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U.S. Government Proposal Highlights Unfair Prescription Co-Pay Practices

U.S. Government Proposal Highlights Unfair Prescription Co-Pay Practices
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Published on December 1, 2017


A proposed change in Medicare regulations highlights a flaw in the system that should concern us all, and should be considered as we tackle growing concerns about co-pay foundations losing funding and out-of-pocket costs for our prescriptions rising. Now we have a chance to voice our opinions and tell the government just what we think.

CMS, the Centers for Medicare and Medicaid Services that administers these programs, has proposed regulatory changes that include a proposal to require that our out-of-pocket payments reflect at least a portion of the rebates and discounts given to the insurance plan by pharmaceutical manufacturers.  It is shocking that this does not happen now.

In my own case, since January (2017) I have been using Medicare Part D to help pay for my daily oral cancer medicine.  Before that I had commercial, insurance and no co-pay. But with Medicare I got hit first with a huge co-pay of over $3,000 and then a monthly co-pay of $623. I work and do not qualify for co-pay assistance through any foundation.

That’s bad enough, but then I did some investigating and found out I was paying Express Scripts and my Part D insurance provider a co-pay based on the full retail cost of my medicine even though they, no doubt, were paying a discounted rate or they got rebates that were never reflected in my charges.

Frankly, this is collusion to boost their profits at the expense of seniors, many of whom are already struggling to make ends meet.

In the proposed rule change CMS confirms that what happens to me is not an isolated issue with Part D, the Medicare program that pays for prescription medicines. “To date, sponsors have elected to include rebates and other price concessions in the negotiated price at the point-of-sale only very rarely.” (Sponsors?  This is government insurance, but the plans are administered by private insurance.)

This has been permitted by law to help lower the calculations used to set insurance premiums; the premiums are based on the final discounted price. However, CMS notes, this premium reduction often leaves excess amounts that “contribute to profits not premiums.”

Reducing our co-pays to reflect the actual costs paid by insurers and middle men may increase premiums. But if the entire pool of people paying premiums, which includes many healthy people, shares the costs, it is less burdensome than putting this squarely on the backs of patients who are counting on insurance. And it is certainly better than just increasing insurance profits.

Further, CMS point out, it is not just a matter of cost, it is a matter of health! “Numerous research studies further suggest that the higher cost-sharing that results can impede beneficiary (patient) access to necessary medications, which leads to poorer health outcomes and higher medical care costs for beneficiaries and Medicare.”

Some final thoughts

  •       If you slog through the entire 713 pages of the proposed rule changes, you’ll see just how cumbersome and burdensome is this concept of insurance. Friends, it should be simple. Insurance is a way to spread the cost of healthcare across a large population so it is affordable by everyone, and not a mountain of debt for those of us who need it.  That’s what any insurance does—car insurance, home insurance, even where I live, earthquake insurance.
  •       Slog through the 713 pages of proposed rule changes, and you’ll begin to think we need a doctor with a business degree not a medical background.
  •       Slog through the 713 pages of proposed rule changes, and you’ll see why a 2010 National Institutes of Health workshop determined we spend $315 billion on “a complex web of payment validation, claims processing and treatment approvals that change from one insurance provider and benefits manager to the next.” 

If we applied just some of that to our healthcare, we would not have as big a worry about co-pays, so let’s do something about it: CMS is asking for public comment on the proposed rule changes. The agency is soliciting data and analytics, not just comment. Nevertheless, Patient Power is asking for your opinions and we’ll combine them and submit them along with data we can get from our partners. This is our chance to impact our co-pays; let’s take full advantage of the opportunity. [comment: let’s discuss how we handle this]

I can’t wait to hear from you! Just email your comment and whether you favor the rule change. Write us at

In the meantime, we wish you and your family the best of health!

Andrew Schorr
Co-founder, Patient Power LLC

Please remember the opinions expressed on Patient Power are not necessarily the views of our sponsors, contributors, partners or Patient Power. Our discussions are not a substitute for seeking medical advice or care from your own doctor. That’s how you’ll get care that’s most appropriate for you.


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