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Looking Ahead to Gene Therapies

New treatments on the horizon will require new ways of paying for care.

illustration of a red white and blue health insurance card

Over the next decade, a flurry of gene therapies are expected to be approved and come to market. Insurers, health care systems, manufacturers and patients are all grappling with how to pay for these innovative and potentially “curative” new therapies. It is generally accepted that current payment models for existing therapies will likely not work for gene therapies. 

CSL Behring had the opportunity to sponsor a recent session at BIO Digital, this year’s virtual international conference for the Biotechnology Innovation Organization, entitled Novel Reimbursement Approaches – Overcoming Barriers. The discussion centered around potential new innovative payment arrangements for gene therapies where insurance payers would be willing to provide coverage for patients. 

Unlike existing drugs and biologics where health insurers pay based on product utilization, gene therapies will potentially “cure” the condition or at least have an extended period where further medication is not needed. Gene therapies will pose a unique financial challenge as the costs are immediate and more expensive over the short term. Long term, gene therapies should bring savings to the healthcare system and bring great benefit to the patient.

CSL Behring’s Head of United States Market Access, Robert Rouse, was joined on the panel by Michelle Rice, Chief External Affairs Officer at the National Hemophilia Foundation and James Kenney, immediate Past President of the Academy of Managed Care Pharmacy and formerly of Harvard Pilgrim Healthcare. The discussion centered around potential payment models where the insurer will see value in the coverage of gene therapies without absorbing all the financial risks.

Rouse posed the rhetorical question of “how does the healthcare system deal with new innovative ‘curative’ therapies” before addressing how industry has to collaborate with payers on the best way to cover such therapies so patients can have access. This can include specific types of value-based arrangements with insurers such as payments based on the effectiveness of the gene therapy and payments being amortized over a period of time as two types of examples.

Kenney stated that if payers see “good value for the money being spent there will be no hesitancy for covering these products.” He stressed that insurers do have to see such value in the form of positive outcomes in order to “have a good return on their investment.”

Rice stated that patient advocacy groups such as the National Hemophilia Foundation serve as a bridge to facilitate dialogue with insurers and manufacturers. As patient groups “do not have skin in the game” other than ensuring the best available treatments for patients, they can be honest brokers. She urged gene therapy companies to engage early on with insurers, well before product approval, to build the relationship, share knowledge about the therapy and to avoid surprises regarding potential coverage.

This session illustrated that gene therapies have great promise for patients and potential long-term savings for the health system, but require a new reimbursement model where insurers can see value with acceptable risk. Only through this collaboration between manufacturers, insurers and patients will models be developed where those in need will be able to access new innovative gene therapies.

screenshot of the four panelists at a virtual conference session at BIO 2021 about reimbursements