Page 143 - Binder2

2. Reimbursement Must Reward Durability, Not
Just Access

Right now, most reimbursement models are front-loaded.
Payers cover the cost of a biologic regardless of how long it
works. A therapy that lasts six months is reimbursed the
same way as one that lasts six years.

This is unsustainable.

Tolerization drives waste:

• Patients cycle through drugs faster, requiring more
switches and diagnostics
• Providers escalate doses or stack therapies to
compensate for loss of effect
• Health systems absorb the downstream cost of
emergency flares, infusions, and
immunosuppression

But none of that cost is borne by the manufacturer once the
drug is paid for.

That must change.

Payers should begin implementing value-based
reimbursement models that tie payment to durability:

• Installment-based payments: pay as the drug
continues to work
• Performance-based rebates: if ADAs develop or
the patient discontinues due to loss of response, the
price adjusts
• Formulary prioritization: therapies with lower
tolerization risk get top-tier access

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