How Co-Pay Accumulators, Maximizers Disrupt Patient Access to Care


In this conversation from the Healthcare Advocate Summit, Ned Woody, associate director of field reimbursement at Daiichi Sankyo Inc. - Oncology, discusses the disruptive impact that these programs have on patients.

Although designed by insurance companies to aid patients, concerns have grown about the burden that co-pay accumulators and maximizers place on individuals seeking access to essential care. As these programs have become more common in the insurance space, thought leaders like Ned Woody, associate director of field reimbursement at Daiichi Sankyo Inc. - Oncology, have questioned their fit in the larger financial puzzle.

In a conversation at the Healthcare Advocate Summit in September, Woody explained the difference between co-pay accumulators and maximizers, as well as how each affects a patient’s insurance and health care benefits.

“In neither the accumulator nor maximizer does any of the manufacturer funding apply to the out-of-pocket maximum for the patient. The difference with the maximizer [is that it’s more gentle], because [insurance companies] are smoothing it out and making the patient’s obligation equal to that program funding. Wherein with the accumulator, [insurance companies] take all the funding from the manufacturer then the patient’s got to pay what they would have paid to begin with.”

The impact that co-pay accumulators and maximizers can be disruptive, Woody said. Many patients are unaware that the programs are being deployed by insurance companies behind-the-scenes, and this unawareness can lead to unexpected financial burdens and interruptions in treatment.

“Most patients have no idea that an accumulator or a maximizer is being applied, so they could go through 3, 4, 5, 6 months of the year having no cost share or maybe $25, and then halfway through the year the pharmacy says [the patient] owes [them] $5,000. And they’re just shocked. It may be enough of a financial burden that they just don’t get the therapy that they need.”

To address the issues associated with co-pay accumulators and maximizers, Woody called for policy changes.

“I can see how from the payer’s side you wouldn’t want [maximizers and accumulators] to go away because it’s a huge source of cost offset, but from a patient outcome standpoint, [they’re] a real barrier. I think legislatively, action arguably should be taken to render them illegal.”

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