[00:00:00] Stacey Richter: Encore with a whole new intro game theory gone Wild copay cards, copay accumulators, and copay maximizers. Today I speak with Dea Belazi,
[00:00:26] Stacey Richter: Well, this episode is suddenly incredibly relevant Again, just with all the stuff going on with copay maximizers. If you're gonna understand maximizers though, you really have to start here. In a nutshell, this whole thing is a battle royale between copay cards and patient assistance programs offered by pharma companies versus copay accumulators and copay maximizers deployed by health plans and PBMs.
I just wanna start by getting everyone grounded on a few really key points. Here's 0.1, drug abandonment is a thing. Patient goes into the pharmacy to pick up their Rx, And the out of pocket is too expensive, so they leave without their drug. This can happen on the first fill. Like, oh wow, I guess I don't really need that new drug.
My doctor just told me I should pick up. Or it can happen downstream like in January when all of a sudden a deductible kicks in. But in all cases we have a patient getting sticker shock on the out of pocket for a med and then going without the drug or pill, splitting or rationing or doing other things to save money.
So that's 0.1 important background point to keep in mind throughout this whole conversation. Here's 0.2 to get grounded on how PBMs shake rebates out of pharma manufacturers. Is to use what I just said, that whole abandonment possibility as a leverage point. Pharma goes into a PBM that controls access for drugs for, I don't know, a hundred million lives.
The PBM says, Hey, you pharma, if you wanna be on our formulary, you gotta kick out this much in rebates. Pharma says, no, that is too much rebate. I cannot pay it. PBM says, well then, okay, you are not on formulary, or you are poorly positioned on formulary. And let me translate what that means. Now, the out of pocket for your drug will be so expensive that patients are gonna actually walk out of the pharmacy without your drug because I, the PBM have control over the patient out of pocket, and I will make it very expensive.
From a pharma's standpoint, all those patients that aren't picking up the drug, that means a loss of market share. And that market share can translate into a lot of lost revenue for the pharma company, and thus begins the whole war of the copays slash out of pockets. So now let's fast forward through the past, say 10 plus years.
It'll be like one of those. Movie montages with the actions sped up so fast. You don't need words to see what's going on, except this is an audio podcast. So I guess you do need words. Alright, so this is what happens next. Pharma starts raising its prices, combined with there's more super expensive specialty pharmacy drugs.
Reaction by the PBMs to this was to try to get more aggressive with pharma, demanding increasingly high rebates and other concessions. Keeping in mind the prize and leverage point that the PBMs offered pharma to secure those rebates, those PBM rebates was lower copays or out of pockets for patients.
Again, it's a well-known fact that the higher the patient out of pocket, the lower the market share of the drug because the higher the patient costs, the more patients abandoned at the pharmacy. Kanter. It's the old supply and demand curve at work. At a certain point here in all of this, the pharma companies start to get really pissed about their dwindling net prices.
As rebates start going up and up and their market share kind of doesn't because the PBMs are keeping the money and maybe not passing it along to plan sponsors or patients. It's a zero sum game. Fight over the money. And pharma feels like the PBMs are getting more than their share, and they're pretty smart, these pharma manufacturers.
So pharma comes up with a Houdini move to escape PBMs holding pharma hostage for rebates by using their control over how much patients pay or don't pay at the pharmacy. Kanter. Fasten your seat belts and let the games begin. Pharma decided to hand out copay discount cards. Then pharma doesn't have to pay PBM rebates to get lower patient out of pocket costs.
They can finesse lower patient out-of-pocket costs all by themselves. Take that PBMs. Except now the PBMs see this And they raise, enter copay accumulators, and also copay maximizers. For this part of the extravaganza of game theory at its finest, I'm gonna let Zia Belazi Pharm, DMPH, my guest today, explain further.
However, one more thing to point out before we begin. In the olden days, this whole war of who has leverage over who transpired in the context of small molecule drugs in competitive markets, a lot of times, so like Lipitor versus Crestor. And the brands all cost like a hundred bucks a month. And maybe there was a generic equivalent.
If the health plan made it too expensive for a patient to get one of those drugs, they usually made another one in the same class attractive financially. So the patient had theoretically at least options, And the stakes were also a lot lower. The dollar volumes that we're talking about here were a lot lower.
Now this same war is being fought on the specialty side of the house where drugs cost thousands or tens of thousands a month, And the patient may have but one option. So if it's made to be financially toxic for a patient to get that one drug. The patient has to choose between their family's health and dipping into their 401k in order to afford their out-of-pocket costs or going bankrupt or dying.
And when I say or dying, that's not hyperbole. There are studies that clearly show the mortality rates for patients who have trouble affording their meds are worse. In these cases, pharma can be sort of authentically a hero who steps in and helps patients who are functionally uninsured because they can't afford the copays and deductibles that their plan sponsors have put in place to actually use the insurance that they are paying handsome premiums to have.
Pharma can step in and help via these copay discount cards or co-insurance programs, or through patient assistance programs, helping those with lower incomes. So there's no question in the short term that when a patient desperately needs a drug and their insurance is insufficient, a pharma manufacturer can be a knight in shining armor financially.
But only if this were so simple, like this is some kind of spaghetti western with the good guys And the bad guys. Now let's think about this copay slash out-of-pocket assistance offered by pharma with a longer timeframe or a more systemic timeframe in mind. How is it that pharma can have prices that are as high as we all know they are?
Right. It's because enough patients don't abandon the med at the pharmacy Kanter or these days in the infusion clinic. So the lower pharma can drive the patient out of pocket for a really expensive drug. The more they have a certain amount of impunity to raise the drug prices. This is a lot of the argument against price caps on out of pockets, just in general.
By the way, they matter for patients. They save lives. But they also have the consequence of kind of getting rid of what is often seen as a big control point, checking pharma prices from zinging even higher than they already are. Bottom line, we have a catch 22 on our hands, And the patient is stuck in the middle.
If you are a patient and you need your miracle drug, and a lot of patients call these drugs their miracle drugs, pharma is your hero, at least right now. However, pharma is also now able to raise their prices even more next year, and now you really need their out-of-pocket support because the price of the drug is so high.
Your employer slash taxpayers can't afford the rising drug spend. And even more costs gets shifted onto patients. It becomes like Stockholm Syndrome, but again, no white hats and black hats here. This whole thing is one of those incomprehensible art house films with like lots of plot twists and in every other scene you start to feel for the character you just hated 10 minutes ago.
Because while pharma is getting busy raising prices, you have PBMs and nothing for nothing. Plan sponsors also up to their own machinations. Like, Hey, here's one that's quite a Marvel, PBM double-dipping. Like if the PBM can get pharma to pay the patient deductible, and then also get the patient to pay the patient deductible.
Huh? By the way, that was a backdoor introduction to accumulators, and then later on Maximizers showed up on the scene. I just wanna say that with Maximizers, not all are created equal. I can certainly see their value for patients when they are deployed by companies and plan sponsors as part of their benefit designs within explicit goal of helping members.
And the plan itself, nothing for nothing afford expensive drugs, it's clear that the patients need. But, Hmm. I have to say, and I'm not well versed enough yet in how this maximizer business has evolved to comment on whether some of what is going on is still a net positive for some members and patients.
Some of these PBMs have opened up entirely separate maximizer companies. Which for sure they are Upcharging employer plan sponsors to use, And the whole point of these separate entities is to get as much cash out of pharma as possible while they, I don't know, may or may not pass that cash on as savings to patients and members.
I need to do a show on this coming up. There's a new bill in the house, by the way. It's called the Help Copays Act, which I don't think is just aimed at accumulators. If you didn't understand what I just said, you will after you listen to this episode. And with that, here is Dea Belazi. Dea is President, and CEO over at Aela Health.
He is a pharmacist by training who has worked for pharma, and then he worked at a health plan, spending a lot of time in the PBM space. In other words, he's seen this tangled web from pretty much every angle. We kick right into the conversation talking about accumulators. My name is Stacey Richter. This podcast is sponsored by Aventria Health Group, Dea Belazi.
Welcome to Relentless Health Value.
Thank you for having me.
[00:10:41] Stacey Richter: So the leadership of PBMs, they all gather together in a room And they brainstorm a solution to undermine the copay cards, which undermine their formulary tier. What do they come up with?
So, so obviously the concept of copay accumulators is one of those things to try to.
Dissuade pharmacies from using copay assistance or copay cards for patients. It's probably the concept of copay accumulators wasn't just a, probably a PBM thought, but it also came from their customers, whether it was health plans or employer groups and, And the premise, if you think about, if I can take a second to describe sort of pre accumulators, you know, if somebody had a hundred dollars copay And the copay assistance or the copay card program was willing to buy down.
That a hundred dollars copay down to 10. In other words, they would pay $90, the patient would be responsible for 10. The payer or the PBM typically wouldn't even know that happened. There's there, the data around getting this insider information is very limited. The payer doesn't really see that.
[00:11:41] Stacey Richter: Patient walks in with a crisp $10 bill of their own.
And a $90 copay card that goes in payment for the a hundred dollars copay, but at the ends of the day, all the PBM knows Is that a hundred dollars got paid?
That's exactly right.
[00:11:56] Stacey Richter: Okay. Then what happens
in the copay accumulator model, if we go back to this a hundred dollars example, that $90 that that copay assistance program for the manufacturer.
Buydown does not go against their deductible. So in other words, if that patient had a $4,000 deductible, only $10 would come off. So the patient would still owe $3,990 versus 3,900. So they're not getting credit or the benefit of that. Copay, as they probably would've before. These concepts of the accumulators have come out,
[00:12:27] Stacey Richter: and I guess this would matter because there's generally speaking, an upper limit for how much the pharma company will pay for any given patient.
So it's like. You know, we'll pay up to $90 per script for a total of $2,000 or a thousand dollars, right? So like you can max out the amount that a pharma company is going to put against any given patient in any given year.
That is generally correct. The majority of them do have some type of budgetary allotment for the patient to, to utilize.
[00:13:01] Stacey Richter: Ahuh. I'm seeing where this road is leading in the sense that if the amount is not getting counted towards the deductible, so a more stark example might be like a multiple sclerosis product. The copay is isn't a hundred dollars. It might be, you know, just for sake of this example, like say a thousand dollars, right?
'cause it's some kind of co-insurance tier.
Yes, yes.
[00:13:21] Stacey Richter: If the Max Pharma benefit is, say, $3,000, And the pharma company is contributing, I don't know, like $900 toward the, the copay, then in three months. The patient's gonna blow through their pharma benefit, but they still haven't satisfied their deductible.
That's exactly right. All the patient has done, in this case, when there's an accumulator's pushed out in a time perspective, their time to pay that instead of paying that perhaps earlier in the year, they're now tier to your example, maybe start paying their deductible out in April, may timeframe.
[00:13:56] Stacey Richter: Yeah, so if I'm the patient and now I'm, now, it's the middle of March, I no longer have a pharma benefit.
You know what I mean? Like I can't use the copay card anymore because I've maxed it out. And my out of pocket that I owe is still a thousand dollars. So now all of a sudden, that's right, you've got a patient who's who goes to the pharmacy and they're told, oh, you gotta pay grand for your drug. And they're like, whoa, wait, wait, wait.
It's only supposed to cost a hundred because I have this copay card. Right.
Those are the real situ, real scenarios or situations that do come up. The patient will then have to pay their, their out of pocket or their deductible if they're in a deductible type of benefit design, uh, until they get past that.
And once they get past that, if there's typically a copay or some lesser dollar amount that typically will kick in, but you're absolutely right at that point, they don't get credit for. The dollars that were, the dollars that were utilized by the copay assistance program.
[00:14:46] Stacey Richter: What's the typical deductible that some of these patients, like examples of a patient acquiring a specialty drug?
If I take your multiple sclerosis example, MS. Products typically today are easily 60, 70, sometimes $80,000 a year. In terms of the product cost, the patient might have some form of co-insurance because it's a specialty product to your point. I have seen co-insurances range from 10 to 20% pretty. Typically, they may be in a five, $6,000 deductible phase, but the co-pay assistance programs are typically a bit more rich.
They might allow a couple of grand per month or maybe up to 20,000 or $24,000 a year. So you can kind of see how this could. Potentially play out, right? They, the patient could be getting the value of the copay And the manufacturer, uh, sponsored copay assistance. It might work out okay for the first three months that they meet their deductible phase.
Now, if there's an accumulator, it won't, they've gotta still pay that $6,000, uh, deductible at some point in time. But again, if it's a, you know, this is all about timing. I mean, this is literally a math problem based on do I spend it now? Do I spend it later? And that all depends on how that copay assistance program is gonna, is gonna try to come up with the, with the dollars to, to do that.
But to your point, it's typically you don't really run out of the, the copay assistance benefit in the first three months. It typically will get the patient through maybe middle of the year, maybe into the third quarter, and then to, you know, if a payer has that accumulator in place, then that $6,000 bill starts to come right in.
For a multiple sclerosis product that typically costs $7,000 a month, that's pretty much a whole month's prescription is being pushed over to the patient to pay for in that particular time, which could be a, a, a significant financial challenge for almost anyone.
[00:16:32] Stacey Richter: Yeah. In fact, I was listening to. Patient who had a kid with cystic fibrosis and her point was suddenly their prescription expenses went up $8,000 a year.
Mm-hmm. And she had to dig into her 401k. To get eight grand to pay for her child's, obviously you can't go without your cystic fibrosis medication, you know? Sure. So she had to dig into her, their retirement fund to fund the eight grand, which they never had to pay for before. And you know, her point was like, I just basically got.
My salary decreased by $8,000. You know, like effectively, like that's how, yeah. She was taking it, that her employer just, you know, might as well have given her a demotion of eight grand. Right?
Sure.
[00:17:20] Stacey Richter: Meanwhile, from the employer's point of view, if I'm thinking about this as an employer, I mean, obviously employers and PBMs are doing this for a reason, so we kind of touched on, we implied a reason before.
In my opinion, this is a very philosophical slash con, potentially contractual obligation that employers or payers see that the patients have to have to meet. The philosophical part of this is, is this something that the patient specific, it has to come out of the patient's credit card or bank account, or.
Is at the end of the day, is this about pushing cost off. So if you think about before the concepts of accumulators, the ideas of deductibles and copays, this was just a way of pushing the dollars either to the patient or to somebody else to pay for. Now we're getting into conversations of, no, no, I want the patient to pay not somebody else.
Right? And we're seeing some very interesting variations of copia assistance programs that that are happening and to try to hit on this philosophical point.
[00:18:21] Stacey Richter: Is this just like a skin in the game argument, like, oh, the patient needs skin in the game. So
I think that's part of it. I think that's part of it.
I think it's, it's some folks who are, you know, it's almost like the nuclear arms race, right? You've got two sides of the fence here and folks are just trying to combat each other, you know, in terms of how this actually gets to play out. And unfortunately the patient's kind of stuck in the middle in some, in, in many instances.
But, but again. You read the language of these benefit design and some of the, the plan documents that these payers and employers produce, it doesn't really say to the T that the, it has to come out of the patient's bank account. It's just, you know, this is patient's liability, which means, you know, the provider's IE pharmacy.
Should pay for that or should, uh, ask for the form, ask for the patient to pay for that. If somebody else, your, your grandparents decide to write you a check, or your mom or a wealthy person standing behind you at the Kanter that sees you're having a problem, does that really matter? You know, the, and these are again, kind of a philosophical kind of conversation, but again, the payers that have jumped onto the accumulator model feel strongly that it should come from the patient and not anyone else.
[00:19:26] Stacey Richter: A lot of times the skin in the game, philosophers,
yeah.
[00:19:30] Stacey Richter: They want patients to feel the financial burden of decisions that are being made relative to, you know, health spending, so that mm-hmm. They can be consumers. It's hard to be a consumer if somebody else is paying for everything, because everything's free.
You act like everything is free. Is the thinking there that these patients are gonna sit there and do a pro and con decision making matrix relative to whether or not the kid really needs this S Med?
I think the answer, it started that way. I think if you think about the financial mathematical model of this, and again, if we just use simple math, what we're seeing now happen is that.
You've now taken, and again, let's say a patient has a $6,000 or $8,000 deductible, whatever that dollar amount, you've basically got pharma to pay for that. When you first, at the, at the beginning, your initial, the way you've created the premium for that family or for that patient is basically saying, you know, $6,000, they've gotta pay for, pay for it first, right?
But what now, what's happened is you got pharma to pay that. Then what you're doing as a payer is you're now coming in saying, I still want the 6,000 from the patient. So in essence, you've now pushed $12,000, for example, of cost when you really modeled this to pay to push down to $6,000 of cost. So now it's become a.
You know, I think it's somewhat of evolved to being a, to your point, let's get the patients feeling this being a consumer, making consumer based decisions to how do I push further push costs on a pharmaceutical budget that's so out of control, especially in the specialty arena, you know, as soon as a product gets designated a specialty, you know, it's gonna be six figures now, seven figures in terms of cost, right?
So, so there's that aspect that I think it's now unfortunately started to, this is another mechanism for payers to push down. Additional costs too. Both the patient and now the pharma company.
[00:21:20] Stacey Richter: So it started out as a rebuttal to pharma's rebuttal,
right?
[00:21:26] Stacey Richter: So the PBMs obviously have a vested interest to get rebates and to put things in tears so they can drive volume, et cetera, to to products which their financially incented to drive volume toward.
You know, then the copay cards come out, which diminishes their leverage effectively. So, you know, the copay accumulators were reactionary to that. But then the prices of the pharmaceutical drugs started to go up and up and up. You start to have employers who just are freaking out because budgets are yes.
It can kill a budget if somebody gets hemophilia. So employers are start asking, you know, I can't pay for this anymore. Then the strategy kind of takes on another core imperative, if you will, which is legitimately to reduce employer cost.
Correct? That's exactly right.
[00:22:16] Stacey Richter: And the patient's stuck in the middle.
Yeah. Do you feel like ultimately, so just taking a step back, there is every incentive. And if you wanna hear more about this, listen to, there's a show with Vene Patel talking about the incentives just in kind of inherent systemic incentives for pharma to actually raise prices. It's kind of weird. Do these accumulators provide a Kanter force to that?
Like this is actually a legit impetus for pharma to not raise prices or to actually be competitive,
so, so I think being competitive and not raising prices are probably two different variables, two different things. I think as it relates to not raising prices, I think the answer is no. In terms of competitiveness, I don't think accumulators are really forcing pharma to be more competitive.
I think where we really see the biggest strides in competition is a couple of reasons. One, there's multiple pharma programs or products in that particular disease state that have now disease alternatives or, or therapeutic alternatives, and we're starting to see more of that competition. So in other words, if I have three uh, biologic products to treat, or three specialty products to treat rheumatoid arthritis, it's a lot better.
I can finagle a better rebate or price than when there's only one and that's the only game in town. Right. And I think there's, that's a, that's a pretty significant driver and less about the accumulators. I think what the accumulators have done really, as I've mentioned before, is they've kind of, payers have figured out to use that to push some of these additional costs to kind of create some breathing room, knowing that the next.
Million dollar hemophilia product is around the corner and they've, they can move dollars around when it, when it comes to trying to break even or trying to, trying to meet their, meet their budgets.
[00:23:57] Stacey Richter: So if I'm an employer, is that the best I can do? Which is basically save money by making my employees pay for it.
So that's one. I think that's one aspect. I think if you look at, well, what are all the tools, you know, the concept of formulary, which then hits to rebates, that's another tool. Do we want to put more clinical requirements to make sure if we're gonna spend hundreds of thousands of dollars to treat a specialized condition, do we wanna make sure that's the right patient?
So these clinical programs, these, these pre-authorization models that are out there to really make sure, you know, if we're gonna spend it, we wanna make sure we're not. We're not creating a scenario where we're throwing money down the, you know what, there are other things, moving sites of care. You know, home-based healthcare is, is now bigger than it ever was.
You know, being able to do I need to send and pay a hospital to infuse a specialty medication where that might be doable to send a nurse to someone's house and half the price, right? So there are other techniques, other applications or tools that can further alleviate. You know, the, this pricing, but I think it's, it's not a one, it's not a simple answer.
It's combinations of these things to really effectively create a program that's tailored for the specific types of patients in that employer population.
[00:25:05] Stacey Richter: Let's add a wrinkle here. Copay maximizers. How are they different than accumulators? I think I, I, I get the feeling that maximizers are kind of like the son of an accumulator.
Yeah, maybe more like a a half brother perhaps, but, um, let me maybe define it And we can get into the weeds of it. You know, if you think of the accumulator being not providing credit for the patient, the maximizer is doing something almost in essence, just, just completely different, which is if I know there's a copay assistance for a particular product, maybe I even know how much money a program even has.
Why don't I tailor a benefit design that's going to push or utilize and press upon the specialty pharmacies to enroll those patients so that pharma pays through those copay assistance programs, more of that cost. That's, this is you're basically maximizing those copay assistance programs and you could penalize the patient much like an accumulator, whether you, you don't give them credit for that.
Or you? You do.
[00:26:03] Stacey Richter: I didn't quite get that. So what exactly Yeah. Is a maximizer. So the accumulator, what that does is it removes the pharma's ability to contribute to a deductible. How does the maximizer differ from that?
If I can give you an example, if we use that same multiple sclerosis example, I'm just gonna use some round math here.
Let's say it's a hundred thousand dollars a year product And we know that copay assistance program. Has $24,000 of value that can be utilized to buy down the patient's, uh, copayment, right? So what the idea would be is, well, why don't I create a benefit design? In other words, a copay that's $2,000 a month, for example, right?
So that it equates to $24,000 perhaps the year before that patient might have had a hundred dollars copay with a $6,000 deductible. I'm kind of putting that away and I'm saying, I am now gonna charge you consistently. As a copay of $2,000 a month knowing that pharma's gonna come in to pay that 2000 Ahuh.
[00:27:02] Stacey Richter: So basically, I'm making my out-of-pocket match the pharma program deliberately.
Correct? Correct. We're try to, yes. We're trying to, yes. That's, that's the idea of the maximizer.
[00:27:15] Stacey Richter: Again, we were talking about game theory earlier. This is kind of like, I'll see your.
So, you know, employers and, and, and PBMs who are leveraging the maximizer strategy, they're doing market research. They're going around figuring out what all the max benefits are. You know, somebody made some giant spreadsheet, wrote down what all the pharma companies are paying, and then decided that they want legit the patient to pay a hundred dollars a month or something like that.
So now they're making the monthly out of pocket. $2,100 so that they're controlling and making sure that the patient isn't hit with like the pre previous example, like all of a sudden $8,000 of out of unexpected, out-of-pocket costs. You know, they're making sure that it's fair, but at the same time, they're recognizing the form of contribution.
That's right. And there's variations of this, but that is exactly a general mindset or, or definition of what a maximizer is.
[00:28:09] Stacey Richter: What's the downside there?
What is this? So, so, uh, whose perception or whose per, you know,
[00:28:13] Stacey Richter: who doesn't
like it? It, there's always
[00:28:15] Stacey Richter: somebody that doesn't like it.
I think the pharma doesn't like it.
I think pharma, you know, has a distaste for both the accumulators And the maximize. Right. They were never intended to be utilized. This way they were intended to be down the financial liability, whether it's a deductible, co-insurance copay. Right. And, and you've now got payers utilizing this and there's lots of variations of this.
I have seen very bizarre ones. Two very,
[00:28:38] Stacey Richter: give examples of a bizarre one. I just, I can't wait.
I have seen where using that cystic fibrosis, 'cause it's such an expensive products, these are 300, $400,000 a year in some cases where the payer might put out a $25,000 copay. Or co-insurance. Right. That, And they basically, the, the pharma company will pay it And they just maximized that entire copay assistance that would've been for the patient in one month in one script.
Right. So there's that kind of, what I think is a very disastrous and, and perhaps, um, inappropriate way of, of applying a copay maximization model. Right. They're just sucking a dry all in. All in one shot or, or, or in two months or what have you.
[00:29:16] Stacey Richter: And then the patient still winds up losing because now in February they ran, they have no subsidy.
Right. They don't have a subsidy. And even if their copay goes to something reasonable, you know, like even a grand, it's still, it's still a challenge. So there's yep, there's absolutely that. But, but again, I mean, I think there's, there's a very, there's variations of approaches here that, that we, I have seen folks attempt at and, and I would say maximizers.
Are a bit new except for a couple of payers out there that have been probably doing this for five, six years. Many folks have maybe jumped onto this in the last year versus accumulators who are even seeing some legislation in certain states that say you can't do accumulators. You know, they're trying to push back on a, on a policy perspective.
But, but again, the maximizer model is a bit newer and, and still try to figure its way in, in sort of mainstream pharmacy benefit services.
[00:30:02] Stacey Richter: You know, another program that always seems to come up in these conversations, which isn't really related, but it's adjacent enough that it always seems to come up the patient assistance programs,
right?
[00:30:13] Stacey Richter: Wherein a pharma company donates, you know, charitably, donates a chunk of change to a patient group, a patient advocacy group. And that patient advocacy group then helps patients pay their out-of-pockets.
That's a, a bit of a different model in the sense that there's a typically a significant qualification that the patients have to meet, such as they don't meet poverty level limits to qualify for Medicaid, for example.
But they're obviously not able to pay for their medications. They're kind of in that. And that little void or gap there, that's, that's pretty wide in terms of number of people in the us And then to your point, they would get qualified in these patient assistance programs that are typically foundations, charitable organizations that are providing those dollars.
Many of those dollars come from pharmaceutical companies, sponsorship, et cetera, to, to help pay for, for those products, right, to help assist those patients.
[00:31:11] Stacey Richter: I think one of the things that probably warrants mentioned with this whole, in this whole conversation is that we're talking about, let's just say it's, it's patient and co-insurance And the patient's responsible for 20% of the cost of the med.
That means the employer's responsible for 80%. It is financially, let's just say advantageous for somebody, meaning the pharma company, somebody to pay the patient's portion so that the patient can get the med, because there's still 80% of the cost of the med on the table, right?
And
[00:31:44] Stacey Richter: that's right, that 80% is being born by these employers.
So like in the cases that we're talking about here, where there's no therapeutically equivalent, alternative. You have this poor employer, I feel, for employers who are, I feel being put to a certain extent in a, in a situation that is almost as untenable in certain cases as the one that the patient's getting put in.
Yes, you're a hundred percent right. This is their biggest challenge. How do I keep healthcare affordable for themselves? Offer reasonable premiums to their employees. And sustain a business. It's, it's definitely a challenge. They are, they are struggling. I have seen multiple times, or especially these gene therapies that come out and, and thank God these employers have reinsurers and stop loss, but even that causes them to their cost to go up in that perspective to pay for these.
Expense about why the cases that are millions of dollars, where they don't even spend that much in their entire prescription benefit, you know, and they've got a $2 million bill that just came about. So it's, it's a, it's, it's extremely challenging. These are the issues that employers are trying to figure out.
There's no clear answer to this.
[00:32:50] Stacey Richter: I was just actually reading a randomly a Milliman report, which suggested that stop-loss very frequently doesn't even cover the gene therapies, like they're excluded anyway. So, you know, it's also a question mark, even if you have stop-loss that you're paying handsomely for whether or not it's gonna cover some of this, this stuff.
That's right.
[00:33:07] Stacey Richter: So Dea, do you wanna talk a little bit about a cell health?
Cell health is a specialty pharmacy cost containment benefit management company.
[00:33:14] Stacey Richter: So if someone is interested in learning more about Acala Health, where can they go for info
ella health.com.
[00:33:21] Stacey Richter: Dea Belazi, thank you so much for being on Relentless Health Value today.
Thank you.
[00:33:25] Stacey Richter: So let's talk about going over to our website and type in your email address in the box to get the weekly email about the show that has come out. Sometimes people don't do that because they have subscribed on iTunes or Spotify and or we're friends on LinkedIn. What you get in that email is a full and unredacted unedited version of the whole introduction of the show transcribed.
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