- Center on Health Equity & Access
- Clinical
- Health Care Cost
- Health Care Delivery
- Insurance
- Policy
- Technology
- Value-Based Care
Insurance Considerations for SMA Therapies
Panelists discuss how insurance challenges impact spinal muscular atrophy (SMA) care, with prior authorizations becoming more streamlined over time but limitations on physical therapy sessions and inequitable access to treatments remain significant barriers.
EP: 1.Describing SMA Progression Over Time
EP: 2.Unmet Needs of Older Patients Living With SMA
EP: 3.Examining the Importance of Early Treatment for SMA
EP: 4.Key Functional Milestones Affected by Disease Progression
EP: 5.The Importance of Supportive Care for Patients Living With SMA
EP: 6.Introduction to Therapies Used to Treat SMA
EP: 7.Splicing Modifiers and Gene Therapy for SMA
EP: 8.Key Clinical Considerations for the Management of SMA
EP: 9.Assessing Different Factors When Selecting a Treatment
EP: 10.Evaluating the Potential of Intrathecal Gene Therapy
EP: 11.Other Investigational Treatment Options for SMA
EP: 12.Insurance Considerations for SMA Therapies
EP: 13.Optimizing Multidisciplinary Care Approaches for the Future of SMA Management
EP: 14.Final Panel Thoughts on the Management of SMA
Clinical Brief: Insurance Challenges in SMA Treatment
Main Discussion Topics
- Prior authorization challenges for disease-modifying therapies
- Insurance limitations for physical and occupational therapy
- Cost-benefit considerations for high-cost treatments
- Disparities in treatment access based on insurance coverage
Key Points for Physicians
- Prior authorization processes have improved but remain challenging, especially for newer providers.
- Physical therapy coverage is often inadequate with arbitrary session limits (typically 10 to 15 sessions annually).
- Adult patients have fewer therapy resources compared with pediatric patients who can access school-based services.
- Documentation of treatment value should include quality-of-life improvements and workforce participation, not just motor function scores.
Notable Insights
The panel highlighted the paradox that evaluations to demonstrate treatment efficacy count against patients' limited therapy session allowances, forcing difficult choices between assessment and actual therapeutic intervention.
Clinical Significance
Advocacy for comprehensive coverage of disease-modifying therapies and supportive services is essential, with emphasis on long-term benefits, including improved quality of life, reduced hospitalizations, and increased workforce participation.
Managed Care Reflections: A Q&A With A. Mark Fendrick, MD, and Michael E. Chernew, PhD
December 2nd 2025To mark the 30th anniversary of The American Journal of Managed Care (AJMC), each issue in 2025 includes a special feature: reflections from a thought leader on what has changed—and what has not—over the past 3 decades and what’s next for managed care. The December issue features a conversation with AJMC Co–Editors in Chief A. Mark Fendrick, MD, director of the Center for Value-Based Insurance Design and a professor at the University of Michigan in Ann Arbor; and Michael E. Chernew, PhD, the Leonard D. Schaeffer Professor of Health Care Policy and the director of the Healthcare Markets and Regulation Lab at Harvard Medical School in Boston, Massachusetts.
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