Speaker Interview: Terry Cothran

From your perspective as Chief Pharmacy Officer at the Oklahoma Health Care Authority, what have been the most significant challenges state Medicaid programs have faced over the past year as more cell and gene therapies come to market?

I have to say that budget constraints are probably one of the most significant challenges. State Medicaid programs are generally very lean on budgets and the budgets have to be approved by the legislature almost a year in advance. So trying to plan that far out and estimate what products may come to market and what they will cost is a definite challenge. I would say one other challenge is not having data on durability. Some consider these products cures or one-time treatments and they are priced in that manner but truly we don’t know how durable they will truly be. Depending on the treatment and product they generally have be administered at a qualified treatment center and many states don’t have a center in their state so there is extra burden and cost associated with out of state travel, lodging, etc.

There is growing interest in value‑based and outcomes‑based payment models. From your experience, how have these worked in practice, and where do these models still fall short?

Some of these models can work in practice but it is often dependent on the disease, treatment, and potential population. For example, if it is a small population where outcome measurements could potentially be tracked manually and work with select providers for collection of that outcomes data then these types of models could be implemented. The short falls with these models is the data is not easily accessible, no electronic medical records that can be shared, and outcome measurements are generally buried in the physician chart notes. As mentioned above, if you have a good relationship with the provider you might be able to obtain this information on a small population. However, when the population is larger then a manual process like this is not feasible. So access and sharing of data seem to be the largest hurdles in this space.

What questions do payers most want answered around treatment burden, durability, and whether patients would choose these therapies again?

The treatment burden for some of these therapies can be pretty extensive. The state Medicaid program would have to cover the costs associated with going through the treatment process but the decision of burden would generally be determined by the patient or physician. I think payers are most concerned with durability. We know the first few CGTs came to market as a “cure” but later we have seen the landscape change and they are now mostly referenced as a one-time treatment. I would say payers are also seeing more and more requests for adding other treatment products back to the patient’s regimen after CGT administration. One of the challenges is there are no studies or trials to determine if this effective and safe? With regards to value-based or outcomes-based proposals, payers are seeing manufacturers only willing to measure the outcome for 3-5 years so long term effectiveness is a mystery to everyone.

Why do you believe it is particularly important right now for payers, manufacturers, and policy stakeholders to come together at forums like the Cell and Gene Therapy Pricing and Reimbursement Summit? Can you give us a sneak peek at what you might cover in your workshop session?

I think it is critical that all parties come together to have these discussions because the ultimate goal is to have a member benefit from these new innovative therapies that can be life changing or lifesaving. All the parties mentioned here have a role in making these life altering treatments available to those in need and even though the parties may have different opinions along the way, I think bringing these groups together allow each party to share their side of the story in hopes we can all work together for successful outcomes. This is the type of dialogue and interaction we hope to have in the workshop.