With advancements in cell and gene therapies (CGTs), employers have the opportunity to dramatically improve health outcomes for patients living with some of the most difficult-to-treat conditions, including genetic disorders and rare cancers. Last year, 38 CGTs were approved by the FDA, and those numbers are expected to increase.
Employers want to do the right thing and make new treatments available to employees. But because these groundbreaking treatments are anywhere from a hundred thousand up to millions of dollars, cost is a real concern. During one of Lantern’s recent Ignite sessions in Aspen, Colorado, benefits leaders delved in deeper to discuss the realities of CGTs and what the future holds.
“They’re super expensive, but also super impactful,” said Luke Prettol, Principal Benefits Strategy Consultant, AT&T. “It’s really important we have a good strategy around this.”
Dickon Waterfield, President of Lantern, agreed: “The problem is not going away because drug development is speeding up at a serious pace. Investment is going into biotech right now to support this.”
CGTs help to treat disorders like cystic fibrosis, cancers like leukemia and lymphoma, neurological diseases such as Parkinson’s and Alzheimer’s, and even heart failure and immune disorders.
Prettol shared the story about an 8-year-old boy with muscular dystrophy who was able to get gene therapy. “Ten years from now, that kid won’t be in a wheelchair and hopefully will be playing soccer,” he said. “We have this opportunity to make a real life-changing impact. Our goal as a company is to connect people to greater possibilities. People can be told they aren’t going to live and then be cured in a matter of weeks.”
We have this opportunity to make a real life-changing impact. Our goal as a company is to connect people to greater possibilities.
Building a Cell and Gene Therapy Strategy
Just like creating a strategy around GLP-1s, Prettol says AT&T applied a similar framework around CGT risk. They ask three key questions: Is it right for the patient? Is it the right provider? And is it the right price?
“And we go in that order,” Prettol said. “Because if you get the wrong patient, you’ve just wasted all your money. If it’s not the right provider and they do it wrong, you can’t do it again, and you just blew your money and any chance that person gets better.”
To put the strategy in place and avoid risk, Prettol said they leverage a proactive patient identification model. Every patient who has a claim with one of the identified conditions is run through an algorithm to understand if they are a good candidate for the therapy. AT&T works with a risk management solution to determine when therapy is appropriate.
“There’s a subset where there’s proactive outreach, both to the patient and the treating provider,” Prettol added. “You don’t want to wait until the patient is at the final day of being eligible from an FDA label perspective. The quality will be much higher if we can get that patient treated early.”
Prettol said they also work with experts to determine which therapies they don’t pursue. “Today, it’s narrower, but tomorrow has new questions,” he said. Strategies can’t be set in stone with emerging medicine.
The Price Tag of Cell and Gene Therapies
When it comes to price of cell and gene therapies, Prettol said it comes down to making sure you’re spending your money wisely. “For us, it’s less about, how do we afford a $5 million claim? It’s more about how to just make sure we’re spending the right money. We created our program strategically, and we know what we should be paying and not be paying.”
Chrissy Farr, author of Second Opinion, a health tech newsletter, asked the question, How are employers going to pay for cell and gene therapies? in her recent blog after attending Lantern’s Ignite Summit. “Imagine the impact for small to medium-sized businesses when a member needs therapy that costs more than $4 million. That would be crushing,” she wrote.
Needless to say, there’s a lot still up in the air when it comes to covering therapies, including whether smaller companies will shift away from being self-insured. “There’s more financial predictability with fully insured plans,” Farr said, noting that CGTs could also force a change with how stop-loss insurers work with employers and pharmacy benefits managers. It could also lead to more patient inequities—only employees who work for the largest companies might have access to CGTs.
The Reality of CGTs
When Jonn Zutter, CEO of Lantern, was on Farr’s podcast, they discussed the reality of why employers won’t likely join to advocate and lobby for themselves. “There’s a huge difference between the needs of a Big Tech company in Silicon Valley versus an oil and gas manufacturer,” Farr said. “There are also massive geographic differences, and some companies are far larger and more profitable. Despite all this, employers do seem to want to do the right thing.”
For Prettol and AT&T, building out their strategy now, rather than waiting “for next year’s problem” is worth the time and investment. “You can look at it and go, ‘It’s going to cost too much, this is insane’ or ‘Oh my, look at all these people we can help.’ It’s always a balance.”
Imagine the impact for small to medium-sized businesses when a member needs therapy that costs more than $4 million. That would be crushing.
