UnitedHealthcare Delays Medical Benefit Accumulator, Anthem Plows Forward

UnitedHealthcare Delays Medical Benefit Accumulator, Anthem Plows Forward

November 2020

In October 2020, UnitedHealthcare introduced an Accumulator Adjustment Medical Benefit Program, the first of its kind to be specific to the medical benefit [1]. Accumulator programs aim to leverage the copay assistance programs offered by the manufacturer, to prevent them from counting towards a patient’s out of pocket payment maximum and thereby shifting costs from the insurers. In their recent history, accumulator programs have mostly affected pharmacy benefit products largely due to limitations in the buy-and-bill model. Under the buy and bill model, the infusion site is responsible for procuring, storing and infusing the product [2]. Once the patient is infused, the site bills the insurer for the therapy and medical services. Therefore, there is limited visibility / control at the point of service, which is required to operationalize an accumulator.

On November 12th, UHC announced the program would be delayed “due to recent feedback we’ve [UHC] received from healthcare professionals like you [1].”

To gain the required visibility into practice-level financial dynamics, the UHC accumulator program planned to leverage the provider or infusion site. UHC’s program would have required “providers to submit payment information received from drug manufacturer copay coupon programs which are applied to a member’s cost share when billing for specialty medications as a medical benefit drug claim” [1].  After claims are submitted and reviewed through an online portal, providers were required to bill beneficiaries as needed.

As a result, UHC’s accumulator program would have a significantly impacted patients, providers & sites of infusion, and manufacturers:

  1. Patients could be stuck paying high out-of-pocket expenses once copay assistance is depleted, leading to increased abandonment.
  2. Providers & sites of infusion would be impacted by the increased workload associated with identifying and reporting manufacturer assistance to UHC. As a result of the increased lift to operationalize the program, potential implications would have included the need to add headcount, ceasing buy-and-bill and requiring white bagging, and/or outright refusal of the referral of UHC beneficiaries.
  3. Manufacturers would have to weigh expanding their copay assistance program to minimize patient out-of-pocket expenses against capping programs, which could result in patients paying high out-of-pocket expenses and disrupting therapy.

While the decision to delay is a win for patients and providers today, it will be prudent for stakeholders to monitor what UHC and other insurers decide to do in the future. Specifically, UHC may choose to roll out the same accumulator program, a modified version or pivot to a different strategy altogether. One potential pivot could be Anthem’s specialty pharmacy mandate [3].

Earlier this year, Anthem notified physicians in California certain medical benefit specialty products administered in the office or outpatient hospital setting must be procured from CVS specialty pharmacy, for their commercial and Medicaid HMO members [4]. More recently, Anthem notified physicians in California that commercial patients in their PPO or EPO plans must procure certain medical benefit specialty products through CVS specialty pharmacy, starting December 1st, 2020 [5]. If the drug is procured through other pharmacies, the claim will be denied, potentially ending the buy-and-bill model for these specialty products.

The policy aims to manage costs of specialty products due to variable reimbursement rates for specialty products administered in the office or hospital outpatient setting [5]. For example, hospital outpatient drug administration is typically reimbursed on a percentage of billed charges, which can exacerbate costs to insurers due to markups.

Anthem’s policy will have a significant impact on patients, providers, and manufacturers:

  1. Patient journey may be disrupted as the provider / site of infusion may prohibit white bagging, limiting the infusion sites available for patients.
  2. Providers & sites of infusion can no longer procure these products through buy-and-bill and may choose to prescribe alternative therapies unaffected by the policy.
  3. Manufacturers may have to bridge patients to avoid any disruption of ongoing therapy and ensure adequate access at the site of infusion.

Although UHC’s path forward is uncertain, it will be important to monitor the situation closely and to assess the potential impact on the broader market. Many insurers (e.g., Humana, Aetna) have implemented policies blocking or not preferring infusions in the hospital outpatient setting. Meanwhile, providers and manufacturers must proactively develop strategies ensuring minimal disruption to patient access.

Jupiter is a global team of strategy experts with a shared passion for shaping value and navigating market access for drug manufacturers. We have expertise in assessing the potential risk and impact of these policies and developing creative mitigation strategies to limit the exposure. Reach out to us at contact@jupiterls.com to discuss how we can help you navigate through these challenging times.

Sources:

  1. UnitedHealthcare (uhcprovider.com)
  2. Fein, Adam J. “Follow the Vial: The Buy-and-Bill System for Distribution and Reimbursement of Provider-Administered Outpatient Drugs.” Drug Channels, 14 Oct. 2016, www.drugchannels.net/2016/10/follow-vial-buy-and-bill-system-for.html.
  3. Anthem (anthem.com)
  4. “Anthem PPO Added to Specialty Medication Policy.” Cmadocs, July 2020, www.cmadocs.org/newsroom/news/view/ArticleId/49028/Anthem-PPO-added-to-specialty-medication-policy.
  5. “Anthem Will Not Delay Specialty Medication Policy.” Cmadocs, July 2020, www.cmadocs.org/newsroom/news/view/ArticleId/48969/Anthem-will-not-delay-specialty-medication-policy.