Gene Therapy Poses Volatility Concerns for the Self-Insured Community: An Actuarial View


In recent years, science and technology have been rapidly innovating, bringing the cure to many genetic diseases within reach. Along with excitement is an equal level of nervousness as the costs of gene therapy poses significant financial concerns to risk-bearers. For large self-insured employers who do not typically purchase stop loss coverage, they are exposed to these new treatments that can cost over $2M.  For example, a 20,000-employee plan sponsor may be spending roughly $200M per year in health and benefit expenses, and is expected to have between zero and four Zolgensma treatments within their population. If they have one, it can be absorbed with the margin built into the premium equivalent rates. If they have four, the expense could exceed $10M, creating volatility that these large plan sponsors just haven’t seen before.

Smaller self-insured plans cannot manage this type of volatility, which is why they purchase employer stop loss coverage. But even the stop loss carriers are not immune to volatility. Take for example a $100M stop loss carrier that expects to run at a 75% loss ratio – one additional Zolgensma claim could impact the loss ratio by 2%, eating into margins that are already suppressed. That impact will eventually make its way down to the self-insured plan upon renewal. It is common for stop loss carriers to purchase excess of loss coverage that provides catastrophic protection, but it doesn’t provide the frequency protection that many carriers, and large self-insured plan sponsors, currently assume (i.e. getting more than your fair share of gene therapy claims).

The gene therapy pipeline is rich with several new treatments in the works and several with expected price tags ranging between $2M and $4M dollars. Expect risk management activities to expand for those in the self-insured community, whether it be large plan sponsors or even employer stop loss carriers. Contact BCS today to find out how we can help with risk mitigation, and provide protection against these treatments, which are creating financial volatility, but also bringing much needed curative therapy to members suffering from genetic disease.