Healthcare costs are rising with the growth of new therapies, including transplant, cell, and gene therapies, to treat conditions such as cancers and spinal muscular atrophy. The increased complexity in care plans and heightened costs are challenges that payer organizations must address.
Managing these conditions requires deeper integration across clinical care, decision making, patient support, and access to care, according to Lisa Latts, MD, Chief Medical Officer, Whole Health Solutions at Optum.
Transplant Trends
Organ donation rates have increased, and donor match criteria have become more relaxed. Treatment of potential transplant complications has also improved.
The use of perfusion devices to protect donated organs has increased transplant utilization. The latest advances in xenotransplantation, or the use of genetically modified animal organs, have expanded the number of organs available for transplant.
Average costs per transplant are estimated at approximately $892,000, making the significant jumps in transplant utilization a concern for health plans.
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Even slight changes in utilization and costs can significantly swing the overall exposure, according to Michael O’Day, Vice President of Product Management at Optum Transplant Solutions.
Gene and Cell Therapies
Cell and gene therapies offer cures for patients with previously intractable conditions, but they are also the highest-costing treatments. These innovative approaches involve greater clinical complexity and financial impact for health plans.
Marjorie Chen, Senior Director of Product at Optum, explained that plans need full end-to-end solutions to manage complexity, cost, and risk associated with these therapies.
Cell and gene therapies work to correct disease at the genetic level, but their high costs and complexity require health plans to apply more sophisticated contracting approaches to manage costs and outcomes.
Payers must consider specialized provider networks with disease-specific centers of excellence and case rate pricing, reinsurance, and full-risk transfer models to manage costs.
Preparing for the Future
Healthcare already has the capabilities to treat complex diseases, but proper coordination is missing to make it more cost-effective.
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Providing care coordination, patient education, care navigation, and clinical oversight throughout the treatment journey can help with outcomes and managing costs.
Lisa Latts noted that combining strong clinical guidance, active care management, and access to high-quality care centers is essential to support these highly specialized treatments.
By addressing the challenges associated with transplant, cell, and gene therapies, health plans can improve patient outcomes and better manage costs.
The growth of transplant, cell, and gene therapies is expected to continue, with more patients seeking these life-changing treatments.
As the healthcare industry moves forward, it is essential to find a balance between providing access to these innovative therapies and managing the associated costs.