Qualitative interview study reveals financial risk limits cell and gene therapy coverage among US payers, indicating an urgent need for sustainable reimbursement models.
Key Points
To evaluate how United States managed care payers perceive, manage, and establish coverage policies and financial risk-mitigation strategies for cell and gene therapies.
Conducted semi-structured interviews via third-party vendors with N=20 US payer decision-makers to minimize bias.
Collected data utilizing Likert-scale ratings alongside open-ended qualitative inquiries regarding formulary processes, therapy access, and reimbursement frameworks.
Although 17 of 20 payers viewed cell and gene therapies as major medical innovations, 18 of 20 reported that the US healthcare system is not adequately prepared for widespread adoption.
High upfront costs and clinical uncertainty regarding long-term durability were cited as the primary coverage barriers, with reinsurance, stop-loss insurance, and risk pools preferred for financial risk mitigation.
Patient mobility between health plans and ongoing data tracking limitations were identified as the leading obstacles preventing the execution of innovative payment models.