CMS Increases Medicare Payment Rule for CAR T-Cells, But is it Enough?

The Centers for Medicare & Medicaid Services (CMS) issued a final rule increasing the amount institutions are reimbursed for the product cost of chimeric antigen receptor (CAR) T-cell therapy from 50% to 65%. This change was published in CMS’ fiscal year 2020 Inpatient Prospective Payment System final rule, which applies to more than 3,000 U.S. hospitals. This will go into effect on October 1, 2019.

CMS Administrator Seema Verma said this would promote access to potentially lifesaving cancer treatments and reduce uncertainty about payments for these agents. But with a list price of $373,000, hospitals will only receive about $240,000 for Medicare beneficiaries with lymphoma, up from $186,500. Some provider groups and manufacturers argued that CMS should raise the payment to 80% to 100% of costs.

Mixed reactions from healthcare stakeholders

Currently, hospitals indicate that they lose hundreds of thousands of dollars administering CAR T-cell therapy. In addition, oncologists have warned that the low payments have resulted in smaller-than-expected numbers of patients receiving the treatment. Despite the increase in reimbursement, some argue that access to these agents will not be universal.

The Leukemia & Lymphoma Society said it was “very pleased” with the decision, and the American Hospital Association said the change will provide “some much-needed short-relief,” but long-term solutions are needed.