There has been some movement in the
state's legislature to address
things like copay accumulators,
open formularies, and pharmacy
access. We're joined by someone
on the front lines of this work, Rob
Gumber I'm sorry, let's start over.
There has been some movement in the
state's legislature to address
things like copay accumulators,
open formularies, and pharmacy
access. We're joined by someone
on the front lines of this work, Rob
Gunderman, president and CEO
of the Coalition of Wisconsin
Aging and Health Groups.
And thanks for being here.
Thanks for having me.
So tell me a little bit about how
you got started in all of
this.
Sure. Well, I started getting calls
from patients who were trying to get
their med medications.
They'd go to the pharmacy counter
and they were being told that it
would be thousands of dollars to get
a medication that they're used to
paying thirty, forty, fifty dollars,
whatever their copay was.
And they were learning that a copay
accumulator had been applied to
their policy. And this is a a new
thing insurance companies are doing
where if you have a an expensive
medication, if you have multiple
sclerosis or any of these conditions
that have expensive medications,
manufacturers will frequently
provide you with copay assistance.
So what they do is they give
you a card and when you go to the
pharmacy counter you present that
card and the f the manufacturer is
actually paying for your medication
until you get to the point where
your donut hole has been your
your deductible has been filled,
and then at that point you're just
paying the copay.
Insurers have started taking the
money that is being paid by
the pharmaceutical manufacturer,
but not applying it to the patient's
deductible and not telling the
patient. So the patient goes up,
they think they're gonna pay their
copay, and it's three, four,
five thousand dollars.
And the one that really struck me
was a woman with a heart condition
who needed this heart medication
to live, and she went up like
she always does to buy her
medication. They said it was gonna
be thirty, eight hundred dollars.
They didn't have thirty, eight
hundred dollars, and her husband had
to go to the bank and take out a
loan so she could get the medication
she needs to live. And I realized we
have a problem here.
And that woman who I've I've come to
know, she her family is going
into debt more and more every year,
having to deal with this.
So that that's how I got involved in
this.
And as you've been working on these
issues, is this just all
too common?
You know, when I started out in
this, it wasn't that common.
It was I was seeing a in a plan here
and and people were starting to come
to me. Now it's become very common.
It it's it's spreading like
wildfire. There are very few plans
left. I don't even know of a plan
left in Wisconsin that doesn't have
a copia accumulator other than
the group the the state insurance
plan.
And since then,
what is the impact you've seen
on patients?
What does this do to someone who's
making this impossible decision?
Well, a couple of things.
One, the financial stress that it's
putting families under that just
can't afford this.
But the other piece is I've had
people tell me they're not gonna
take their medication anymore.
I had a friend of mine who has MS
and he says if they put one of these
Cope accumulators on my policy, I'm
gonna stop taking my medication.
So, you know, you you then end up
with more problems with their
their health. And so I I don't think
that's a a cost savings measure.
By you know, taking this money they
may get some money out of it.
But I think in the long run
the increased h health expenses that
you're gonna have for people if they
stop taking their medications are
gonna offset that.
And as you said and as we've seen in
these stories, people don't
know until they're so far along
that they owe all this extra money.
There's no ability to
have a payment plan for your
medications, so you either get it
or you don't.
How difficult is it for people to
even know that something like
this is on their plan?
How much of it is just
poor communication?
That's a lot of it. It's very
difficult.
I've looked at some of these plans
fifty, sixty pages.
And and who's gonna read fifty s
sixty pages of fine print?
Some of this is very small, it's
hard to read, especially if your
eyes are in aren't so good as mine
aren't anymore.
It's hard to spot this little clause
in there that says, and even if you
read it, if you don't know already
what a copay accumulator is,
you're not gonna understand what
what they're saying in there.
And there's accumulators,
maximizers, and those sound
like good things.
They do, you know, they use catchy
terminology and they've probably
run this through marketing groups to
see what what people like and what
people don't like.
But you're exactly right, they're
copay accumulators, they're copay
maximizers, they're all doing
essentially the same thing, but just
from a little bit different angle.
Now Senate President Mary Felskowski
has been working on legislation like
this for many years,
many sessions.
What are the concerns that state
lawmakers have had making
it so difficult to move this
forward?
Sure, I think the the one thing
that's really held us up with state
law, well, a couple of arguments
that the insurers have made.
One is that this will drive
patients to more expensive brand
name medications.
We know 98% of the medications
in this group, these expensive
medications, there isn't a generic
for. But Senator Falzkowski
put it language in the bill saying
that this only applies to
medications for which there's not a
generic equivalent.
So that's off the table.
They're still making that argument
though. The other argument that
we're hearing is that it will drive
up insurance premiums.
But there's studies that have been
done looking at states that have
already passed this type of
legislation where the premiums
haven't increased.
And conversely, studies have looked
at states that haven't passed this
legislation and premiums aren't
lower there. Like in Wisconsin, our
premiums aren't lower where we don't
have that.
And the current legislation for this
session is still in play.
Where does it currently stand and
what, if anything, has
changed thro throughout this session
as it's gone through committee?
Sure. Well we had a a committee
hearing which was the first this is
the second session that we've tried
to run this bill and we
weren't able to get a vote out
of committee last session.
This session we've got a a five to
zero votes of the entire committee
voted in favor of passing this
out in the Senate and we expect
that to come up to the f onto the
floor at some point in January.
We just don't know when.
And so this, you know, there's
a definite shift here where the
momentum has has shifted.
I think there are forty co sponsors
on the bill, but I think I think the
votes are there to pass the bill if
we can get the votes.
Overall premiums are going up.
If people feel like they're not
properly covered under a
plan that they're paying a lot of
money for every month, do
you think patients will just end up
foregoing a health plan altogether?
That's our fur that's our our our
concern, our worry.
I think there are people who they're
gonna look at this and say, I'm
paying so much out of pocket anyway.
I'm not ever using the insurance.
So what's the point of having it?
And then when they have something
serious happen then it's more
problems and it's not like
someone isn't paying for that.
We saw in Cole Schmidtnek's
story that he didn't know that
the formulary had changed and
that's something that's been a point
of contention in the legislation.
Has that changed as it's gone
through committee?
Yeah, so th the insurers wanting
to be able to change the formulary
throughout the year.
And right now they could only change
it during the window and people can
change plans.
And I said we didn't have a problem
with that as long as they weren't
able to force the the patient to
change their medication mid year.
So I think it's actually a benefit
to patients because if you're going
to to make a formulary change,
tell them in June or July,
give them as much time as possible
to figure out what they're gonna do
and find a new plan that will cover
whatever the medication is that
they're taking that is going to be
leaving your formulary.
So I think I I don't
see a downside to that.
Now we just saw Congress go through
the longest government shutdown in
history over these enhanced
tax credits,
and we're
still seeing premiums go
up all around.
How much of this is kind of reaching
a turning point as health care
premiums costs are all
going up and there doesn't seem to
be an end in sight?
We're getting to the point where
something has to happen.
We can't my insurance went up about
almost twenty five percent this
year. We can't have twenty five
percent annual increases in our
health costs.
We can't afford it. So we're gonna
have to figure something out and I
don't know what that answer is.
I mean people br smarter people than
me have been trying to figure this
out for a very long time.
But we're getting to the point where
we have to.
This isn't an option anymore.
We can't afford to keep going the
way that we're going.
And for a lot of families
without the the Affordable
Care Act plans being available
to them, I think we're gonna have a
lot of people who are just not gonna
be insured.
Anything else you'd like to add?
I think the only thing that I I
would say is that w you know, when
you look at this copay accumulator
piece, it just to me this is just so
unfair and I don't it's
been difficult for me to understand
how this has been allowed.
If you and I went out to dinner
and I paid for your
your dinner and the restaurant said,
We've adopted a copay
policy where you have
to pay for your your meal and you
say, Well Rob already paid for my
meal. Yes, and we appreciate that
and we're gonna keep his money, but
you also have to pay for your meal.
You would say if this isn't fair,
you're getting paid twice for the
meal. This is what the insurance
companies are doing and they think
it's fine.
Well thank you very much for joining
us.
Thanks.
As we've seen, most patients don't
get the option of a payment plan
for these costly prescriptions.
You either pay up front or you
don't receive treatment.
In all of these stories, complex
diagnoses, convoluted health
plans, decreasing access,
and steep prices are overwhelming
patients with impossible decisions.
But they're not always alone.
Patient advocates are stepping
in, using their knowledge of the
system, and doing what they can to
make sure patients are getting the
treatment they need.