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Effective reimbursement models are the key to the future success of gene therapies, a new PwC report shows.
Navigating the emerging challenges of gene therapies can be a daunting task across the entire healthcare space, and not just for biopharmaceutical companies.
For provider executives, the challenge is how to get adequate reimbursement for administering these therapies, and even to determine whether your facility should be involved in the development of gene therapies, according to one industry expert.
“For payer executives, the challenge is determining how to pay for gene therapies and whether outcomes-based models can help alleviate costs or help to ensure greater predictability for premiums,” says Ben Isgur, PwC Health Research Institute Leader. “And for biopharmaceutical executives, the challenge is to make, distribute and market gene therapies.”
PwC Health Research Institute’s new report, Beyond the hype: Gene therapies require advanced capabilities to succeed after approval, investigates the three main challenges and their impact on the industry. One of those challenges is planning to design novel reimbursement models for patients receiving this treatment.
“Reimbursement models are crucial to the commercial success of gene therapy,” Isgur says. “The industry needs to satisfy payers and providers with novel payment models to make sure these therapies are viewed as affordable for patients. Gene therapies often come along with a six- or seven-figure price tag, so companies need to think through payment models that spread out costs over time and guarantee outcomes for patients. Without functional reimbursement models, it will take longer for patients to realize the full potential of gene therapies.”
Isgur sees three main gene therapy reimbursement models gaining prominence in this space:
“We could also see additional models in this space depending on its evolution, including capitation models to limit the overall cost associated with a therapy and indication-based pricing to allow for a therapy to be paid for based on the disease being treated,” Isgur says. “While interviewing payer executives for this report, what we heard loud and clear was the need for flexibility to help payers afford these treatments, so biopharmaceutical companies may not just offer one model-they may offer several of them.”
There are three things healthcare executives need to know about gene therapy reimbursement, according to Isgur. They are: