WASHINGTON — Under a new proposal, the Medicare program would pay for expensive new cancer therapies known as CAR-T for patients across the country.
The Centers for Medicare and Medicaid Services on Friday released a so-called national coverage determination for the therapies that lays out exactly when, and for whom, Medicare will cover a given drug. The proposal specifies that Medicare will cover all FDA-approved CAR-T therapies as long as data is collected about how the patients fare, which could inform the government’s policies about paying for the therapy in the future.
CMS did not propose any changes to how much money Medicare will pay for the treatment. Currently, the program reimburses hospitals for at most half the price of the drug, and it also pays for some of the associated costs of treatment. It has different rules for reimbursing the product in an outpatient setting, though the therapies are not currently offered in those settings. Drug makers, insurers, and others can comment on the proposal for 30 days before CMS decides whether to finalize it.
What may be lost in this is the likelihood that CAR T will become a 3rd line therapy and generally replace the need for Bone Marrow Transplant. The latter is quite expensive and has overall poor survival. In patients failing on this, you will see repeated transplants and multiple admissions for infections. Screening and getting Donors also adds to the costs, as does follow up studies.