Presentation (CTI)

OBJECTIVES: High-cost specialty therapies may present affordability challenges for insurance plans and patients. This research explored US stakeholders’ perspectives on accumulators, maximizers, and alternative funding programs (AFPs) as mechanisms to reduce plan spending.
METHODS: A qualitative, web-based survey was fielded via the Rapid Payer Response^TM online portal (RPR^®) to 16 payers, 3 employer benefits service specialists, 2 patient advocacy group representatives, and 2 physician KOLs.
RESULTS: Payers currently place higher priority on established cost containment tactics (stricter PA criteria, formulary exclusions, step edits, tiering) than on Acc/Max and AFPs. Use of these programs varies based on plan types, state regulations, and organizational priorities. While use of Acc/Max is expected to remain stable, most payers foresee an increase in AFP enrolment based on growing interest from employer sponsors, higher opportunity for cost savings than Acc/Max, and because risk is diverted away from payers, employers, and patients. Employers are not fully aware of these programs, although they seek to understand how they impact patient affordability, in line with their goal to balance cost management with satisfaction and coverage adequacy. Patient advocacy groups view these programs as strategies by insurers to increase profits at the expense of patients. They highlight the current lack of objective data linking the programs to clinical and economic outcomes. KOL perceptions were mixed; the oncology KOL had a negative perception of Acc/Max, but viewed AFPs favorably due to their ease of navigation. The HIV KOL had a more positive perception of maximizers for spreading out costs over the year, but viewed AFPs negatively due to income eligibility limitations and adherence issues.
CONCLUSIONS: This research highlights current stakeholder perspectives on Acc/Max and AFPs and underscores the need for further research on how these cost containment tactics impact patient affordability, treatment adherence, quality of life, long-term clinical outcomes, and health equity.