It’s all hands on deck in the coronavirus battle, but the industry must continue work on other breakthrough treatments—and ensure patients have access to them. Here’s a look on some of the latest activity on the CAR T-cell reimbursement issue.
Remind me, what’s CAR T? Chimeric antigen receptor (CAR) T-cell immunotherapy is a powerful cancer treatment that uses “the patient’s own immune cells to help them take on cancer,” as RealClearHealth put it, with gentler side effects than chemotherapy and radiation.
Why are we talking about it now? Currently, Medicare covers the treatment with a new technology add-on payment (NTAP)—but this expires on September 30, 2020. Without further action by CMS, hospitals could be left with wholly inadequate payment rates for CAR T and may be reluctant to provide the therapy for America’s seniors.
And health care execs, patients, and think tanks agree: The current Medicare inpatient payment model is confounded by the entry of breakthrough treatments and reduces patient access to them for years.
American Action Forum (AAF), a conservative think tank, published new research saying CAR T needs its own diagnostic related group (DRG) to ensure the treatment is “broadly accessible to patients.”
And they say the DRG should exclude clinical trials: “Since the cost of drugs are not factored into a case treated through a clinical trial, including clinical trials involving CAR T in payment rate determination skews the true cost. Payments for CAR T must be set solely for non-clinical trial cases in order to accurately capture the price,” AAF explained.
Health care CEOs have chimed in,calling for a “stable reimbursement model” that adequately reimburses hospitals “so they may continue to deliver innovative, lifesaving cancer therapies.”
And a former CAR T patientexplained in a recent op-ed how the “clinically proven, innovative option” saved his life—and Medicare patients should have the same opportunity.
What they’re saying: “When I was out of options, CAR T therapy gave me back my life. Everyone deserves the same opportunity. Patients’ locations and coverage—whether Medicare or not—should not dictate who can be treated with potentially lifesaving therapies,” concluded Dr. Brian Koffman.
BIO’s Take: BIO has long advocated for the creation of a specific payment code for CAR T-cell therapies so America’s seniors can access this groundbreaking cancer treatment—a model that would set the stage for other transformative medicines in the pipeline, too.
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