Specialty Pharmacy Exec: Gene Therapies Require Innovative Payment Strategies

Rob Osborne

$16 billion dollars. That’s the projected cost of gene therapies in 2024, according to EvaluatePharma, a London-based firm that provides commercial intelligence for the life science industry.

“The cost of many medications has a significant impact on the budgets of employers and insurers and can become unsustainable for health plans, patients, and their families,” says Rob Osborne, vice president of pharmaceutical trade relations for Accredo, a specialty pharmaceutical provider, and CuraScript SD, a pharmaceutical distributor, both of which are part of the Express Scripts family of companies.

The consequence of not figuring this out for payers, providers, and patients? High costs and unpredictability-both of which create tough coverage decisions for employers and health plans, says Osborne, who will speak at the Pharmaceutical Care Management Association Annual Meeting, which takes place in Scottsdale, Arizona, on September 23 and 24.

To address the challenge of getting these costly and lifesaving therapies to patients, he asks pharmaceutical leaders to channel their innovation-the very same innovation they tapped to bring lifesaving therapies to the marketplace-into figuring out how to make them accessible and affordable to patients and families.

Managed Healthcare Executive (MHE) recently talked to Osborne about the need for new payment and contracting models for specialty drugs. The conversation was lightly edited for clarity.

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MHE: What’s your overall strategy regarding new payment and contracting models for these new treatments?

Osborne: Express Scripts, which is part of Cigna, is a health services company that helps employers and health plans make medications safer, more accessible, and more affordable for more than 100 million Americans. We want to offer the marketplace new payment and contracting models that are simple, affordable, and predictable.

For more than 30 years, Express Scripts has stood alongside our clients, improving their members’ access to medications by inventing cost-saving solutions that provide great care to patients. We’re committed to looking for ways to expand access to innovative medications through solutions that improve quality and affordability.

MHE: Tell me about concrete efforts you’ve made to increase access to gene therapies.

Osborne: Gene therapies are one-time use drugs, and sometimes they’re curative. They’re innovative and can be very effective, but they’re expensive.

Embarc Benefit Protection, our most recent initiative, provides predictability for payers [to manage] the shock of a gene therapy claim through a fixed-dollar amount, per-person payment. This solution may insulate payers from the unpredictable “lightning strike” of high-cost gene therapy drug expenses, and thus make exclusion of coverage less likely.

An innovative payment model that Accredo is offering to payers is the ability to pay for these one-time therapies over time. Over a pre-determined payment schedule, health insurers can pay for these high-cost therapies over a number of years. This solution may help payers with their budgets and offer predictability in order to potentially make exclusion coverage less likely. 

Aine Cryts is a writer based in Boston.