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Health insurers and employers are developing collaborative payment frameworks to manage financial exposure for cell and gene therapies, which can cost between $500,000 and $3 million per treatment, according to Medscape Medical News. Will Shrank, chief executive of Aradigm, a newly formed health benefits platform company, emphasized that individual payers cannot solve access challenges on their own, requiring collective action and resource pooling to ensure treatment sustainability.
Aradigm has consulted 15 of the largest U.S. employers and multiple insurers to create systems for pooling and capping financial risk associated with expanding cell and gene therapy applications. The healthcare system currently covers about 24 approved cellular and gene therapies, such as chimeric antigen receptor T-cell treatments for cancer, and many more are expected soon to focus on autoimmune diseases.
A September JAMA analysis by James Chambers and colleagues at Tufts Medical Center examined commercial health plan coverage policies for 25 approved cell and gene therapies. The research found that insurers typically cover approved indications but impose restrictions, including step-therapy requirements. The analysis highlighted the unique challenges payers face: they must absorb substantial one-time costs for patients who may switch insurers before recouping their investment.
Coverage innovations currently being tested include outcomes-based agreements. The Centers for Medicare and Medicaid Services finalized performance-based payment agreements with Vertex Pharmaceuticals and Genetix Biotherapeutics for gene therapies for sickle cell disease, covering 33 states, the District of Columbia, and Puerto Rico.
Companies are also pursuing manufacturing approaches to reduce costs. Fate Therapeutics says it is creating ready-to-use cell therapies from stem cells that cost about $3,000 per dose, much cheaper than current CAR T-cell therapies. These options could significantly affect healthcare budgets and may help more patients get necessary treatments for diseases like systemic lupus erythematosus and other autoimmune disorders that need complicated medications.
