Cell & Gene Therapy: Life-changing Drug Costs Millions

Why are some medical advancements shockingly expensive? A new form of cell and gene therapy (CGT)[1, 2] to treat spinal muscular atrophy can significantly improve the quality of life of young patients, but the required one-time dose costs upwards of $2 million.

That price tag represents a pressing problem in American health care: how to support the development of new treatments while keeping drugs affordable for individuals and payers. This playbook traces the path to market of one CGT to better understand the forces that shape its price and accessibility.

Condition: Spinal Muscular Atrophy

Spinal muscular atrophy (SMA) is a rare hereditary disease in which motor neurons are progressively destroyed.[3] Those neurons are cells that control essential activities such as breathing, walking, speaking, and swallowing. There are four forms of SMA, all caused by inheriting a mutated gene. In most cases SMA symptoms will present in children by 18 months. Since the disease worsens over time, the sooner treatment starts, the better.

Treatment: Zolgensma

Currently, there are no definitive cures for SMA, but Zolgensma, which was approved by the United States Food and Drug Administration (FDA) in 2019, prevents further complications and has demonstrated the ability to significantly improve quality of life.[4, 5, 6] Developed by Novartis, Zolgensma is a one-time treatment[7] currently approved only for children under the age of two. The list price was announced at $2.1 million in 2019 and has stayed above $2 million since then.[8]  There are no direct competitors, though other treatments (Spinraza, Evrysdi) exist to manage SMA symptoms, but they are not CGTs.

What is Cell and Gene Therapy?

CGT is a catch-all term for three distinct types of treatment that directly impact the cellular or genetic structure of an individual. Many of these therapies are potentially curative and others significantly halt the progression of a debilitating or life-threatening disease. Their costs can range from a few thousand to millions of dollars for a single dose or short course of treatment.

Click the button to see how different treatments work, and the price tag for some treatments:

Illustrative diagram showing three steps for how cell therapy works. One, stem cells are extracted from a patient or donor, the cells and patient are illustrated with an arrow pointing to the next step. Two, stem cells are modified for treatment, a larger cluster of stem cells are illustrated, with an arrow pointing to the final step. Three, stem cells are injected back into the patient, with a syringe illustrated near the illustration of the patient.
What it is:
Transfer of stem cells, either the patient’s own cells (autologous) or a healthy donor’s cells (allogenic). Cells are infused with a functioning protein.
How it works:
Enhances immune response.
Provenge, to treat advanced prostate cancer.
Price at Launch (2010):

From Production to Patient

Tracking a $2 million price tag. The federal government offers incentives to get cell and gene therapy treatments to market, but CGTs like Zolgensma remain crushingly expensive. Overall, research and development (R&D) costs are high and the potential market size to treat patients with rare diseases is small.

Learn about the key factors in production and marketing that influence a drug’s price.


Research & Development

Low Prevalence of Rare Diseases is Barrier to Development

SMA is diagnosed in approximately one in 10,000 people, resulting in an addressable patient population that is less than a fraction of a percent. The market size is made even smaller since Zolgensma is only indicated for patients less than two years of age. Since its launch in 2019, sales of Zolgensma have declined, with revenues dropping by 15% from 2021 to 2022.[9] Without government incentives for rare disease drug development like those created through the Orphan Drug Act of 1983, innovative funding models for drug development, as well as business models that reduce risk and channel financing more efficiently, the continued development of drugs to treat some of the most rare diseases are at risk.

Research & Development

Manufacturers Aim to be Profitable

To financially justify the tradeoff of research and development costs with the potential for revenue among a small patient base, manufacturers target high price points to achieve profitability and sustainability. As with many rare diseases, there is little competition among CGTs to treat a particular condition and prices can remain high well after launch.

Regulatory Landscape

Accelerated Approvals Help Bring Treatments to Market

To address the treatment of illnesses that have a high unmet need, the FDA allows CGTs to go through the Accelerated Approval Program.[10] At the time of its approval, Zolgensma had just completed a small Phase 1 study consisting of only 15 patients. There is an ongoing Phase 3 trial with 21 patients, which focuses on two primary endpoints: the ability to sit without support for 30 seconds at 18 months and survival at 14 months.[11] While the FDA determined the drug is promising enough to approve, the treatment hasn’t been on the market long enough to understand long-term outcomes, which has significant implications for the complex dynamics at play when parents, along with their providers and payers, are faced with the decision to pursue this treatment.

Government Support

Orphan Drug Act is an Incentive for Manufacturers

So-called orphan drugs treat rare diseases. The Orphan Drug Act, signed in 1983, is designed to encourage R&D by offering patent and financial incentives to manufacturers. By definition, a rare disease impacts fewer than 200,000 persons in the U.S. or affects more than 200,000 people but there is no reasonable expectation that the cost of development will be recovered by potential sales.[12] For these treatments, manufacturers are provided a variety of incentives such as seven years of market exclusivity and tax credits of up to 50% of R&D costs. Since its passage, over 1,000 orphan drugs have made it to market.[13]


Pricing Decision

Many Orphan Drug Prices Stay High for Years

Manufacturers of drugs for rare diseases target high price points to achieve profitability and sustainability. At minimum, these high prices can be sustained during the seven-year market exclusivity period, keeping these medications out of reach for some patients. Manufacturers will also monitor competitors’ efforts to bring new therapies to market for rare diseases, aiming to be the sole product in a given class. This contributes further to a lack of competition.[14]

Pricing Decision

High Cost of Production and Delivery for Zolgensma

Since CGTs target a small patient population, production is often limited to a small number of drug manufacturing plants.[15] Zolgensma, for instance, is approved to be manufactured at only two locations. The method of producing an adeno-associated virus, the vector used to carry the corrective gene in Zolgensma and many other CGTs, typically results in low yields.[16] Other requirements related to delivery and treatment, involving close coordination with patients, add to the complexity and, ultimately, the cost.[17] Zolgensma has to be administered to a patient within 14 days of arrival at the site of administration.

Patient Access

Cost Structure

Precision Financing is One Option

One-size-fits-all reimbursement models do not work for CGTs. The exceptionally high upfront costs, limited insight into long-term outcomes, and need for payers to remain financially solvent, mean that alternative payment models may be necessary to support the adoption of these life-changing therapies.[18] Precision financing arrangements, specifically those that tie longer-term outcomes and performance to payment, may address many of these issues.[19] However, they pose several potential challenges for all stakeholders, including patients. New thinking is required.

Imagining the Patient Experience

Here we look at two scenarios where a variation in health insurance coverage affects a newly diagnosed patient’s ability to access Zolgensma and, if inaccessible, there is a need to seek out alternative therapies.

See how the same patient’s access to Zolgensma differs in two scenarios.

Note: Patient scenarios are meant to be illustrative only. Prices are based on publicly available information when available and good-faith estimates when prices were not available.

Scenario 1: Zolgensma is Covered

The newborn is covered by Massachusetts Medicaid (MassHealth), diagnosed with SMA type 1, and is prescribed Zolgensma. Zolgensma is covered by MassHealth, under a value-based payment arrangement with Novartis, that involves financial risk-sharing based on clinical outcomes measures. Due to favorable coverage policy, the patient has access to and can receive a one-time dose of Zolgensma via intravenous (IV) infusion.

Illustration of a hypothetical patient, a baby, in a scenario where expensive cell therapy is covered by the state's health system.

Scenario 2: Zolgensma is not Covered

The newborn is covered by a commercial health insurance plan, diagnosed with SMA type 1, and is initially prescribed Zolgensma. Coverage decisions and guidance for how to determine which patients are eligible for SMA treatments vary considerably by state and by payer, significantly impacting patient access.[20] Though the physician prescribes Zolgensma, the newborn’s health insurance denies coverage. As a result of the Zolgensma denial, the patient’s family seeks alternative treatment with Spinraza. The patient begins Spinraza treatment, which involves multiple spinal injections.

Illustration of a hypothetical patient, a baby, in a scenario where the therapy may not be covered by the state where the patient lives.

New Thinking Needed to Solve the Dilemma of Life-saving, Costly Drugs

The market for high-cost CGTs is just beginning, and each time a new therapy or innovation is approved, we learn more about what the market can bear. These treatments often target rare and life-threatening conditions, putting exceptional pressure on payers and patients to devise strategies that make them accessible without threatening the financial solvency of the involved parties.

Cost Challenge Will Increase

The number of CGTs is expected to rise and there will be an increasing need to solve the cost dilemma. Precision financing and value-based arrangements may be viable solutions. Regulatory changes may be another.

Insurance is a Big Issue

Given the uniquely disjointed environment of health care coverage in the U.S., there are substantial questions about how to manage the financial risk and arrangements for patients requiring expensive treatments. Patients in different states and those under differing coverage types currently face different, uneven options and access to treatments.

Incentives Could Boost Access

The need is clear for more attention and focus on the unique conditions in this landscape to develop a greater understanding of the incentive changes that could improve access to these therapies.

For More Information

To learn more about the unique cost dynamics for call and gene therapy, read the full playbook.