Innovative Insurance to Improve US Patient Access to Cell and Gene Therapy.

Area of Science:

• Health Economics
• Biotechnology
• Genetics

Background:

• Cell and gene therapies (CGTs) offer life-saving treatments for rare diseases.
• High costs and uncertain outcomes lead insurers to restrict patient access, potentially worsening health disparities.
• Reinsurance is a tool insurers use to manage high-cost claims, but current plans may not adequately cover CGTs.

Purpose of the Study:

• To estimate the incremental annual per-person costs of covering existing and expected CGTs in the US from 2023-2035.
• To analyze these costs by payer type, including commercial plans and state Medicaid programs.
• To assess the impact of reinsurance fees on overall CGT coverage costs.

Main Methods:

• Simulated incremental annual per-person reinsurer costs for CGTs (2023-2035).
• Utilized published estimates of US CGT spending and assumed a US population of 330 million.
• Calculated costs based on current CGT reinsurance fees and illustrated with sickle cell disease-targeted CGTs.

Main Results:

• Estimated annual incremental spending on CGTs to reach $20.4 billion ($15.69 per person) between 2023-2035.
• Spending is projected to be concentrated among commercial insurance plans.
• Sickle cell-targeted CGTs may add up to $0.78 PMPM, primarily impacting state Medicaid programs; reinsurance fees increase total costs.

Conclusions:

• Annual per-person costs for CGT access are expected to be concentrated in commercial and state Medicaid plans.
• Current insurance policies may not sufficiently cover CGTs, necessitating policy improvements.
• Enhanced policies are crucial for improving CGT coverage and affordability to ensure patient access.