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Accumulator adjustment program gives insurers permission to hike drug costs


In the blink of an eye, a brain injury, the most common cause of disability and death can occur, causing catastrophic and long-term damages. Once that damage is done, it can be a long road to recovery. Moreover, individuals who experience a traumatic brain injury often must undergo special treatment regimens to combat extreme physical pain and cognitive problems as the delicate circuitry of the brain rewires. As you can imagine, the necessary treatments and medication can lead to sky high, out-of-pocket costs, especially if a generic equivalent isn’t available.

Though individuals with brain injuries may accept the difficult medical circumstances they must live with, they should not be forced into unexpected financial crises too. Unfortunately, new federal measures will do just that by allowing insurers and Pharmacy Benefit Manager middlemen to be the judge of whether patient assistance programs count toward a patient’s out-of-pocket maximum at the pharmacy. This is very concerning as history shows that insurers and PBMs often prefer to pocket savings rather than passing it on to benefit patients.

Carrie Collins-Fadell

Carrie Collins-Fadell

This tricky insurance practice, called accumulator adjustment programs, ultimately shifts a greater share of drug costs onto patients as they will be forced to pay more out-of-pocket in order to hit their deductible. Too often, this leads to delayed or abandoned medications due to financial circumstances. In fact, one study found that 69% of patients abandoned their prescriptions when cost sharing increased. Considering many individuals living with brain injuries depend on financial assistance to afford their medications, disregarding cost-sharing assistance will lead to an extraordinary increase in prescription abandonment—the exact problem cost-sharing assistance was designed to solve.

As an organization that represents the 55,000 Arizona residents who will visit the hospital this year with concerns of brain injury and the thousands more living with brain injury, their caregivers, and the professionals who administer care, we know firsthand how important adherence to the prescribed medications can be for recovery. Skipping one prescription is risky and survivors of brain injuries understand the consequences. Not to mention the fact that skipping treatment could result in emergency room visits, which will drive up costs for the entire healthcare system.

If this opportunistic relationship that could force already vulnerable patients to pay more for the drugs they need isn’t reason enough for employers and insurers to negate this dangerous policy, then the current economic environment that is putting both a financial and medical strain on sick patients should be. It is now up to the states to wrangle over how to carry out this measure. In 2019, the Arizona State Legislature became the third state in the nation to pass legislation (HB2166) banning these accumulator adjustment programs. While it’s hard to believe only a handful of states have taken action since then, more lawmakers are beginning to see the necessity and we hope they will speak up for their worried constituents in 2021 when the new measure is instituted.

Legislation requiring health insurers and PBMs to pass along discounts and savings to lower drug costs for patients is long overdue. But now that this pandemic has strained access and created more economic uncertainty, patients need assistance and support instead of senseless roadblocks designed to pad the profits of corporate middlemen. Patient assistance programs are a lifeline for individuals living with a brain injury and remains a program a majority of them cannot go without. I hope individual states, employers, and insurers understand the significant impact this change would have and choose to support rather than impeded patient access at this critical time.

Carrie Collins-Fadell is executive director of The Brain Injury Alliance of Arizona.

One comment


    Arizona Legislature passed this in 2019, taking effect 12/31/2019

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