ACR: UHC's New Co-pay Policy Is "Disastrous" for Patients

Physician groups and patient advocates are opposing a “co-pay accumulator” initiative by UnitedHealthcare (UHC) they contend would force providers to report funding assistance patients receive so that it cannot be applied toward co-pays and maximum out-of-pocket requirements.

The provider groups contend the policy, which goes into effect on January 1, 2021, would increase levels of patient financial distress, leading to therapy abandonment, and place physicians in an awkward ethical position.

“Our organizations oppose this change as it would endanger patients’ access to care and undermine the doctor-patient relationship,” they said in a joint letter to UHC. “We urge UHC to explore other pathways to rein in drug costs without jeopardizing patients’ health.”

Chris Phillips, MD, chair of the Insurance Subcommittee for the American College of Rheumatology (ACR), noted that biologics for the treatment of chronic conditions such as rheumatoid arthritis and lupus are costly and, increasingly, payers are establishing specialty drug tiers that force patients to shoulder part of the costs of these agents.

Less Relief From Out-of-Pocket Costs

“If co-pay assistance funds are no longer counted towards deductible and out-of-pocket maximum requirements, patients will have to pay these additional costs. This is particularly concerning for rheumatology patients, because the medications they require are often single-source therapies with no equivalent generic product or therapeutic alternative that is cheaper,” the ACR said in a statement.

According to UHC, the proposed co-pay accumulator plan would require providers to report the use of drug manufacturer coupons for specialty drugs covered under the UHC commercial medical benefit. “These drugs tend to be subject to a high co-pay/cost share and the coupon may pay for part (or all) of the member’s financial responsibility on a claim. However, if the portion paid by the coupon isn’t recorded, the member’s deductible or annual out-of-pocket payments won’t accurately reflect the amount paid by the member,” UHC said in a policy explanation intended for providers.

UHC notes that coupon use by patients may affect the “you may owe” amounts and “what’s been paid toward their annual deductible and out-of-pocket maximum.”

In addition to the ACR, signing organizations included the American Academy of Dermatology Association, American College of Gastroenterology, American Gastroenterological Association, Arthritis Foundation, Association for Clinical Oncology, and Council of State Rheumatology Organizations.

What makes the co-pay accumulator policy particularly onerous for patients, the groups said, is that there are limited alternative medicines for the specialty drugs affected by this policy, “meaning patients do not have lower-cost options.”

“As deductibles and out-of-pocket maximums rise, co-pay assistance programs allow patients to access these life-altering medications without regard to their personal financial status. When health plans block co-pay assistance funds from being applied toward patient deductibles, the funds are depleted mid-year and patients face thousands of dollars in unexpected medical bills. This predictably leads to discontinuation of treatment, often with disastrous consequences,” the letter stated.

“These concerns have already led at least 4 states to prohibit accumulators in individual and small group health plans,” the group said.