8Insurance Business ReviewOctober 2022SOLUTIONS FOR FINANCING AND REIMBURSEMENT OF GENE THERAPIESFor quite some time now, Genetic Engineering has been promising to reshape the Health Care landscape and to help humanity overcome diseases and avoid health problems by providing us with the tools to manipulate two of the pillars of the evolution: random mutation and natural selection. These promises have become a reality and the understanding and knowledge of how genes function have given place to several treatments/drugs to fight orphan diseases, cancer, and other chronic conditions. All these treatments can be summarized under one name: Gene Therapy.Although the option of Gene Therapy is a reality, its novelty, along with the limited number of manufacturers developing these treatments and the small number of patients with low incidence diseases that can be treated with these therapies, has introduced several challenges into the health care system worldwide. Manufacturers, health care providers and the insurance/reinsurance industry must collaborate to be able to cope with, for example, the challenges that Gene Therapy brings to the current system in terms of product development, pricing, treatment accessibility, and financial coverage. Otherwise, just a select number of patients with the financial means will have access to this innovative therapy which remains unregulated in terms of pricing.For the insurance sector, cost of treatment of these therapies is at the center of the many factors that influence the decision making process, and there are several areas that need to be reevaluated and redesigned by payers under the current insurance structure to be able to cover, fund, and follow up the outcome of these new treatments.The first factor that a health plan or plan sponsor should consider is that of evaluating the financial risk that Gene Therapy represents due to the uncertainty of the number of members in the insured population that could qualify for gene therapy treatment. Innovative actuarial evaluation and working with experts in risk management is necessary now more than ever to develop new solutions, new products, and tools to help payers to evaluate their exposure. Making coverage decisions for treatments with six or seven figure prices is a big challenge in a market that is always looking to offer competitive and sustainable premium rates, while also expanding the plan benefits to make products more By Blanca Diaz, Vice President Claims, Risk Strategies CompanyBlanca DiazIN MY OPINION
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