CMS will now cover pricey CAR-T therapies for Medicare patients
The Centers for Medicare and Medicaid (CMS) has been busy. Earlier this week, the agency prescribed ways to resuscitate the fledgling antibiotic industry by restructuring the payment apparatus for new antibiotics. On Wednesday, CMS unveiled its decision to cover CAR-T cancer therapies — which can cost up to $1 million per patient — for Medicare beneficiaries.
These products require the manufacturers to first isolate cells from the patient, manipulate them in the lab by adding chimeric antigen receptors to direct T cells to snuff out cancer cells and then re-infuse them back into the patient. The price tags carried by the therapies reflect that complex personalized manufacturing process.
The CMS’ decision will help cover the therapies in healthcare facilities that have the infrastructure in place to track patient outcomes. CMS administrator Seema Verma in a recent interview with STAT suggested that the agency had struggled to come up with a CAR-T specific reimbursement policy partly because by law it requires a certain amount of patient outcomes data that so far has not been available. By agreeing to cover costs for hospitals that will track patients, the agency is in a position to kill two birds with one stone.
Until now, the CMS was helping hospitals with new technology add-on payments (NTAP) — a provision ushered in 2000 to help smooth the entry for fresh products while a specific reimbursement paradigm was being worked out for them. NTAPs are usually capped at 50% but last week the CMS raised that bar to 65% for CAR-T therapies — although the move was characterized inadequate. In response, the American Society of Hematology said it was disappointed as it had requested the CMS to increase this payment to 80%.