Policy Changes Need to Address OOP Costs to Have a Real Impact on Patients

Out-of-pocket (OOP) costs remain a problem, and even patients who are receiving co-pay assistance worry about these expenses. Unfortunately, charitable foundations that provide financial assistance are under increasing strain as demand rises, with funds running out of money quickly, explained Ayesha Azam, senior director of medical affairs, Patient Access Network (PAN) Foundation.

In 2019, the biggest change for underinsured patients on Medicare is the closure of the Medicare Part D gap, also known as the donut hole. Azam said that change is expected to be finalized by the end of the year. Once it is implemented, patients will not have to dread reaching the coverage gap, when OOP costs rise substantially and they are usually unable to afford drugs without some sort of assistance.

“So, it was great news that the coverage gap is closing,” she said. “And theoretically, this should mean across the board lower out-of-pocket costs for Medicare beneficiaries with prescription medications.”

However, the truth is not so clear cut. With OOP costs continuing to rise, more patients are hitting the amount needed to push them over the catastrophic threshold. The result is that patients will still be facing high OOP costs even once the donut hole is closed, Azam explained.

A PAN survey of patients who are already receive co-pay assistance found that 83% were worried about financial problems they will have in the future as a result of their illness or treatment and 80% said their OOP expenses have been higher than expected.

From 2016 to 2017, financial assistance increased significantly. While that is encouraging, there has been a plateauing effect, Azam said. And despite the assistance available, there are funds for certain disease states that remain closed or run out of money quickly.

What the PAN Foundation has seen is that when a disease fund opens up again after being closed for a few days, weeks, or months, there is a flood of patients who go to PAN for assistance. While that makes sense, it is concerning that the money allocated will be used up so quickly, she said.

“While it’s definitely helping patients in need, there’s the effect of having a very limited window for them to be able find assistance,” Azam said. “And while it’s good for those who are have processes in place who can be able to identify the assistance and where it’s needed, it’s not great for those folks who aren’t able to get a grant before a fund closes.”

This experience has made it clear how policy makers are focused on lower drug costs, but haven’t addressed lowering OOP costs independently, she said. Closing the coverage gap helps, but not as much as it could if the price of specialty medications continues to rise. The 5% or 10% that patients pay continues to grow over time as drug prices increase.

“All of this means that there is a continued reliance on charitable foundations until there is a change in the overall system, where we can go to a different area where patients do not need to apply for grants to help them get through their benefits structure,” Azam said.