Medicare Payments for CAR T-Cell Therapy May Be on the Rise

Medicare beneficiaries with relapsed or refractory leukemia and lymphoma may soon have another treatment option. At least, that’s the hope of officials at the Centers for Medicare and Medicaid Services (CMS), who recently proposed increasing Medicare’s rate of reimbursement to hospitals for chimeric antigen receptor (CAR) T-cell therapy.

The six-digit price tags on the two U.S. Food and Drug Administration–approved CAR T-cell therapies, tisagenlecleucel and axicabtagene ciloleucel, plus additional expenses stemming from treatment complications, could be causing hospitals to withhold potentially life-extending treatment from patients on Medicare, according to CMS Administrator Seema Verma.

The CMS proposal includes an increase of the reimbursement rate to 65 percent of a CAR-T product’s cost, up from 50 percent. The agency may also change the formula it uses to calculate payments to hospitals, as part of its proposed rule for reimbursement rates for fiscal year 2020. If adopted, the changes would go into effect October 1.

“While the proposal from CMS is promising, it is not a one-stop solution for making CAR-T more accessible to patients,” said 2019 American Society of Hematology (ASH) President Roy Silverstein, MD, in a press release. “Just as these therapies are innovative, it is going to take some innovation on the part of CMS to develop a plan that equitably compensates providers and institutions so that offering the therapy is sustainable.”

Sources: The Washington Post, April 23, 2019; American Society of Hematology press release, April 25, 2019.