The clinical team from Goodroot and its affiliate companies — including AlignRx, Nuwae and RemedyOne — released an insights guide today titled “Cost vs Cure: Gene Therapy’s Financial Blueprint.” There have been rapid and significant advancements recently in the realm of gene therapy, but treating or preventing once-incurable diseases can come with monumental costs.
“In a system already straining under the cost of care, these therapies present a new challenge for plan sponsors,” says AlignRx chief pharmacy officer Beckie Fenrick. “As gene therapies become more widespread, insurers and employers are searching for solutions to manage the cost.”
Goodroot’s insight guide explores the nine gene therapies now available in the U.S. and the complete pipeline landscape of 65 therapies currently under consideration by the FDA. It also explores emerging cost solutions for these six- or seven-figure therapies. Hemgenix, a one-time treatment for hemophilia, currently holds the title of world’s most expensive drug with a price tag of $3.5 million.
“Gene therapies are becoming more common for more diseases,” says RemedyOne executive vice president of clinical services Rob Louie. “The FDA projects that by 2025 there may be 10 to 20 such therapies gaining approval each year. This will absolutely solidify their role in modern medicine. Plan sponsors need to thoughtfully engage in this issue now, so they aren’t caught off guard.”
Employer groups and health plans that adopt gene therapy financial protection products will have an advantage while navigating new terrain that is likely to require a number of steps for patients and employers.
“Patients must align with clinical benchmarks and meet strict prior authorization stipulations for gene therapy claims,” explains Fenrick. “These therapies often require specialist facilities and clinician administration, so plan sponsors might consider channeling treatment exclusively through recognized centers of excellence, in addition to implementing thorough utilization management strategies. Market stop-loss offerings should also be analyzed.”
In addition to the cost, the fluidity of insurance dynamics is also adding to health plans’ hesitancy in covering gene therapies. People change jobs frequently over the years and this churn complicates the landscape, particularly given the upfront, high costs of treatments. Shelling out hundreds of thousands or millions of dollars for an employee who may be working elsewhere in a few months is enough to give any payer pause.
“Gene therapies are both miraculous and astronomically expensive,” says Goodroot CEO Mike Waterbury. “The arrival of these therapies now requires innovation on the business side of healthcare to make them financially feasible for patients and payers. This is an area that needs more solutions to address the cost and accessibility, and there’s an opportunity here for innovative healthcare entrepreneurs who can address this issue effectively.”
Download the guide here
