Rob Gundermann on Copay Accumulator Impacts on Health Costs

Marisa Wojcik:
There has been some movement in the state’s legislature to address things like copay accumulators, open formularies and pharmacy access. We’re joined by someone on the front lines of this work. Rob Gundermann, president and CEO of the Coalition of Wisconsin Aging and Health Groups. And thanks for being here.

Rob Gundermann:
Thanks for having me.

Marisa Wojcik:
So tell me a little bit about how you got started in all of this.

Rob Gundermann:
Sure. Well, I started getting calls from patients who were trying to get their medications. They’d go to the pharmacy counter, and they were being told that it would be thousands of dollars to get the medication that they’re used to paying 30, 40, $50, whatever their copay was. And they were learning that a copay accumulator had been applied to their policy. The one that really struck me was a woman with a heart condition who needed this heart medication to live, and she went up, like she always does, to buy her medication. They said it was going to be $3,800. They didn’t have $3,800. And her husband had to go to the bank and take out a loan so she could get the medication she needs to live. And I realized, we have a problem here. And that woman who I’ve come to know, she — her family is going into debt more and more every year having to deal with this. So that’s how I got involved in this.

Marisa Wojcik:
And as you’ve been working on these issues, is this just all too common?

Rob Gundermann:
You know, when I started out in this, it wasn’t that common. It was — I was seeing in a plan here and people were starting to come to me. Now it’s become very common. It’s spreading like wildfire. There are very few plans left. I don’t even know of a plan left in Wisconsin that doesn’t have a copay accumulator other than the group, the state insurance plan.

Marisa Wojcik:
And there’s accumulators, maximizers and those sound like good things.

Rob Gundermann:
They do. They use catchy terminology, and they’ve probably run this through marketing groups to see what, what people like and what people don’t like. But you’re exactly right. There are copay accumulators. They’re copay maximizers. They’re all doing essentially the same thing, but just from a little bit different angle. You know, when you look at this copay accumulator piece, it just to me, this is just so unfair and I don’t — it’s been difficult for me to understand how this has been allowed. If you and I went out to dinner and I paid for your dinner and the restaurant said, We’ve adopted a copay policy where you have to pay for your meal and you say, “Well, Rob already paid for my meal.” Yes. And we appreciate that and we’re going to keep his money. But you also have to pay for your meal. You say, This isn’t fair. You’re getting paid twice for the meal. This is what the insurance companies are doing and they think it’s fine.

Marisa Wojcik:
What is the impact you’ve seen on patients? What does this do to someone who’s making this impossible decision?

Rob Gundermann:
Well, a couple of things. One, the financial stress that it’s putting families under that just can’t afford this. But the other piece is I’ve had people tell me they’re not going to take their medication anymore. I had a friend of mine who has MS and he says if they put one of these copay accumulators on my policy, I’m going to stop taking my medication. So you then end up with more problems with their health. And I don’t think that’s a cost saving measure by, you know, taking this money, they may get some money out of it. But I think in the long run, the increased health expenses that you’re going to have for people if they stop taking their medications are going to offset that.

Marisa Wojcik:
And as you’ve said and as we’ve seen in these stories, people don’t know until they’re so far along that they owe all this extra money. There’s no ability to have a payment plan for your medications. So you either get it or you don’t. How difficult is it for people to even know that something like this is on their plan? How much of it is just poor communication?

Rob Gundermann:
That’s a lot of it. It’s very difficult. I’ve looked at some of these plans, 50, 60 pages, and who’s going to read 50 or 60 pages of fine print? Some of this is very small, it’s hard to read, especially if your eyes aren’t so good as mine aren’t anymore. It’s hard to spot this little clause in there that says, and even if you read it, if you don’t know already what a copay accumulator is, you’re not going to understand what they’re saying in there.

Marisa Wojcik:
Now, Senate President Mary Felzkowski has been working on legislation like this for many years, many sessions. What are the concerns that state lawmakers have had making it so difficult to move this forward?

Rob Gundermann:
So I think the one thing that’s really held us up with state law — well, a couple of arguments that the insurers have made. One is that this will drive patients to more expensive brand name medications. We know 98% of the medications in this group, these expensive medications, there isn’t a generic for. But Senator Felzkowski put in language in the bill saying that this only applies to medications for which there is not a generic equivalent. So that’s off the table. They’re still making that argument, though. The other argument that we’re hearing is that it will drive up insurance premiums. But there’s studies that have been done looking at states that have already passed this type of legislation where the premiums haven’t increased. And conversely, studies have looked at states that haven’t passed this legislation and premiums aren’t lower there. Like in Wisconsin, our premiums aren’t lower where we don’t have that.

Marisa Wojcik:
Where does it currently stand? And what, if anything, has changed throughout this session as it’s gone through committee?

Rob Gundermann:
Sure. Well, we had a committee hearing, which was the first. This is the second session that we’ve tried to run this bill, and we weren’t able to get a vote out of committee last session. This session, we’ve got a 5 to 0 vote. So the entire committee voted in favor of passing this out in the Senate. And we expect that to come up to the onto the floor at some point in January. We just don’t know when. And so, you know, there’s a definite shift here where the momentum has shifted. I think there are 40 co-sponsors on the bill. But I think, I think the votes are there to pass the bill if we can get the votes.

Marisa Wojcik:
We saw in Cole Schmidtknecht’s story that he didn’t know that the formulary had changed and that’s something that’s been a point of contention in the legislation. Has that changed as it’s gone through committee?

Rob Gundermann:
Yeah. So the insurers wanted to be able to change the formulary throughout the year. And right now they could only change it during the window when people can change plans. And I said we didn’t have a problem with that. As long as they weren’t able to force the patient to change their medication mid-year. So I think it’s actually a benefit to patients, because if you’re going to make a formulary change, tell them in June or July, give them as much time as possible to figure out what they’re going to do and find a new plan that will cover whatever the medication is that they’re taking that is going to be leaving your formulary. So I think I don’t see a downside to that.

Marisa Wojcik:
Overall, premiums are going up. If people feel like they’re not properly covered under a plan that they’re paying a lot of money for every month, do you think patients will just end up foregoing a health plan altogether?

Rob Gundermann:
That’s our — that’s our concern, our worry. I think there are people who they’re going to look at this and say, “I’m paying so much out of pocket anyway. I’m not ever using the insurance, so what’s the point of having it?” And then when they have something serious happen, then it’s more problems. And it’s not like someone isn’t paying for that.

Marisa Wojcik:
Now we just saw Congress go through the longest government shutdown in history over these enhanced tax credits, and we’re still seeing premiums go up all around. How much of this is kind of reaching a turning point as healthcare premiums, costs are all going up and there doesn’t seem to be an end in sight?

Rob Gundermann:
We’re getting to the point where something has to happen and we can’t — my insurance went up almost 25% this year. We can’t have 25% annual increases in our health costs. Just as Americans, we can’t afford it. So we have to figure something out. And I don’t know what that answer is. I mean, people, smarter people than me, have been trying to figure this out for a very long time. But we’re getting to the point where we have to. This isn’t an option anymore. We can’t afford to keep going the way that we’re going. And for a lot of families without the Affordable Care Act plans being available to them, I think we have a lot of people who are just not going to be insured.

Marisa Wojcik:
Thank you very much for joining us.

Rob Gundermann:
Thanks.