As cell and gene therapies move into mainstream care, pharmacy leaders say health systems are confronting a shared reality: While they may be clinically prepared, their infrastructure might be insufficient — especially in terms of financing, coordination and sustainability for therapies that can cost millions of dollars per patient.
David Young, vice president of pharmacy operations at Signature Healthcare in Brockton, Mass., said traditional pharmacy workflows and financial models are poorly suited for one-time, potentially curative therapies.
“Traditional cost-per-prescription metrics become obsolete when a single patient treatment can exceed $2 million to $4 million,” he said, noting that systems often lack the infrastructure to manage tracking, storage, reimbursement and long-term outcomes across extended care timelines.
That disconnect between legacy pharmacy operations and next-generation therapies is echoed across health systems. Melissa Chase, PharmD, director of pharmacy at Valley Children’s in Madera, Calif., said pharmacy teams are often unprepared for the end-to-end operational and financial orchestration required to safely deliver cell and gene therapies, from coordinating clinical eligibility and payer requirements to contracting, executive approvals and post-infusion reimbursement. Without tightly controlled workflows, she said, organizations risk missed safeguards and financial exposure.
Bickkie Solomon, PharmD, director of pharmacy at HCA Florida North Florida Hospital, part of Nashville, Tenn.-based HCA Healthcare, who is also an assistant professor of pharmacy at West Coast University and founder and president of Stat Rx LLC, said the challenge compounds as cell and gene therapies expand across disease states and become more routine. Leaders are frequently underprepared for the cumulative coordination burden, including compliance standards that differ from traditional specialty drugs and the need to integrate apheresis scheduling, specialty drug management, inventory stewardship and reimbursement pathways. These responsibilities often extend beyond conventional pharmacy training.
Payer misalignment — and the growing financial risk tied to evolving reimbursement models — poses another issue. Durga Zally, PharmD, director of hematology and oncology pharmacy at Geisinger in Danville, Pa., said pharmacy leaders are grappling with a shift toward invoice-based reimbursement models that pay after therapy administration, increasing financial exposure.
“Some health systems are agreeing to these arrangements largely due to limited understanding of the downstream risk,” she said, adding that the expanding web of intermediaries in payment and distribution has made revenue capture more complex.
Ryan Haumschild, PharmD, vice president of pharmacy at Emory Healthcare in Atlanta, said part of the challenge stems from a lack of alignment on what success looks like for cell and gene therapies.
“Agreeing on clinically meaningful, measurable endpoints that are acceptable to the payer, manufacturer and treating center is still a challenge,” he said. Without shared definitions of value, it becomes harder to structure sustainable reimbursement models or performance-based contracts.
Several leaders framed the issue not as a single operational gap, but as a broader alignment problem across stakeholders. Nilesh Desai, chief pharmacy officer at Baptist Health System in Louisville, Ky., said success depends on coordinating the “four Ps” — patient, provider, payer and pharma — and aligning incentives, expectations and risk across all parties.
Donna Feild, chief pharmacy officer at PeaceHealth in Vancouver, Wash., emphasized the importance of payer and finance partnerships, noting the need for teams “who follow through with getting single-case agreements in place prior to treatment and who follow claims all the way through to payment.”
To close these gaps, pharmacy leaders said they are increasingly focused on building governance structures, financial modeling capabilities and operational “headroom” before expanding access.
“The most effective approach has been establishing organizational headroom through cross-functional governance, financial modeling and early investments in care coordination pathways,” said Madeline Camejo, PharmD, chief pharmacy officer at Baptist Health South Florida in Coral Gables.
At Valley Children’s, Dr. Chase described building internal headroom by developing a customized digital workflow to track high-cost therapies from provider order through insurance verification, executive approval, infusion scheduling and reimbursement.
“This approach has proven effective in reducing variability, preventing missed financial safeguards, and enabling leadership to make informed decisions,” she said.
Mr. Young said organizations are also leaning on payer partnerships, outcomes-based contracts and centers of excellence models to manage financial exposure and operational complexity. Centralizing expertise, he noted, improves efficiency, strengthens negotiating leverage with payers and manufacturers, and creates economies of scale. Predictive analytics and earlier patient identification, he added, are helping systems plan for high-cost cases before they become financial shocks.
The health systems making the most progress are those “treating cell and gene therapies not as an add-on to existing operations, but as a catalyst for fundamental transformation,” he said.
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