the name for the ridiculous names for these products.
I'm so sure.
Good God.
This says, review the language in your plans document.
These programs may be called, quote, coupon adjustment,
benefit plan protection program, or out-of-pocket protection
program, or copay leveling program.
I mean, if I read something that said protection program,
or out-of-pocket protection, it would
be pretty rational to assume that meant
it was going to protect me, right?
Protect me from out-of-pocket costs.
So these are deceptive and have been
identified as deceptive by numerous states.
I asked you this, when we spoke earlier,
do you think it's fair to characterize them as double dipping?
Yes.
And that's where we have to get into what
was the manufacturer's intent with issuing a coupon.
Or it's also called a copay card.
Copay card.
Yep.
So exactly.
So right.
So if we forget about the copay card for a minute,
if we have a high deductible plan where
the patient is expected to pay $7,000 out of pocket,
then the insurance company is expecting,
for someone who has high medication expenses,
is expecting the patient to pay $7,000
before the insurance starts to pay.
If there is a copay card or a copay coupon,
the manufacturer is paying the insurance company
the amount of the coupon, let's say it's $4,000.
And then if there's also the patient deductible,
then the patient is paying the $7,000 on top.
So I think it's a fair statement to call it double dipping
because the insurance company is getting money
from the patient and money from the manufacturer.
And when you say the manufacturer's intent
behind helping patients, manufacturers
are the ones needing this very expensive drug.
They are pricing this very expensive drug.
What motivation could they possibly
have to say we're going to pay $4,000 of your share?
What is the manufacturer's intent?
Well, it's fair to say that I can't
speak to their actual intent, but what I can say
is one of the challenges in health care
is that the list price is always inflated
because of the way contractual arrangements work.
And so what a coupon does is right size the price,
if that makes sense, so that it takes the inflated price down
to probably what it should cost, which
is why this whole thing is so complicated.
And we have pharmacy benefit managers,
another third party involved in this mix that's right,
that is sort of inflating costs to then have these credits,
and who's getting the slice of the right.
And it's very confusing.
And what I feel comfortable saying as a health advocate
is that patients are getting lost in the middle of this.
This is not benefiting patients.
And the manufacturer's coupon or copay card
originally was meant to go towards patient deductibles.
Christ.
Yeah.
And so does it make sense that manufacturers are just saying,
all right, then we're not going to do these coupons
or we're not going to, if you ask for more help,
we're not going to give it to you.
Because your health insurance plan
has just decided they're just going to take all that money
anyways and not apply it to help the patients deductible.
Do you see what I'm getting?
Yeah.
I mean, I think that it's always important
to think about incentives and unintended consequences.
And I do think that if what was designed
to make it possible for patients to get a brand name drug
or choose this manufacturer's medication A over B,
that is no longer benefiting patients in that way
and has been creatively deceptively redesigned
in a way that is lining the pockets of insurance companies,
that it would be a rational action for a manufacturer
to say, yeah, no, no, no more.
So the connection between self-funded plans
and a accumulator maximizer is you don't need
to be in a self-funded plan in order
to have accumulator maximizer prescription benefits.
However, if you have a accumulator maximizer benefits,
under a self-funded plan, is that kind of a double whammy?
Are you, do you have even less options for appeals
or for places to turn to try and help you as the consumer?
That's what I would say.
I think the issue is accumulator maximizer plans
are not working for patients.
And when something's not working for a patient,
the question is what's the remedy?
And if it's self-funded, then it doesn't matter
if the state has passed a law that's prohibiting this thing
in insurance product, because that won't cover
if it's being used in a self-funded plan.
So your remedy, if it's a self-funded plan
using an accelerator maximizer coupon,
is the federal government.
Your protection is the federal government.
And right now, the Department of Health and Human Services
that would provide that protection has said we're not,
we're actually not enforcing the federal court case right now.
So I think this will be addressed.
I don't know to what extent the remedies will be
or the enforcement, the protection.
But right now, there's a consumer protection vacuum
for these in self-funded plans.
And for these in insurance plans,
unless you're in one of the 19 states that's passed a law,
there's also limited protection, right?
So the regulatory agency could look into it,
but if it hasn't been explicitly prohibited, right?
We're in the loophole Wild Wild West.
And as a health advocate, what worries me too is that
they found this loophole, this loophole is harming patients, right?
Now, there's attempts to close the loophole,
and then we're going to move to the next loophole.
So you're saying even if Wisconsin were to pass legislation
that interests a cumulative maximizer prescription benefits,
that wouldn't apply to self-funded?
Correct.
Because states only regulate insurance,
and self-funded plans are regulated by the federal government,
either under ERISA or in terms of the maximizer plans,
it sounds like it's part of the Affordable Care Act.
And the court case said, yes, these should not be allowed,
but that requires the federal agency to enforce that rule.
So after all of that, are there positives to self-funded plans
or to euretically accumulate or maximize their plans?
I'm not seeing positives to accumulator maximizer plans for consumers.
I am also wary for consumers of anything that seems like too good of a deal, right?
Like one of the reasons we have such high costs in health care are the administrative
costs and administrative burdens, and I think simple is better,
and throwing in a copay coupon on top of a high deductible plan.
How about we just don't have the high deductible piece of the plan to begin with?
Right.
And I understand we have a cost crisis, so we have to fix it,
but I don't see this being a solution for consumers.
What else do you think is important to address with either of these?
I think at the end of the day, I want us to sort of go back to our values and roots
and sort of remember that at the center of these stories are people facing a life-threatening
or chronic illness who are needing to access life-affirming or life-saving medication.
We've got too many cooks in the kitchen who are sort of not focused on what we need to
be focusing on, which is let's make sure that people can be healthy and stay healthy and
access the medically necessary care to address what they need to address.
So that for me as a health advocate is I really try to keep the north star of the patient,
and I just think we've lost our way a little.
Are there any besides state legislation addressing the loophole for a cumulative maximizer,
which could be something that Wisconsin sees maybe next session?
Is there anything else that policy-wise for either of these types of packages of plans that,
I don't know, people should call their representative about or are there things that are
ways to address some of these issues? Yeah, I think it's always good for consumers to remind
their elected officials and people who work at state agencies who they work for, right?
And we want to be open for business for insurance companies, and I think it's great for us to stay
to say Wisconsin is a place that we want all companies to work in good faith, right?
So we want insurance companies to work in good faith, and we want large employers
who sell fund, who choose to sell fund to save money, to make sure they're doing that in a way
that is thinking about Wisconsinites, that is thinking about their employees, right?
Which is where they're thinking about whether they would want to be on that plan,
whether they'd want their child to be on that plan, right?
Whether they're really offering the benefits that are going to support
the flourishing of communities and our economy.