Despite New Rules, Extreme Costs Make Hospitals Balk at Offering the Latest and Greatest Therapies

According to a story from statnews.com, new, groundbreaking forms of treatment, such as gene therapy and CAR-T cell therapy, are giving patients with rare genetic disorders and advanced cancers more opportunities than ever to get effective treatment or even a cure. So far, CAR-T cell therapies have been approved for acute lymphocytic leukemia (ALL) and non-Hodgkin lymphoma (NHL). However, the success and wider use of these therapies is hindered by their extreme cost, which can run to around $500,000. Even recently issued changes that allow Medicare to cover a greater portion of the expense of these drugs may not be enough.

New Rules Aren’t Enough

The Centers for Medicaid and Medicare Services (CMS) recently announced that it will now cover the cost of CAR-T therapy for Medicare recipients at 65 percent. Previously, Medicare would only cover 50 percent of the costs for hospitals. While this is an improvement, it still leaves hospitals with costs running into the hundreds of thousands. It’s hard to imagine that more hospitals or cancer centers are going to want to offer CAR-T cell therapy when they have to foot bills like that. Currently, only a limited number of top-of-the-line treatment centers and hospitals offer CAR-T cell therapy, and most of them are around large metropolitan areas. This inherently limits treatment impact and access.

The American Society of Hematology has previously called for the CMS to cover at least 80 percent of the cost if not pay for the treatment entirely. Only then would hospitals have a strong incentive to offer CAR-T cell therapy. Hopefully, future CAR-T therapies with broader utility and reduced side effects will eventually lower the costs, but cancer patients don’t exactly have time to wait around for that to happen. 

Greater Changes Are Needed

Ultimately, we need to figure out a more effective way to cover the cost of these high dollar breakthrough therapies like CAR-T and gene therapy if they are going to reach their full potential and have the world-changing impact that their developers are so eager to bellow about. It is clearer and clearer that decisive, transformative changes to the health system must be made, but the likelihood of them coming any time soon still feels distant.

 


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