The Centers for Medicare & Medicaid Services has launched a groundbreaking multi-state initiative to improve access to gene therapies for sickle cell disease, addressing the significant barriers that have limited patient uptake of these transformative but expensive treatments since their approval.
New Payment Framework Addresses Access Challenges
The "Cell and Gene Therapy Access Model" brings together 33 states, plus the District of Columbia and Puerto Rico, to centrally coordinate insurance coverage for sickle cell gene therapies. The participating states represent approximately 84% of Medicaid beneficiaries with sickle cell disease, a critical population given that between 50% and 60% of people with sickle cell in the U.S. have Medicaid coverage.
Under this outcomes-based payment model, states will receive guaranteed discounts and rebates from participating gene therapy manufacturers if their drugs fail to deliver promised benefits. CMS will negotiate these agreements on behalf of state Medicaid agencies, eliminating the need for each state to arrange individual deals with manufacturers.
Slow Uptake Despite Therapeutic Promise
Two gene therapies currently approved for sickle cell disease have shown limited adoption despite their clinical potential. Vertex Pharmaceuticals' Casgevy, priced at $2.2 million, and Bluebird bio's Lyfgenia, costing $3.1 million, were approved by the FDA in December 2023 after demonstrating the ability to free patients with severe sickle cell disease from serious pain episodes.
However, uptake has been slow since approval. Vertex reported $14.2 million in Casgevy revenue in its last quarterly report, with cells collected from approximately 90 patients seeking therapy through May 1. Bluebird bio, which was taken private this year partly due to challenges selling its gene therapies, reported that 17 patients had started on Lyfgenia through the first nine months of 2024.
Complex Treatment Process and Cost Concerns
The gene therapies involve a complex, monthslong administration process that includes a "preconditioning" chemotherapy step carrying the risk of infertility. These factors, combined with the multi-million dollar price tags, have raised significant concerns about affordability and the potential impact on state Medicaid budgets.
Federal Support and Future Expansion
The federal government will cover a "defined scope" of fertility preservation services and other costs, including travel expenses. CMS could provide up to $9.55 million in additional support per state to assist with outreach and data tracking, as outcomes-based deals require extensive information collection.
States have optional start dates ranging from January 2025 to January 2026. CMS indicated that the program could expand to cover "other diseases with high-cost, high-impact therapies" in the future.
"This model has the potential to improve health outcomes for patients with sickle cell disease while also ensuring state and taxpayer dollars are being used more effectively," said Abe Sutton, CMS's deputy director and head of CMS's Innovation Center.
The initiative represents a significant step toward making gene therapies more accessible while managing financial risks for state Medicaid programs through coordinated, outcomes-based payment arrangements.
