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Medicare beneficiaries nationwide will soon have coverage for cutting-edge CAR-T cancer therapy, the Centers for Medicare and Medicaid Services announced this month.  The decision marks a significant step forward for Medicare patients with blood cancers like non-Hodgkin lymphoma and acute lymphoblastic leukemia.

Prior to CMS’ announcement, regional administers decided which patients were eligible to receive the treatment.  The approach led to inconsistent coverage across the country. 

CMS’ initial coverage rules presented other challenges as well.  The agency called for strict reporting requirements – essentially limiting access to patients near academic medical centers with the technology and staff to comply.  CMS also initially limited access to patients whose cancer had returned, and CMS required that medication be administered only in a hospital.  

But CMS changed course on both reporting and administration locations in its final decision, meaning more patients in more health care settings will have access to the treatment.

One significant hurdle remains, though.  CAR-T therapy, which use a person’s own cells to fight cancer, is potentially life-saving.  It’s also expensive – more than $375,000 for the treatment and up to $1.5 million, by some accounts, when considering related health care expenses. 

CMS’ national coverage determination is poised to increase the number of CAR-T reimbursement claims, and the agency also recently increased its reimbursement rate from 50% to 65% of estimated costs.  So while CMS may be exploring how it will cover the reimbursement expenses, some hospitals and medical centers may be questioning how they can cover the loss.  Some may opt not to offer CAR-T, again limiting patients’ access to the pioneering medicine.

Advocacy organizations such as the American Cancer Society Cancer Action Network, the Alliance for Patient Access, the Leukemia & Lymphoma Society and the American Hospital Association have commended CMS, signaling their appreciation for a step in the right direction.  They have, however, balanced praise with calls for longer-term solutions. So has the American Society of Hematology, which called on CMS to increase their payment rate to at least 80% of estimated costs.

Adjusting payments and determining how the cash-strapped Medicare program will pay for CAR-T therapies “over the long term” is a continuing struggle for Seema Verma, administrator of the Centers for Medicare and Medicaid Services.  For now, though, patients and providers should remain optimistic about greater availability of life-saving cancer treatment for those who need it.

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