This is the question that a recent AJMCcommentary by William Shrank, Ellen Kelsay, and Mark Fendrick aims to answer. When talking about cell and gene therapies, the authors argue that cost sharing is not being used to avoid unnecessary use of low value care, but rather as a form of rationing that creates disparities in access to these innovative cell & gene therapies.
In a category where eligibility is narrowly defined, clinical oversight is intense, and inappropriate use or overuse is extremely unlikely, adding financial barriers risks undermining access to these therapies for populations of patients who stand to benefit most.6
Do Co-Payments Make Sense for Curative Therapies?
Patient cost sharing is traditionally justified as a tool to reduce low-value utilization and encourage consumer price sensitivity. That logic collapses when applied to a $3 million physician-administered therapy delivered at a handful of specialized centers to patients who meet strict clinical criteria.
It is reasonable to posit that consumption of gene therapy is not discretionary. Patients do not “overuse” cures, in particular when there are no other alternative therapies. Once a therapy has cleared stringent regulatory thresholds for safety and effectiveness, patients’ out-of-pocket obligation no longer functions as a value signal but punitively operates as a rationing mechanism. It is difficult to justify shifting thousands of dollars of financial responsibility onto patients—often those who cannot afford this burden—who have no meaningful clinical alternative.
The authors claim that when evidence around cell & gene therapies are less certain, there are better ways to manage payer financial risk than patient cost sharing. These could include stronger utilization management, mandating participation in long-term outcomes registries, and/or outcomes based contracts (e.g., outcome guarantees).
You can read the full article here.
