Medicare Increases Coverage of CAR T-Cell Therapy

The Centers for Medicare and Medicaid Services (CMS) has issued a final rule that raises payments for new technologies, including chimeric antigen receptor (CAR) T-cell therapies, from 50 percent to 65 percent, according to Medicare officials.

This decision comes after months of criticism from hospital officials citing insufficient reimbursements.

CMS Administrator Seema Verma stated that this payment increase will provide greater access to lifesaving, but expensive, CAR T-cell cancer therapies. Health care providers have said this will only partially alleviate the financial burden of these treatments.

The U.S. Food and Drug Administration has approved two CAR T-cell therapies: Novartis’s tisagenlecleucel and Gilead Science’s axicabtagene ciloleucel. Both are used to treat diffuse large B-cell lymphoma, while tisagenlecleucel can be used to treat pediatric patients with acute lymphocytic leukemia. Hospitals currently pay a list price of upwards of $373,000 for a single infusion of these therapies; the costs can increase further to cover associated expenses and management of complications. The new rule will only reimburse $240,000 for cancer treatment for Medicare beneficiaries with lymphoma.

Health care providers’ opinions of how this will affect providers and patients vary. Medical organizations such as the Leukemia & Lymphoma Society said that they are “very pleased” with the decision, however, others, including the American Society of Hematology (ASH), noted that the increase may not provide enough relief. ASH President Roy Silverstein, MD, stated that, while it is a “positive step, … we are disappointed that CMS did not take additional steps to address the barriers faced by institutions in recouping the cost of the product as well as the cost of additional medical care these patients require.”

Offering CAR T-cell therapy is still an expensive proposition for hospitals, who can lose anywhere from tens to hundreds of thousands of dollars on each Medicare patient receiving treatment.

The new rule will go into effect for fiscal year 2020, which begins October 1.

Sources: The Washington Post, August 2, 2019; American Society of Hematology press release, August 6, 2019.