Paying for cell and gene therapy - Is the future already here?
Multiple novel payment models for CGT are in development but an open and collaborative approach among all healthcare stakeholders is needed if the significant legal and practical barriers are to be overcome
- The first horizon (H1) has involved conducting pilots and has mainly driven patient access within the existing reimbursement system. These were the early attempts through informal discussion with CMS, proposals intended for CMMI models, use of Medicaid state plan amendments, and considerable VBC activity in the commercial markets avoiding best price implication. It works, but it’s cumbersome.
- In the second horizon (H2), reimbursement models evolve through partnerships and collaborative structures beyond the traditional pharma-payer/PBM frameworks. We are looking at reinsurance risk pools, consortia for annuity funding, and new commercial actors taking on risk and therapy management. Leaders are active today in defining the new parameters required, disrupting historic arrangements by engaging with new partners.
- And in the third horizon (H3), the aim is to unleash a regulatory transformation that would see today’s legal, systemic and practical barriers fully replaced with a novel reimbursement paradigm successfully enabling the value-based payment of any number and type of future therapies. The CMS rule, if finished, would be a major enabler in this direction. Other regulations may follow in the flood of drug pricing proposals reaching a new Congress in 2021.
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