Copay Accumulator Victory

Janson Silvers  0:03  
Welcome to health care policy pop. I'm Janson Silvers it's Tuesday October 17 2023.

Janson Silvers  0:10  
Today's pop topics a court case ruling that many are calling a, quote, major victory for patients. We speak with a plaintiff about the case and what it means moving forward. George Huntley is the CEO of the diabetes Leadership Council and explains what happened.

George Huntley  0:27  
We joined with the HIV Hepatitis Policy Institute to and sued the federal government, the Department of Health and Human Services over a rule that they had that they put out in 2021, that allowed insurance companies to create these copay accumulator programs. And these programs effectively steal the value of a manufacturer's Patient Assistance away from the patient by not giving the patient credit for the assistance that they're providing.

Janson Silvers  0:54  
And how did the lawsuit go? 

George Huntley  0:56  
Well, the great news is we won. Very excited, very excited the judge agreed with us in our interpretation of the ACA that payments made by or on behalf of patient need to be credited to the patient. So effectively, the court vacated that 2021 rule that we were fighting, and that meant that the guidance now reverts back to what was in place in 2020. Prior to when that rule went in place.

Janson Silvers  1:22  
Although in 2020 copay accumulator programs could exist. Huntley still says this is a big win.

George Huntley  1:28  
In 2020 copay accumulator programs could exist, but they were only allowed if the drug involved had a lower cost generic available, and they don't want manufacturer assistance driving patients to a higher price drug. Now that sounds all well and good, but over 96% of the manufacturer assistant programs are for drugs that don't have a generic equivalent. So effectively, this was a major win. That was a false flag argument on the other side's perspective. 

Janson Silvers  2:01  
As deductibles continue to rise, the victory was needed now more than ever, 

George Huntley  2:06  
And the overall average deductible for all plans has risen 90% since 2015. So the math that the patient has to cover keeps getting higher and higher and people can't afford the treatments that they need. It's bad enough to get the diagnosis but to lose your life savings or have to decide between food rent or medicine, that's a choice no one should actually ever have to make.

Janson Silvers  2:28  
Huntley says the reason they had to fight was quite simple. 

George Huntley  2:32  
Fundamentally, these programs are pure evil. They take money away from patients struggling to afford their medications, the most vulnerable of our population, these programs have grown to the point where over 80% of commercial plans have them. 

Janson Silvers  2:49  
Of course, more can always be done. But for now, Hunley is excited for the win.

George Huntley  2:54  
You know, I'll take the win. It was a pretty much a complete win from our perspective. We wanted them to vacate that ruling. And that's what they've done they didn't go so far as to say all copay accumulators are illegal. That would have been nice, but it's not that I'm we're gonna go back and try another round of this. I think we got the victory that we wanted out of this. And so I'm going to I'm going to be satisfied with that. I think we helped 1000s if not millions of people.

Janson Silvers  3:22  
Learn more about the decision by using the link in the show notes.

Janson Silvers  3:30  
Cigna will pay $172 million to settle allegations that it violated the False Claims Act by submitting false and inaccurate Medicare Advantage diagnostic codes, supposedly to boost reimbursements. US Attorney Damian Williams claimed Cigna has for years submitted quote false and invalid diagnosis information for its Medicare Advantage plan members as part of the settlement Cigna group will enter into a five year Corporate Integrity Agreement with the Office of Inspector General of the United States Department of Health and Human Services. Finally, today, the unions that represent 85,000 health care workers have reached a tentative agreement with Kaiser Permanente after a strike over wages and staffing. The new deal includes minimum hourly wages of 23 to $25 an hour, and wages will go up 21%. Over the next four years. It is being reported that both sides prioritize patient care during the negotiations. And Kaiser says rates will not be affected. More on this story is in the shownotes that's all for today. We're back on Thursday for another health care policy pop, a resource of patients rising now. I'm Janssen Silver's, have a great day.