Blue Cross and Blue Shield plans might move to adopt unique outcomes-based payment strategies, as new immunotherapy drugs and therapies to treat non-alcoholic steatohepatitis (NASH) pose more cost-control issues.

FDA approved the first chimeric antigen receptor (CAR) T-cell therapy, Kymriah, in 2017, under which immune cells are removed from a patient, altered genetically and then transfused back in. A one-time treatment costs $475,000.

“CAR-T is a really, really big-ticket item,” says Eric Estes, R.Ph., senior director, pharmacy services for Independence Blue Cross (IBC). “Right now, it’s of somewhat limited utilization, but it will probably begin to increase in use, and we need to worry about it.”

Estes says CAR-T therapy could have a significant effect on costs in 2019 and beyond, and Independence is discussing cost control “much earlier than we would have in the past.” The insurer also wants to bring other Blues plans along in order to have a cohesive approach.

Outcomes-based contracting might be the choice. “The start may be to sit down with a center and say, ‘For CAR-T therapy, [the price the plan will pay] will be ‘x’ — $1 million, or $1.5 million — and it’s all in,” Estes says.

In addition, the FDA is considering new migraine biologics, including Amgen Inc.’s erenumab, Teva Pharmaceuticals Industries Ltd.’s fremanezumab and Eli Lilly & Co.’s galcanezumab, which are expected to have a high uptake.

Estes says with a large population on current therapies, including Botox, for chronic migraine, IBC most likely will use step therapy to gain control over utilization for the new drugs, as moving from Botox to new products would be a cost inflator.

Since medications for NASH are expected to be pricey, Estes notes Independence already is considering how to manage what could be a new drug expenditure. At least 10 agents for NASH are in the pipeline.