped many patients access therapies, they have also been criticized for undermining payers' efforts to manage formularies and control costs. Thus, as Bill Rush, Head, Value and Access Alliance Immunology, Sanofi, said, “What we have is this constant circular rotation of interest where the patient is not at the center of these decisions.”

Bill Rush, Head, Value and Access Alliance Immunology, Sanofi

Speaking to Access Insider prior to his participation on the panel “Building Bridges – Collaborative Copay Reimbursement Strategies for Manufacturers & Payers”, Rush noted that the nullification of manufacturer copay assistance leaves patients facing unexpected and sometimes unaffordable out-of-pocket expenses.

"We've come to a precipice," said Rush. "Manufacturers and payers now have a common interest in doing the right thing for the right patients, as ideally decided by the health care provider in the patient throughout that journey. We're finally at a point where there's discussion on what kind of models we can compliantly work on that allow formulary integrity and patient affordability instead of working in isolation and creating unintended consequences.”

One area of focus could include the development of new models that still separate copay assistance from discussions about rebates and utilization management criteria but directly address affordability predictability. "These are two hard firewall topics that are completely separated," explained Rush. "I think as an industry, that's why there’s been such back and forth but in isolation of each other around how to address this."

Collaboration efforts would include manufacturers recognizing the payers need to control their formularies, while payers recognize the need for affordable models for patients. And that involves open conversations about the clinical value of specific drugs, the hurdles faced by each stakeholder, and how to address these challenges without resorting to tactics that may harm patient access/affordability to appropriate therapies. Rush suggested this could involve revisiting utilization management criteria or engaging in more traditional value-based conversations about products.

However, the path to collaboration is not without obstacles. Competitive pressures in the payer market make it difficult for individual companies to take the first step Rush said, "If you want to take that first step as a payer, but payers X and Z are still utilizing those models, your business could be at a competitive disadvantage."

Rush recently changed his role to focus on immunology at Sanofi, which he says is comparable with recent oncology or rare disease therapies with rapidly advancing science and potentially high-cost treatments. “There are diseases that haven't had solutions previously, so they end up being a higher cost spend for payers because the category does not exist. This automatically puts them on the payer radars,” said Rush. “These drugs have a higher propensity – from my experience – of ending up in these categories where alternative models are being created in order to try to reduce the burden to the payer on that unanticipated cost.” And that is where Rush believes they can meet payers at the precipice and collaborate on true patient solutions. "We're creating band-aids for certain issues versus directly addressing those topics. Now it's time to have real conversations about what's the right way to resolve this to ensure access and affordability for patients."