News & Commentary

Medicare May Pay More for CAR-T

Insurers, physicians, and—certainly—hospitals will doubtless offer their two cents as CMS invites public comment on its proposal that slightly increases coverage for CAR-T cell therapies administered at certain large hospitals.

Every little bit helps. Novartis’s immunotherapy, Kymriah (tisagenlec­leucel), lists for between $373,000 and $475,000, depending on the type of cancer being battled, and Gilead Science’s immunotherapy, Yescarta (axicabtagene ciloleucel), lists for $373,000.

CMS wants to raise the maximum on its “new technology add-on payment” (NTAP) to hospitals from 50% of costs to 65%. So, using $373,500, Medicare would raise reimbursement from $186,500 to $242,450.

CMS’s April 23 announcement made headlines, as might be expected, because just how to pay for CAR-T has been a challenge. Made for each patient, CAR-T therapies involve the removal of immune-system cells, reengineering them so that they can locate and fight cancer, and then infusing them back into the patient. The often-serious side effects mean that the treatments are given in hospitals, and that can boost the cost to over $1 million.

If given final approval, the discount won’t go into effect until Oct. 1, 2020 (the start of fiscal year 2021), and would apply to any treatment or technology that the FDA regards as a breakthrough, not just CAR-T.

Administrator Seema Verma says CMS will relax evidence thresholds for the first two years a treatment is available. “I am particularly concerned about cases that have been reported to the agency in which Medicare’s inadequate payment has led hospitals to curtail access to needed therapies,” she said in a statement. “We must continually update our policies in response to the rapid pace of advancement in medical science.” (For what health insurers might be thinking, see “Can Plans Dodge CAR-T Coverage?”)

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