Health Plans Brace For Cell And Gene Therapy Costs
Cell and gene therapies are breaking ground as life-saving treatments, but their six- and seven-figure price tags are an increasing worry for employers and healths, according to a new analysis.
More than 70% of employers and health plans expect affordability of gene therapy for their health plan members and workers will be a 'moderate or major challenge' over the next 2 to 3 years, according to a report released Monday at Asembia ASX25 in Las Vegas by Pharmaceutical Strategies Group (PSG). The analysis was based on responses from more than 230 health benefits executives from health plans, employers and unions.
The report comes with up to a dozen new cell and gene therapies expected to launch on the U.S. market this year, PSG's report said. Such therapies, which can 'prevent or treat a disease by adding, replacing, or turning off genes,' come with high prices such as $475,000 for a treatment for acute lymphoblastic leukemia or more than $3 million for a treatment for hemophilia B.
Yet despite the headline-grabbing costs of some of these new treatments, those picking up the tab for the bulk of the costs aren't prepared for potential expenses to their budgets for healthcare.
Even though 73% of plans expect cell and gene therapies to 'pose a moderate or major financial challenge in the next 2–3 years, most express low confidence in their understanding of the financial impact,' PSG said in a statement accompanying its report. 'What's more, nearly 40% don't currently use any financial protection product to manage their financial risk related to cell and gene therapies.'
'These therapies aren't one-size-fits-all,' said Renee Rayburg, vice president of clinical strategy at PSG. 'Not only do gene therapies present financial challenges, they're also complex in terms of which patients are eligible as well as the treatment process, and demand is higher for some gene therapies than others. Payers need expert analysis that considers their population, pipeline exposure, and vendor ecosystem.'
Specialty drugs already account for well more than half of the total prescription spending any health plan, employer or government health program manages. Employer clients tell benefits consultants specialty costs easily account for 60% or more of their total drug spending, particularly as more Americans flock to anti-obesity GLP-1 medicines, prescriptions hailed for their ability to help people lose weight.
But the PSG report says employers are increasingly finding ways to deal with specialty drugs.
Take Humira, for example, an expensive rheumatoid arthritis drug derived from biotechnology that at its peak generated more than $20 billion in annual sales as the world's top selling drug for its maker, Abbvie. Humira costs more than $50,00o a patient.
But increasingly health plans and employers are covering less expensive biosimilar versions of Humira in a 'preferred position' in their preferred list of drugs known as formularies. The PSG report said '65% of plans have implemented a preferred drug strategy for one or more Humira biosimilars.'
'Leaders are eager to try new approaches to address costs while preserving access to drugs that their members need,' said PSG's chief operating officer, Rebekah Gregg. 'Yet many benefit leaders lack the data, infrastructure, and confidence to fully implement those strategies. Transparency and clear, data- driven insights will be vital to adapt to the pressures payers face.'
Hashtags
Try Our AI Features
Explore what Daily8 AI can do for you:
Comments
No comments yet...
Related Articles
Newsweek
13 minutes ago
- Newsweek
Mushroom Recall Sparks Nationwide Warning to Customers
Based on facts, either observed and verified firsthand by the reporter, or reported and verified from knowledgeable sources. Newsweek AI is in beta. Translations may contain inaccuracies—please refer to the original content. Hofood99 Inc. is recalling packages of their Enoki Mushrooms due to fears the product may be contaminated with listeria. Newsweek reached out to the company via phone for additional comment on Wednesday and left a voicemail. Why It Matters Numerous recalls have been initiated this year due to the potential for the following: damaged products, foodborne illness, contamination and undeclared food allergens. Millions of Americans experience food sensitivities or food allergies every year. According to the Food and Drug Administration (FDA), the nine "major" food allergens in the U.S. are eggs, milk, fish, wheat, soybeans, Crustacean shellfish, sesame, tree nuts and peanuts. The FDA warns that Listeria monocytogenes is an organism that could cause serious and sometimes fatal infections in frail or older people, young children and those with weakened immune systems. Listeria could also lead to stillbirths or miscarriages in pregnant women, the FDA says. What To Know According to the FDA alert, the mushrooms were distributed nationwide to stores and retailers. The recalled mushrooms are sold in 200-gram green plastic packaging with a with UPC Barcode of 6 976532 310051 seen on the back label. No illnesses or injuries have been reported related to the recalled mushrooms. The mushrooms were distributed by Hofood99 Inc., located at 21903 56th Avenue Oakland Gardens, New York 11364. Recalled packages of Enoki Mushroom from Hofood99 Inc. can be seen in a June 11, 2025, recall alert. (Photo from the U.S. Food and Drug Administration) Recalled packages of Enoki Mushroom from Hofood99 Inc. can be seen in a June 11, 2025, recall alert. (Photo from the U.S. Food and Drug Administration) What People Are Saying The FDA in the alert in part: "The contamination was discovered after samples were collected from a store in Michigan and subsequent analysis by Michigan Department of Agriculture & Rural Development (MDARD) Laboratory Division revealed the presence of Listeria monocytogenes." In an email to Newsweek in January, the FDA said: "Most recalls in the U.S. are carried out voluntarily by the product manufacturer and when a company issues a public warning, typically via news release, to inform the public of a voluntary product recall, the FDA shares that release on our website as a public service. "The FDA's role during a voluntary, firm-initiated, recall is to review the recall strategy, evaluate the health hazard presented by the product, monitor the recall, and as appropriate alert the public and other companies in the supply chain about the recall," the FDA continued. It added: "The FDA provides public access to information on recalls by posting a listing of recalls according to their classification in the FDA Enforcement Report, including the specific action taken by the recalling company. The FDA Enforcement Report is designed to provide a public listing of products in the marketplace that are being recalled." Additional information on recalls can be found via the FDA's Recalls, Market Withdrawals, & Safety Alerts. What Happens Next Customers who have purchased the recalled mushrooms may return the product to the original place of purchase for a full refund or destroy it, the FDA says. People with additional questions may contact the company at (917) 756-9833 weekdays from 9 a.m. to 2 p.m.
Yahoo
28 minutes ago
- Yahoo
Church hosts conference to address mental health in the Black community
MEMPHIS, Tenn. — According to the Centers for Disease Control (CDC), in 2023, suicide was the third leading cause of death among African Americans ages 15 to 34 in the U.S. Pastor Dianne Young with the Healing Center says this is why her church gathered professionals from across the country to educate people about depression and break the silence surrounding suicide in the Black community. 'We want to be able to let people talk freely about their struggles. We mention that we have them, but we don't talk about it,' said Pastor Young. Her church hosted the National Suicide and Black Church Conference at Southwest Community College. 📡 for Memphis and the Mid-South. 📧 and have the latest top stories sent right to your inbox. 'There was a theory that it didn't happen to Black people or African-Americans, but we found out it did from our own personal experiences,' she said. Executive Director of the American Psychiatric Association Foundation, Rawle Andrews Jr., says the stigma surrounding depression among Black people stems from three things: fear, shame, and discrimination. 'We were already thought to be less than human or second class, and then when I tell you I'm struggling with a mental health condition, now I'm leaning into the perception that I'm less than. I'm less than human,' said Andrews Jr. The APA says some of the common warning signs include talking or writing about death, withdrawal from friends and family, dramatic mood changes, and increased alcohol or drug use. 'If you don't see that person for a couple of days and their body language changes, get interested. Get curious,' said a workshop speaker. 'This is teaching you all to recognize, not diagnose, because when you diagnose somebody inappropriately, that can feel like a judgment or a label. Don't do that.' If you or someone you know is experiencing a crisis, experts encourage you to call the National Suicide and Crisis Lifeline at 988. Copyright 2025 Nexstar Media, Inc. All rights reserved. This material may not be published, broadcast, rewritten, or redistributed.
Yahoo
42 minutes ago
- Yahoo
Opinion - We're cancer doctors. Here's why Medicare Advantage fails America's elderly.
'It's nothing,' Tom, a retired firefighter from rural Texas, thought when he had persistent stomach pain. After shedding 30 pounds in three weeks, his family physician ordered a CT scan. Tom was not concerned — after all, the 65-year-old had gotten Medicare Advantage earlier that year. Like millions, Tom switched his insurance after he was solicited by a broker who promised low premiums and a gift card. Absent from the sales pitch was the fact that Medicare Advantage plans — privately run and separate from government-funded traditional Medicare — often delay and deny coverage. One of us met Tom nearly three months after his CT scan, and his doctor discovered the abdominal mass. The job as the first oncologist he had been able to see after months of jumping through hoops was to get initial scans, identify an in-network provider, wait for further referral and approval processes and finally schedule and complete a biopsy. The delays became a death knell. Tom was diagnosed with Stage 3 pancreatic cancer. Tom's first question was, 'It's going to be fine, right?' Despite the urge to reassure him, Tom's life and treatment options were not up to a doctor. They were up to his insurance. The same insurance that delayed urgent testing and care. By definition, Medicare Advantage is meant to support elderly medical care and increase efficiencies; in function, it is a business model that allows the American government to decrease its liability for sick seniors. Instead of absorbing and managing costs, the responsibility is outsourced to third-party operators, such as UnitedHealth Group, Humana and CVS Health. While Medicare Advantage provides excellent coverage if you never get sick, this insurance can quickly become a precursor to medical bankruptcy if the patient develops a deadly disease, a highly probable outcome when you consider that nearly 40 percent of Americans get cancer in their lifetime. After nearly two decades of experimentation and $450 billion of taxpayer money, Medicare Advantage has proven porous in terms of corruption, fraud and abuse. Yet, 32.8 million elderly Americans (54 percent of the eligible Medicare population) are currently enrolled in Medicare Advantage. In 2023 alone, Medicare Advantage plans fully or partially denied 3.2 million prior authorization requests. No one, especially among folks facing the daily drudgery of fighting cancer, truly understands how the cogs within the insurance machine work. Few of our elderly patients fight the goliath institution, and many succumb to poorer health outcomes in their quest for lifesaving treatment. Last year, countrywide and across disease groups, 79 percent of patients who experienced a delay or denial of coverage paid out of pocket for medication at least sometimes. Unsurprisingly, more than 100 million Americans are in medical debt. Of those who appealed between 2019 and 2023, over 80 percent were approved, implying that the initial claims were valid. This game of attrition directly contradicts Medicare Advantage's promise to provide efficient, patient-centered healthcare. These denials are not just medically dangerous because they enable deadly diseases to progress unchecked. They are also emotionally erosive. Daily, we see patients shrink in the face of denials, unable to emotionally navigate the complex Medicare system and the immense pain, isolation and depression resulting from this behemoth that stands between their disease and their hope to be free of it. During one of Tom's chemo visits, with thousands of dollars worth of IVs in his veins, his skin pale and translucent, he realized he was begging his insurance at every turn to support him. Stories like Tom's reveal the truth: Medicare Advantage is unapologetically failing its elderly cancer patients. Sick American seniors deserve more than insurance coverage in name only. We advise our patients to avoid Medicare Advantage. The better choice is traditional Medicare, plus a secondary or supplemental insurance. Often, people do not enroll in supplemental insurance because they do not understand its importance, believe they will never get sick, miss the deadline for approval without a medical exam (you must do this within three months before or after your 65th birthday), or think it is too expensive. Although supplemental insurance costs nearly $500 a month (exact amounts vary based on age and income), choosing this add-on — and paying roughly $6,000 a year — is much more affordable than Medicare Advantage's yearly out-of-pocket (potentially adding up to $8,500) and fighting for approvals for basic treatment. On Medicare Advantage, Tom quickly reached his maximum yearly out-of-pocket of $8,500, but then it reset on Jan. 1. After four months of treatment, he was responsible for paying $17,000 for 16 months of care, on top of his insurance premiums, simply to receive standard care. Of course, if you are one of the fortunate few to have never experienced illness — and we hope you are — Medicare Advantage can be a cheaper option. The question is, how can we make Medicare Advantage advantageous for the vulnerable? There is a bipartisan opportunity to change the narrative around this insurance model. During his confirmation hearing as the head of the Centers for Medicare and Medicaid Services, Mehmet Oz criticized Medicare Advantage insurers for some of their practices. Strategic change — omitting out-of-pocket costs for cancer patients, curbing insurance companies' rights to deny claims submitted by doctors and speeding up the process — along with more rigorous oversight of the program are worthwhile goals the Trump administration and Congress should take on. While Democrats and Republicans disagree on many issues, we believe we can all agree that people like Tom — and the millions of other Americans enrolled in Medicare Advantage — deserve comprehensive and just care. Dr. Pramod Pinnamaneni, MD, MBA, and Dr. Nitya Thummalachetty, DrPH, are founders of the Nau Project, a start-up dedicated to helping everyday Americans navigate the complexities of our healthcare system. Copyright 2025 Nexstar Media, Inc. All rights reserved. This material may not be published, broadcast, rewritten, or redistributed.
