Unlocking the Promise of Cell and Gene Therapies

Cell and gene therapies represent one of the most transformative advancements in modern medicine. In a recent webinar, The High-Cost Claim Your Benefits Strategy Isn't Ready For, experts explored both the life-changing potential of these therapies and the complex challenges they introduce for employers, health plans, and the broader healthcare system.

The takeaway was clear. While cell and gene therapies can deliver extraordinary outcomes, realizing their full value requires a fundamentally different approach to access, financing and care coordination.

Don't have time for the recording? Read below for a breakdown of what you need to know.

The panel of experts

• Caitlin Hohman, Clinical Pharmacist, Quantum Health
• Will Shrank, CEO, Aradigm
• Emily McRary-Ruiz-Esparza, Moderator and Editor, From Day One

A breakthrough in treatment and expectations

Unlike traditional treatments that manage symptoms over time, many cell and gene therapies are designed to address disease at its root, often with a single intervention.

For patients with rare or life-threatening conditions, this can be life-altering. These therapies are redefining what is possible in healthcare. They are also reshaping expectations from both patients and employers around outcomes, timelines, and value.

The cost challenge: High impact, high stakes

With innovation comes complexity, especially when it comes to cost.

Cell and gene therapies are among the most expensive treatments available today, often ranging from $1 million to more than $4 million per patient. While these therapies may ultimately reduce long-term healthcare costs by eliminating chronic treatment needs, the upfront financial burden is significant.

For employers, the risk is not just theoretical. In some cases, a single member can trigger a claim in the those ranges, creating sudden and substantial financial exposure within a single plan year.

As Caitlin Hohman, Clinical Pharamacist at Quantum Healht stated, "“We no longer have the capacity to operate in silos. These decisions require a full view of treatment, cost and population impact.”

This creates a misalignment in the current healthcare system, one that is especially acute for self-funded vs fully insured plan sponsors, since annual budget structures make it difficult to absorb the cost of a one-time, high-impact therapy, even if it delivers long-term savings.

Fragmentation: The hidden barrier to access

Beyond cost, fragmentation in the U.S. healthcare system presents another major obstacle.

Patients who may benefit from cell and gene therapies often face a complex journey that includes navigating diagnoses, referrals, specialty providers, and coverage approvals. Without coordination, delays and missed opportunities are common.

The webinar emphasized that the system is poorly aligned when it comes to ensuring that eligible patients actually receive these therapies. Identifying the right patients, guiding them through provider steerage to appropriate treatment centers, and managing the end-to-end experience requires a level of integration that most systems lack today.

As new therapies expand beyond rare diseases into conditions that may affect larger populations, potentially even millions of people, the need for a more coordinated approach will only grow.

What a cell and gene therapy solution must address

For benefits leaders, supporting access to cell and gene therapies requires more than just coverage. It demands a comprehensive strategy.

Key components include:

• Early identification of eligible patients to ensure timely intervention
• Specialized clinical expertise to evaluate and guide treatment decisions
• Financial risk management to handle high-cost, low-frequency events
• Care coordination across multiple providers and settings
• Long-term outcome tracking to measure effectiveness and value

Some emerging models aim to address the financial challenge by spreading risk across populations, in some cases adding only one to two dollars per member per month. These approaches highlight the growing need for innovative financing alongside clinical excellence.

No single lever is enough. The most effective solutions bring these elements together into a cohesive model.

The role of partnership and navigation

This is where partnerships play a critical role.

By combining deep clinical expertise with benefits navigation and member advocacy, including tools that help members find a doctor or specialist with the right credentials, organizations can help bridge the gaps that exist today. Quantum Health, for example, brings a member-centered approach to care coordination, helping ensure that individuals not only understand their options but are actively guided through the process.

This kind of support is especially important for complex, high-stakes treatments like cell and gene therapies, where the margin for error is small and the impact is profound.

Looking ahead: From innovation to implementation

Cell and gene therapies are no longer theoretical. They are here, and their use is expected to grow rapidly in the coming years. For employers, the question is no longer if they will encounter these therapies, but how prepared they are when they do.

Benefits leaders: Start planning now. Evaluate your current strategy, understand the risks, and consider how integrated solutions can help manage both the clinical and financial dimensions of cell and gene therapies.

These therapies have the power to transform lives. It will take equally innovative approaches to ensure they are accessible, affordable, and effectively delivered.