Paul Levine, vice president of analytic services at TrialCard.

In the simplest view, co-pay cards provide access, grant that first use to the patient, and then drive persistence. However, Paul LeVine, vice president of analytic services at TrialCard, argues the assistance program can be much more than that.

“The co-pay card is really an entrée into an association of different constituencies involved in a transaction over a pharmaceutical product,” he said during his session, entitled “Improving Co-pay Performance with Patient Engagement Strategies,” at CBI’s fifth annual Coupon and Co-pay meeting on September 14 in Philadelphia. “Anytime a person uses a card like this, you’re engaging the patient, the HCP, and the pharmacy together.”

Rather than solely providing some benefits “right here and now” for purchasing a drug, the co-pay card ultimately represents a starting point of a powerful engagement tool, added LeVine, who has started to call it an affordability and engagement channel, as opposed to just an affordability solution.

“When you have these different constituencies involved,” he explained, “it means you can address a whole bunch of different issues this industry really struggles with.”


When discussing adherence in general, the industry mostly talks about moving a patient from 3.5 to 4.5 prescriptions. However, LeVine feels that line of thinking misses the mark.

“If we don’t get them to their first prescription, you will never get them to 3.5, let alone 4.5,” he emphasized. “This abandonment issue is real — and it’s big. About 30% of patients, in general, will not use that first prescription.”

This translates to a $300 billion impact on lost revenue due to poor adherence, he said, drilling down the numbers with another dire statistic. He related a story about one manufacturer who reported that about 75% of patients who abandoned their first diabetes prescription came off all diabetes medications in three months, which LeVine dubbed a “public health crisis.”


LeVine jokingly called the co-pay card the “hardest working acquisition tool in show business” – and for good reason.

Studies show that about 10% of the US’ non-publicly insured population have used a co-pay card/coupon. (For comparison, direct marketers typically consider a 1% to 2% response rate successful.) Furthermore, 73% of physicians and 70% of pharmacists report always recommending co-pay offset programs to patients.

Looking even deeper, evidence demonstrates co-pay programs work to improve adherence. LeVine pointed to a 2015 TrialCard study that revealed co-pay card use translated to a 17% to 20% improvement in adherence.

“The funny thing about adherence approaches is that lots of things work,” he added, noting data that packaging, text reminders, and telephone monitoring all had positive results on adherence.


Despite this affirmation, however, the research did highlight some remaining major gaps. For example, 31% don’t fill their first prescription, 20% go unfilled, 17% say cost is a barrier, and 43% drop off their medication after six months.

“How do you look at something where every single intervention for adherence works, but nothing seems to work at a global level?” he asked. “What the heck is happening?”

In pondering the puzzling question, LeVine examined a couple of studies focused on non-compliance.

One paper found that 23% cited “forgot to use” or “refill” as the cause, while 17% described cost as an issue. “That means there’s 60% we’re not touching,” he said.

Other parts of the pie included unwanted side effects, having no need for the drug, or inability to get the prescription.

LeVine then turned his attention to another study that underscored psychological problems, cognitive impairment, and poor discharge planning as reasons for subpar compliance.

“If we’re going to get better with adherence,” he suggested, “we have to figure out strategies to start addressing some of these other issues and make real progress.”

And LeVine didn’t mince words when discussing abandonment. “It’s where the pharmaceutical industry folks want to weep,” he surmised. “Everything has gone right up until this point. You have filled the channel, the doctor wrote the prescription, the patient gets the prescription, and then, it just doesn’t happen.”

To address this, LeVine suggested a focus on the point of sale as a possible approach. When patients are about to give up on their medications at the counter, some pharmacies will receive a pop-up message stating an opportunity for a buy down.

LeVine compared this method to the role of a soccer goalie. “It’s the last line of defense when every other approach hasn’t worked,” he explained. “[It’s not ideal], but if you have the chance to save that sale, you must take it.”


Another growing — and delicate — issue with co-pay cards revolves around the activation step. Pharmaceutical manufacturers have mixed feelings about activation, LeVine noted, with some worrying that it will put an impediment on patients getting the product.

However, does it actually adversely affect participation in a program? The answer: It’s complex.

According to data from TrialCard compiled over nearly 200 million offers, 16% of patients in a program without an activation step will redeem the card, as opposed to only 11% with an activation step.

“That’s not great,” LeVine opined. “You would like to see it higher, but when you factor in the adherence levels, it’s a different story.”

Although 16% will use the card, they will only use it an average of 2.2 times. Compare that to the activators who use the card a more impressive 5.3 times.

“[The activation] seems to have something of an influence, perhaps on the patient’s commitment,” he said.

Delving deeper into this paradox, TrialCard conducted a pilot study last year to see whether they could favorably improve the timely use of patients’ co-pay cards.  

The vast majority of patients activated their co-pay cards and used it the same day. The number declined significantly over time, but the research showed a sizeable — and perhaps surprising — spike in use five days or more after activation. LeVine deemed it a classic glass-half-full or half-empty scenario.

“I look at this and say, ‘The people were committed enough that they used it; however, I sure wish they used it faster,’” he noted.  However, there was an even larger group of patients – 34% – who had activated their card but never used it. “The question is whether we could bring some of those folks back into the program.”


The results from the pilot were very favorable. An incremental 15% of patients who otherwise would have abandoned wound up coming back into the program. Similarly, for patients who were seven or more days late in refilling their prescriptions, the pilot succeeded in re-engaging 16.6% of them.

The study didn’t offer the most sophisticated targeting or messaging either, LeVine explained. “This was blunt, brute force: ‘Please use your card, please refill.’ There’s way more that can be done with this. This is a floor impact.”

Still, in this study for one specific drug manufacturer, engagement effectiveness would yield more than 6,000 newly using patients, which goes back to the “first-fill problem,” he reminded the audience. “If you don’t get that first fill, you don’t get the second, third, fourth, or fifth.”

And that all translates to huge dollars. This particular manufacturer would recoup more than $14 million when re-engaging these patients and improving timely filling.


LeVine concluded his talk by underscoring his belief that once these people are “rescued,” they can be engaged as well. Patient engagement, he said, is one strategy to achieve the “triple aim” of improved health outcomes, better patient care, and lower costs.

In related work, Judy Hibbard, senior researcher of the Health Policy Research Group at the University of Oregon, found patients with the highest activation scores — those having the best skills and confidence to actively engage in their own health care — incurred costs up to 21% less than patients with the lowest activation levels.

As far as ways to better engage patients, LeVine recommended looking at the ubiquitous smartphone as an option, including gamification, text reminders, and educational information.

“Is it the perfect solution?” he asked. “Absolutely not. We’re dealing with human beings and a multiplicity of reasons as to why they’re non-adherent. That’s the bottom line, but it opens up this question: Do we have a better way of thinking about them?”

When viewed in that light, LeVine concluded, this could be the birth of a new paradigm where engagement is the driving force to propel access, acquisition, adherence, and outcomes.

This article was curated by the MM&M Content Lab, on behalf of TrialCard. The MM&M editorial team was not involved in the creation of this article.