DocWire News sat down with Thomas G. Martin, MD, Professor of Medicine and Associate Director of the Myeloma Program at the University of California, San Francisco, about the impact that Medicare coverage has on treatment for older patients with multiple myeloma (MM), and the insurance coverage challenges that promising therapeutic agents introduce.


Docwire News: MM is a disease that mainly impacts older adults, which means many patients are enrolled in Medicare. How does insurance coverage impact care for these patients?

Dr. Martin: I’ll say two things. One, I’m not an expert on reimbursement and billings for these things. That’s number one. And number two, I’m a little sheltered from that working in academia, which is kind of nice, but we all do know about a lot of the challenges that currently exist. Some insurers actually reimburse at different rates for different types of therapeutics. For Medicare, we don’t have to get pre-approval for relapse therapy. So if we choose a triplet or we choose a quadruplet or whatever we choose, we typically don’t have to get pre-approval on that. And that makes it nice because we don’t have to work on a commercial insurer to ask, “Hey, can we do this? Is it on label, et cetera?” We try to do all therapies on label. So that’s really, in my mind, it’s moot, but it’s easier just to get them right on.

The more difficult thing is these very expensive novel therapies like [chimeric antigen receptor (CAR)] T cells, right? And the question is, are we going to be able to afford these very expensive therapies, including CAR T cells? Now, the [Centers for Medicare and Medicaid Services (CMS)] has come up with a variety of different, new ways to reimburse CAR T cell therapies. In some [cases] it’s dependent on whether it’s a commercial CAR T or whether it’s a research CAR T, and they provide funding for actually purchasing the CAR T, but also other additional billable items like the hospital stay, et cetera. They’ve increased the reimbursement.

However, honestly, in the Medicare patient, the reimbursement that we get from Medicare—based on the [Diagnosis Related-Group (DRG)], the outlier costs that we put through, and the additional costs we asked for—doesn’t really cover the costs of the CAR T or the care that we give to that patient. It’s really hard. And as we get more and more approvals for CAR Ts and we do this more and more, we really…All institutions in all places, I think right now there’s 70+ licensed CAR T cell centers across the US. We all are looking at our finances and seeing is this… We at least have to be at a break-even point to be able to offer these therapies to people. And this is a crazy thing, because these are potentially lifesaving therapies for a lot of patients.

I do think that it will evolve over time. Medicare and CMS has already come to the realization that these therapies are here to stay and they’ve made some adjustments. And I do think the adjustments will continue to happen over time. And we all have to be in it together in communicating with CMS and with our business people at our individual academic centers on why these treatments are so important and how these are going to be able to be maintained over time.