This is a question that has come up recently AJMCThe commentary by William Schrank, Allen Kelsey, and Mark Fendrick aims to provide an 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 inequities in access to these innovative cell and gene therapies.
In a category where eligibility is narrowly defined, clinical monitoring is intense, and inappropriate use or overuse is extremely unlikely, adding financial barriers reduces access to these treatments for the patient populations who would benefit most.6
Are co-payments for curative treatments worth it?
Patient cost sharing is traditionally justified as a tool to reduce low-cost utilization and encourage consumer price sensitivity. This argument collapses when applied to a $3 million physician-administered therapy offered at a handful of specialized centers to patients who meet strict diagnostic criteria.
It is reasonable to assume that taking gene therapy is not discretionary. Patients do not “overuse” treatment, especially when there are no other alternative treatments. Once a therapy has cleared rigorous regulatory thresholds for safety and effectiveness, patients’ out-of-pocket obligations no longer function as a price signal, but rather as a punitive rationing mechanism. It is difficult to justify placing the financial responsibility of thousands of dollars on patients – often those who cannot afford this burden – who have no meaningful clinical options.
The authors claim that when the evidence about cell and gene therapy is less certain, there are better ways to manage payer financial risk than sharing patient costs. These may include robust utilization management, mandating participation in long-term outcome registries, and/or outcome-based contracts (for example, outcome guarantees).
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