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immunosuppression is baked into the economics of
specialty care.

But this equilibrium is fragile.

As value-based care becomes more mainstream,
outcomes—not volume—will determine reimbursement. If
a biologic stops working after 12 months, its cost-
effectiveness will be challenged. Payers are already
watching. Employers are asking questions. Governments
are calculating the long-term inefficiencies.

And on the other front, biosimilars are coming. Not
identical, but close enough to challenge the pricing power
of originator biologics. As competition increases and
margins narrow, manufacturers will no longer be able to
rely on repeat revenue from therapeutic churn. In a world
where every biologic has to prove its staying power,
durability will become a competitive advantage—not
just a scientific goal.

So, while tolerization may still be profitable today, that
margin is shrinking. The market will eventually reward
what the immune system already demands: drugs that are
not just powerful, but biologically sustainable.

And when that happens, the incentives will shift.
Not because of ethics. Not because of outrage.
But because the math will change.

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