Cell and Gene Therapies: Redefining Value in Managed Care Pharmacy

Aug 12

Exploring the Potential Impact of Advanced Therapies on Pharmacy Management and Patient Care

Healthcare innovation continues to reshape treatment options across a wide range of disease states. Among the most notable developments are cell and gene therapies, which have introduced new possibilities for managing conditions that were previously considered difficult or impossible to treat. While these therapies currently have limited application within traditional workers' compensation claims, they are generating important discussions about treatment value, reimbursement, and long-term outcomes across the healthcare industry.[1,2]

For workers' compensation stakeholders, the relevance of cell and gene therapies extends beyond their current indications. As regenerative medicine and advanced biologic treatments continue to evolve, pharmacy professionals, payers, employers, and clinicians may increasingly encounter questions about how these innovations could affect future treatment strategies, claim costs, and patient recovery.

Understanding Cell and Gene Therapies

Cell and gene therapies differ significantly from traditional pharmaceuticals. Rather than managing symptoms through ongoing treatment, many of these therapies are designed to address disease at the cellular or genetic level. In some cases, a single administration may provide long-term clinical benefits. [1]

Examples of currently approved gene therapies include Casgevy® (exagamglogene autotemcel) for sickle cell disease and Hemgenix® for hemophilia B. These therapies represent a shift toward potentially transformative treatment approaches but also introduce new reimbursement and affordability challenges because of their exceptionally high acquisition costs. [1,3]

Why Workers' Compensation Should Pay Attention

The more relevant development for workers' compensation may be the growth of regenerative medicine. Unlike traditional treatments that focus on managing symptoms, regenerative therapies aim to support the body's natural healing processes. Researchers are studying treatments such as stem cell therapies and platelet-rich plasma (PRP) for conditions involving damaged cartilage, tendons, ligaments, muscles, and spinal discs.[4,5]

These types of injuries are often seen in workers' compensation. For example, researchers are evaluating whether stem cell therapies could help repair damaged tissue in conditions such as:

Tendon tears
Ligament injuries
Degenerative disc disease[4]

Similarly, PRP involves using a patient's own blood components in an effort to promote healing and has been studied for orthopedic injuries.[5]

The Cost Conversation

When discussing advanced therapies, cost is often the first issue raised. Some gene therapies have attracted attention because their price can exceed $2 million for a single treatment.[1,3]

However, focusing solely on the upfront price may oversimplify the conversation.

Traditional workers' compensation treatments typically spread costs over time through physician visits, medications, rehabilitation services, and surgical procedures. In contrast, many advanced therapies involve a substantial initial investment with the potential to deliver benefits that last for years or even decades. [1,2]

Could Outcomes-Based Reimbursement Play a Role?

The high upfront costs associated with cell, gene, and regenerative therapies have prompted healthcare payers to explore outcomes-based reimbursement models, which link payment to predefined clinical goals rather than paying solely for the treatment itself.[2]

In a workers' compensation setting, potential measures of success could include:

Functional improvement
Return-to-work outcomes
Reduced need for future medical interventions
Avoidance of surgery
Sustained clinical benefit over time

Under these arrangements, reimbursement may be tied to whether a therapy delivers meaningful, measurable outcomes. This approach aligns closely with the traditional goals of workers' compensation: recovery, function, and return to productive activity.

However, implementing outcomes-based models may be challenging. Treatment outcomes are often influenced by factors beyond the therapy itself, including injury severity, comorbid conditions, workplace accommodations, and psychosocial factors. Despite these complexities, the concept highlights how stakeholders may increasingly evaluate advanced therapies based on their ability to improve long-term outcomes and overall value rather than upfront cost alone.[2]

Looking Ahead

The conversation surrounding cell and gene therapies extends beyond any single treatment. It reflects a growing emphasis on therapies designed to improve outcomes, enhance recovery, and potentially reduce the long-term burden of injury and illness.

As research advances and new treatment approaches emerge, workers' compensation stakeholders will likely continue evaluating how innovation can support the goals that matter most: restoring function, improving quality of life, and helping injured employees return to productive activity. The future may bring new tools and new challenges, but the focus on meaningful recovery remains unchanged.

By Sarah Cirildo

PharmD

For questions, e-mail pharmd@prodigyrx.com

References

1. Academy of Managed Care Pharmacy. Managed Care Pharmacy Policy Outlook 2026. Published 2026. Accessed August 9, 2026. https://www.amcp.org/letters-statements-analysis/amcp-managed-care-pharmacy-policy-outlook-2026. 
2. OneDigital. 2026 Leading Trends in Pharmacy Benefits Management. Published 2026. Accessed August 9, 2026. https://www.onedigital.com/en-US/resources/pharmacy-benefits-management-trends-guide/. 
3. U.S. Food and Drug Administration. Approved Cellular and Gene Therapy Products. FDA. Accessed August 9, 2026. https://www.fda.gov/vaccines-blood-biologics/cellular-gene-therapy-products/approved-cellular-and-gene-therapy-products. 
4. Trapana J, Weinerman J, Lee D, et al. Cell-based therapy in the treatment of musculoskeletal diseases. Stem Cells Transl Med. 2024;13(10):959-978. doi:10.1093/stcltm/szae049. Available at: https://academic.oup.com/stcltm/article/13/10/959/7748363. 
5. Goulian AJ, Goldstein B, Saad MA. Advancements in regenerative therapies for orthopedics: a comprehensive review of platelet-rich plasma, mesenchymal stem cells, peptide therapies, and biomimetic applications. J Clin Med. 2025;14(6):2061. doi:10.3390/jcm14062061. Available at: https://www.mdpi.com/2077-0383/14/6/2061.