The CMS proposed boosting payment for a pricey but novel cancer treatment called chimeric antigen receptor T-cell therapy, or CAR-T. There are currently two treatments on the market, both with list prices ranging from $373,000 to $475,000.
The proposed inpatient payment rule would increase the maximum add-on payment from 50% of the estimated costs of the treatment to 65%, resulting in a hike from $186,500 to $242,450.
“Hospitals and health systems have been taking on this financial burden to ensure access to these lifesaving treatments for patients, and while this proposal is not a permanent solution, it will help in the short term,” American Hospital Association Executive Vice President Tom Nickels said.
This is the latest move by the CMS to address the high cost of CAR-T, which right now can only be administered in hospitals.
However, new treatments are in the pipeline.
The agency issued a proposal to develop a new national coverage determination for CAR-T a few months ago. Currently local Medicare administrator contractors determine coverage of the therapy.
However, the CMS declined to create a new code under the Medicare Severity Diagnosis Related Groups for CAR-T treatments.
Under a rule finalized last August, CAR-T was assigned to the MS-DRG for T-cell immunotherapy and autologous bone marrow transplants, resulting in a base payment rate of $36,000 and a maximum add-on payment of $186,500.
The American Society of Hematology said in a statement last year that hospitals “will not be able to deliver the therapy at this reimbursement rate, particularly as other CAR-T products receive FDA approval.”
For now, the agency decided to stand pat.
The CMS said it wants to get more data on the charging and billing practices to evaluate the potential creation of a new MS-DRG specifically for CAR-T treatments.