As more gene therapies are set to come down the pipeline, payers and employers can proactively prepare for those products in several different ways, according to a new white paper from CVS Health.
In the report (PDF), the healthcare giant offers a four-point strategy health plans and plan sponsors can adopt to get out ahead of the costs associated with these treatments, which are set to balloon significantly as they’re applied to more common diseases.
The suggested steps are:
Extend the centers of excellence approach to gene therapy providers.
Continue to evolve the role of specialty pharmacy.
Embrace value-based contracting.
Try financial protection programs.
CVS estimates that costs for gene therapies could range from $14.8 billion to $45 billion between 2020 and 2024, depending on how much they proliferate. Products in the pipeline set to launch in that window include gene therapies targeting hemophilia A and B as well as sickle cell anemia.
It’s hard to gauge at present how many patients will use these treatments and how effective they’ll be at a larger scale, according to the report. For example, if just 5,000 people were prescribed Zolgensma, for now the world’s most expensive drug, that would add $10 billion in healthcare spending to the system, according to the white paper.
Gene therapy products are a perfect place to roll out a value-based contract, as manufacturers really believe in them and want to grow their use, Troy Brennan, M.D., executive vice president and chief medical officer at CVS Health, told FierceHealthcare.
“They lend themselves to value-based contracting better than almost any other kind of therapy,” Brennan said.
In addition to the drugmaker’s drive to get these treatments out there, the relatively small patient population makes it easier to track outcomes data over time, he said.
There are challenges to consider, however, according to the report. For one, the insurer will need to track outcomes long-term, even if the employer switches to a different plan provider or the patient jumps to a new job. Brennan said payers will need to consider contractual obligations for ongoing monitoring in these instances.
Another solution posited in the white paper is offering employers a payment plan so they can shoulder the potentially multimillion-dollar cost of these drugs over several years instead of upfront. In that case, contracts may also need to be written to ensure these payments remain in place if the employer switches to a new health plan, according to the report.
“I think people believe that’s reasonable during a specific period of time,” Brennan said.
Aetna operates a National Medical Excellence Program that could serve as a model for centers for excellence in this realm, according to the report. In transplant care, providers “welcomed” the chance to work with knowledgeable case managers, and the insurer believes it would see similar results for gene therapy providers.
Brennan noted that traditional centers of excellence at times required support for patients to travel to those providers, but for gene therapy, providers have good regional distribution.
“I think from the employer’s perspective, if you’re going to pay for these particular kinds of therapies you want them to be administered by experts,” he said. “I think the employers have always found these centers of excellence programs important and appropriate.”