CMS Finalizes New CAR T-Cell Payment Structure

The Centers for Medicare and Medicaid Services (CMS) announced a new payment structure for inpatient administration of the two chimeric antigen receptor (CAR) T-cell therapies approved in the U.S. – axicabtagene ciloleucel and tisagenlecleucel. The medications will now be classified as Medicare Severity–Diagnosis Related Groups (MS-DRG) 016 – Autologous Bone Marrow Transplant with CC/MCC or T-cell Immunotherapy.

Axicabtagene ciloleucel and tisagenlecleucel have list prices of $373,000 and $475,000, respectively. In April, CMS had announced outpatient administration reimbursement rates for these therapies of $395,380 and $500,839, drawing criticism from the American Society of Hematology (ASH) and the American Society for Blood and Marrow Transplantation (ASBMT). Both organizations had urged CMS to adopt site-neutral, equitable payments for CAR T-cell therapies. In a statement, ASH called the revised classification an improvement over the status quo, but noted that CMS payments would still not cover the total cost of the therapy.

ASBMT agreed, expressing disappointment with the relatively small changes to CMS’ payment structure. “Everyone was really counting on it being a different reimbursement scenario for the upcoming fiscal year, and it is, but again, it’s that bare minimum difference,” Stephanie Farnia, MPH, director of health policy and strategic relations for the ASBMT, said in an interview with MDEdge.

The rule also fails to address reimbursement for cancer centers that do not provide noncancer services, which are excluded by law from the DRG payment system. ASH representatives indicated that the organization plans to follow up with congressional leadership about possible legislative intervention in CAR T-cell payment structure policy.

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