EP459: Cost Containment by Co-Pay Maximizer or Co-Pay Accumulator: Points to Ponder, With Bill Sarraille
Release Date: 01/02/2025
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In this episode of Relentless Health Value, Stacey Richter engages with Mark Newman, CEO and founder of Nomi Health, in a deep dive into the administrative and transactional inefficiencies plaguing the American healthcare system. The conversation highlights how plan sponsors often spend more than a dollar to purchase healthcare, yet healthcare providers receive only a fraction of that amount due to data fragmentation and varied accounting practices. Mark Newman reveals two main issues: 'data isn't data' and 'a dollar isn't a dollar,' explaining how inconsistencies and misalignments in...
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INBW45: Extremely Actionable Themes That We Covered Throughout 2025
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INBW44: The Relentless Health Value Themes That We Covered Throughout 2025—A Recap, Part 1
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Encore! EP450: When Your Health Plan Is $9 Million in the Hole, Who Are You Going to Call? A CPA. And Tell Them to Bring Their Spreadsheets, With Marilyn Bartlett, CPA, CMA, CFM, CGMA
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EP494: Six Tensions of Pharmaceutical Drug Pricing, With Sarah Emond
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Bonus Add-on for EP494: Who Is ICER and What Is the Arms Race of Pharmaceutical Pricing That the Status Quo Has Created? With Sarah Emond
Relentless Health Value
In this bonus episode of 'Relentlessly Seeking Value,' host Stacey Richter engages in a conversation with Sarah Emond, CEO of the Institute for Clinical and Economic Review (ICER). They discuss the complex 'arms race' of pharmaceutical pricing in the current healthcare system, emphasizing issues like inflated drug list prices, patient affordability, and cost-effectiveness. They highlight ICER's role in conducting value assessments of prescription drugs to ensure fair pricing and improve affordability and access. The episode underscores the need for multi-stakeholder dialogues to...
info_outlineIn Episode 459, host Stacey Richter speaks with healthcare attorney Bill Sarraille about co-pay maximizers and accumulators, mechanisms designed to extract maximum co-pay support dollars from pharmaceutical companies.
They discuss the financial implications for patients, plan sponsors, and pharmacy benefit managers (PBMs), emphasizing the legal and ethical issues and potential patient harm due to high out-of-pocket costs and surprise expenses.
Sarraille provides five key pieces of advice for plan sponsors and highlights the importance of transparency and proper utilization management to minimize patient access problems and legal risks. Listen or read the show notes on our site for the full list.
(continued below the links)
=== LINKS ===
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https://cc-lnk.com/EP459
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Co-pay maximizers and accumulators are programs designed to capture maximum co-pay assistance from phara. Maximizers spread pharma co-pay support evenly throughout the year, ensuring plan sponsors benefit while, in theory, patients face minimal costs. More on how that can go wrong in the episode.
Accumulators, however, design their plan to deplete pharma dollar support quickly, surprising patients with significant out-of-pocket expenses mid-year when they go visit the pharmacy.
These programs usually exclude pharma assistance dollars from deductibles, potentially causing financial hardship because when pharma is paying your co-pay, those payments don't count against your deductible.
09:31 What should plan sponsors be aware of right now?
14:01 What is the justification for maximizers, and why is this at odds with the purpose of insurance?
18:05 Where does the issue of “fairness” land within cost containment?
20:00 Brian Reid’s LinkedIn post on insurance company access challenges.
21:30 What are the real legal issues presented by some of these co-pay maximizers and co-pay accumulator programs?
27:06 How are these programs creating perverse incentives?
29:28 EP450 with Marilyn Bartlett, CPA, CGMA, CMA, CFM.
32:16 “If you’re covered by the ACA, I think this is unlawful.”
32:57 What advice does Bill have in regard to these programs?
33:49 What potential litigations does Bill see coming in the near future in regard to these co-pay maximizers and co-pay accumulator programs?