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Survey Offers Payer Insight on Current and Future Gene Therapies

April 30, 2021

By Edan Stanley

Diane Smith, PhD, associate director of reimbursement & policy Insights, Ana Stojanovska, vice president of commercial consulting, Matthew Sarnes, PharmD, senior vice president, business development & strategy, and Amanda O’Hora, senior director of reimbursement, policy and insights, all at Xcenda (a part of AmerisourceBergen) discuss results from a survey of managed care professionals about marketed cell and gene therapies as well as how payers currently pay for and reimburse said therapies.

What existing data led you and your co-investigators to conduct this research?

There is more momentum than ever before in bringing innovative products, like cell and gene therapies, to market. However, these advanced therapies require unique payer and reimbursement models due, in part, to their cost and administration. For example, many cell and gene therapies are one-time treatments. Current payment systems and reimbursement paradigms are not designed to capture the value of a cell and gene therapy product over the term of a patient’s policy. Across the industry, we’ve heard about the emergence of new payment models, including a value- or outcomes-based model, pay-over time model and a subscription-based model. However, it wasn’t known how many payers were using these innovative payment models to manage novel therapies, and how—if at all—that would change in the coming years.

Please briefly describe your study and its findings. Were any of the outcomes particularly surprising?

To address these questions, we conducted a survey of payers in Xcenda’s Managed Care Network, a market research panel of more than 160 advisors including medical and pharmacy directors, health care executives and other managed care experts.

We discovered that the vast majority of US payers use traditional techniques, like formulary or utilization management tools. In fact, only about 28% of those surveyed reported using a value-based model. However, we anticipate a substantial shift toward these innovative payment models in the next couple of years, with payers more frequently using reinsurance, value-based contracting and installment payments. Nearly half of the payers surveyed said they were very likely to use a outcomes-based model. Meanwhile, the majority of payers said they are likely to use reinsurance to manage the costs of cell and gene therapies.

What are the possible real-world applications of these findings in clinical practice?

Manufacturers and payers need to be flexible, agile, and open-minded in considering arrangements that may support improved patient access to these potentially curative therapies. We anticipate new and traditional payment mechanisms will likely co-exist for quite some time. That said, there are opportunities to advocate for incremental change to modify existing payment and reimbursement methodologies to better account for the long-term value and clinical outcomes over the term of the patient’s policy. Ultimately, the evolution and increased use of these alternative payment models will help expand access to these therapies and drive product success.

Do you and your co-investigators intend to expand upon this research?

Yes, we plan to follow this topic closely to continue to monitor how the payment landscape evolves. Looking ahead, we may expand beyond our focus to include the provider perspective on cell and gene therapies. Our extensive market research in the C&GT space confirms the need for many stakeholders (payers, providers, manufacturers, patient advocates) to stay well-coordinated in order for a therapy to be most successful. We’ll leverage our respective networks - for instance Xcenda’s Global Provider Insights Network and Managed Care Network—to continue gathering critical insights across this unique patient journey.

Smith D, Stojanovska A, Sarnes M, O’Hora A. Current and future payment of cell and gene therapies. Poster presented at: AMCP 2021, April 12-16, 2021; Virtual. 

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