Are Payers Ready to Address the Financial Challenges Associated with Gene Therapy?

Health Affairs, June 28, 2018

While the development of gene therapies holds substantial promise for the treatment of rare diseases, some patients will face barriers accessing them due to payer concerns. These concerns include expected high one-time payments, uncertainty about the clinical effects over the long term, and the potential for patients to switch from one insurer to another over time.

Several alternative payment strategies have been proposed to help mitigate these concerns and address potential patient access barriers; these include long-term financing agreements that smooth payments over time and performance agreements that link payments to certain clinical milestones. But are payers interested in adopting these new mechanisms or will they instead rely on existing access and risk management mechanisms, or simply exclude coverage for gene therapy altogether?

That question was addressed by a group of researchers that included Analysis Group Managing Principal Noam Kirson, Vice President Michaela Johnson, and coauthors from the National Pharmaceutical Council. They conducted an online survey of payers – including pharmacy directors from 21 national and regional managed care organizations that cover 123 million lives in the US – about the roles that existing and new payment methods could play in managing the financial uncertainties created by these therapies. In a blog post for the journal Health Affairs, they summarize key findings from the survey's results. Among their findings are that these concerns are significant for most payers, and that payers expect to use a combination of new and existing approaches to manage the financial risk of gene therapy. While many would, under the right circumstances, consider alternative payment models to manage plan risk, their preferred payment approaches may not be entirely effective in addressing their concerns.

Read the blog post


Ciarametaro M, Long G, Johnson M, Kirson N, Dubois R