Gene therapy will redefine health care, and we don’t plan on taking a back seat

A drug’s price is rarely its cost. The search to define value.

December 17, 2017

The last few years in health care have been challenging. These next few years are going to continue to redefine health care in this country. The specialty sector, specifically gene therapy and other high cost cures, will force us to face some truths about who we are and what we value.

We believe Prime’s relationships with our Blue Cross and Blue Shield Plan owners and clients give us an advantage. Our medical and pharmacy benefit integration helps us more easily work together for the best interest of our members:

  • Prime’s drug watch list and predictive modeling give our clients advance financial impact information.
  • Our drug cost calculator shows plan sponsors how to project plan-specific costs for high-cost drugs in the pipeline.
  • Our suite of Prime Drug Insights publications keeps our plan sponsors and consultants well informed on:

o Traditional brand-name drugs

o Single-source generics

o Multi-source generics

o Specialty drugs

o High-cost specialty drugs


A drug’s price is rarely its cost


Price, cost and value

The first thing you learn on the operations side of health care is that a drug’s listed price is rarely its actual cost. That’s why contracts and rebates are complicated, and why Prime’s commitment to transparency is so important.

The industry is seeing a renewed push toward value-based pricing.

ICER logoIn 2016, Prime joined the Institute for Clinical and Economic Review (ICER) as a flagship member of its advisory board. This influential group of leaders from 20 organizations included insurers, pharmacy benefit managers, life science companies and pharmaceutical manufacturers. We advise ICER as they perform continuous quality improvement on the processes and policies that guide their work.

This includes health technology assessment processes and value assessment frameworks.

In July 2017 ICER published its report on the effectiveness and value of abuse-deterrent formulations (ADF) of opioids. We were pleased to participate in an engaging panel discussion with ICER as part of their process.

ICER has begun its research for a report on the value of gene therapies like Kymriah™ and Yescarta™. Their draft evidence report can be found here. The final report is expected March 2018.

Gene therapy is considered disease-modifying – potentially curative. It’s given one-time (usually). But clinical data on lasting effects won’t be available for years. This will impact discussions about value and pricing.

Prime looks forward to developing innovative payment models so that gene therapy can be available to all who need it, at a cost-effective price.

I read an interesting quote from an MIT scientist who follows gene therapy. He said, “These advanced therapies require that everyone change a little so that patients can win a lot. To be effective, those changes need to be coordinated rather than independent actions which might be oblivious to the impacts of other stakeholders. The most immediate challenge is not brainstorming changes, but creating the environment for the changes to be designed and coordinated outside of the pressure of a product access negotiation.”

Prime and our Blue Plans have several forums uniquely designed for discussions of this type. I’m excited about the possibilities we have to influence the future.

New drug technology like gene therapy will spur innovative payment models, new partnerships and more. Prime strives to assist our Blue Plan owners and clients in developing best in class management strategies.

We believe these medical breakthroughs should be carefully evaluated to understand their value. We are committed to working with our Blue Plans to help make this happen.

In another part of this series, we state that there are about 70 more gene therapy treatments in Phase III clinical trials. This is the step right before final FDA evaluation.

As gene therapy treatments and cures become commonplace, affordability remains a concern. We believe all those who could benefit from these advancements should be able to receive them. However, these therapies should not lead to unsustainable health care cost growth.

Drug names are the property of their respective owners.

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