Dr John Sweetenham: Issues Persist Among Medicare Beneficiaries for Reimbursement of CAR T-Cell Therapy

Reimbursement for CAR-T therapy has progressed to where commercially insured patients obtain coverage regularly, but issues remain for patients with Medicare, said John Sweetenham, MD, professor in the Department of Internal Medicine at UT Southwestern Medical Center and the Associate Director for Clinical Affairs at UTSW’s Harold C. Simmons Comprehensive Cancer Center.

Transcript

How has reimbursement for CAR-T therapy been altered? Are providers more inclined to offer the therapy when compared to the past?

It depends on the insurer. So, I think in general, for commercial insurance what I’m hearing, our experience and the experience of many of the people I speak to, is that we're pretty well getting the treatment covered for patients who are insured commercially. With Medicare, I would say that we still confront the same problems we had before. So, the recent coverage determination has improved the situation, and we can typically recover, as I mentioned before, about 80% of the cost, and that's helpful, no question; but in terms of how we move forward it is very challenging. We know that every patient that we treat at the moment, we're at significant financial risk, especially if it is a Medicare patient. I think what we're likely to see over the coming months and years is a gradual shift of CAR-T cell therapy to outpatient. Part of the reason for that is the way that it's reimbursed as an outpatient therapy is slightly more favorable—so, financially it is better to do that. The problem is that these are very toxic treatments, and that many of the patients are not going to be manageable in the outpatient setting; but I do see that as 1 of the factors which is influencing a slow transition to outpatient CAR-Ts.