The Little-Known Way Pharma Companies Hook People

December 15, 2018

Kip Burgess was relieved last year when pharmaceutical giant Amgen overnighted him a $2,976 check to help pay for his go-to arthritis drug, Enbrel. The 36-year-old psychologist had run into an increasingly common problem: The copay coupon sent by Amgen couldn’t cover the drug’s more than $4,000 monthly price.

“Nothing in the world gives me more anxiety than just getting my medication,” Burgess said. “There’s nothing you can do but beg.”

Panicked, Burgess had called Amgen and pleaded for help. The drugmaker sent him the check after he provided a credit card statement and an explanation of benefits to prove he bought its drug.

It’s one of the little-known secrets in health care: When financial incentives like copay coupons and debit cards won’t work, pharmaceutical companies sometimes will write a check — what they call direct reimbursement — to make sure a loyal patient will stay on a high-cost, brand-name drug.

Drugmakers began using now-popular copay coupons and other forms of assistance more than a decade ago to help patients pay out-of-pocket costs for medicines, particularly high-cost specialty drugs such as those that treat autoimmune disorders. The coupons have a dual purpose: They mask the true costs of a drug for patients and give patients a financial incentive to stay on an expensive drug until their insurance deductible is met.

Ellen Albritton, a senior policy analyst with Families USA, said the multiple calls Burgess made to his insurer, pharmacy manager and the drugmaker to pay for his drug is “a lot to put on a patient.”

“This highlights just how dysfunctional the system is, and it just isn’t working for patients,” Albritton said.

The practice of sending checks is legal as long as the patients are not enrolled in government-funded insurance such as Medicare and Medicaid, said William Schiffbauer, a Washington, D.C.-based health insurance attorney.

“You can accept cash from anybody as long as it’s not a government program,” Schiffbauer said, noting there may be income tax obligations for the patient. The federal anti-kickback and Stark laws were meant to prevent bribery of patients and doctors and do not apply to private commercial insurance plans.

AbbVie, which makes the blockbuster arthritis drug Humira, will send a check if patients can prove their copay card doesn’t work for a variety of reasons, said Adelle Infante, director of external communications for the company.

Amgen, the maker of Burgess’ arthritis medicine, provides up to $12,000 of copay assistance each year to commercially insured Enbrel patients who need help meeting out-of-pocket expenses, often regardless of the patient’s financial status. When the cards fail to work, for whatever reason, Amgen can send direct reimbursement.

While Amgen’s primary assistance is through copay cards, “in some instances, based on patient preference, Amgen will provide direct reimbursement” after a patient has already paid for the medicine, Amgen’s Kristen Neese, director of corporate affairs, said in an emailed statement.

Harry Totonis, chief executive of ConnectiveRx, a pharmaceutical services company, said sending checks to patients is “not a commonly used practice” and happens “a fraction of 1 percent” of the time. He declined to confirm the average value of the checks or name the drugmakers that issue checks via ConnectiveRx.

“All of these programs try to help patients afford the medications,” said Totonis, whose company bought PSKW, which issued the check Burgess received from Amgen in 2017.

Daniel Nam, executive director of federal programs for AHIP, the America’s Health Insurance Plans, said direct reimbursement using checks is just another way for manufacturers to make insurance companies pay for expensive drugs, which helps jack up monthly premiums. This approach will “create a new black hole of patient-directed payments and avoid any scrutiny,” he said.

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