CAR T Conundrum: Reimbursement Shadows Clinical Value
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CAR T Conundrum: Reimbursement Shadows Clinical Value
Some providers have touted CAR T-cell therapy (CAR T) as the most innovative treatment of the last decade. Although CAR T offers new promise for patients with cancer, high costs, cash flow issues, and lack of real-world evidence have stunted aggressive CAR T adoption by both providers and payers. The gradual but slow uptake in utilization and inconsistent reimbursement policies have forced the industry to rethink strategies for key market access areas.
Access matters
Access and reimbursement issues are especially daunting for CAR T. Unique hurdles have made the administration of these cutting-edge treatments a risky investment for providers. CAR T administration presents immense cost pressures, and providers worry they will end up absorbing the cost if payers are reluctant to cover the full breadth of the therapy. Plus, if CAR T treatment doesn’t work, and the patient ends up in the hospital, the provider is on the hook to cover further accumulating medical costs.
Barriers to access and reimbursement must be thought through well in advance of a CAR T product launch.
Current CAR T hurdles
Reimbursement uncertainty — Site of service (eg, outpatient versus inpatient) is an important consideration for providers as reimbursement and associated profitability varies widely based on location. Understanding the differences between Commercial and Medicare plans is also key. Medicare has capped CAR T reimbursement at levels well below the cost of inpatient therapy administration. Therefore, providers that lose money on these cases are put in a difficult business predicament
Site-of-care inconsistencies — More data is needed to determine which patients are optimal for inpatient versus outpatient administration from a clinical perspective. Providers need support to better identify these patients. Many providers are working diligently to move all patients into the outpatient setting where total cost of care is lower and reimbursement rates are higher, but this may not be the best approachAncillary patient support needs — Reimbursement for product is only one piece of the CAR T cost puzzle; many CAR-T patients require extensive ancillary resources to receive treatment, including travel, lodging, caregiver support, and care coordination
Market response
The complexities and high cost of CAR T have ignited a top-down approach at many organizations with the C-suite holding decision-making control. Policy stagnation and communication breakdown is a common complaint with this centralized approach, and may put CAR T in a holding pattern for the near future.
Future implications
Healthcare decisions rely on analogues to anticipate and prevent errors. In the case for a pioneer cell therapy like CAR T, collecting this knowledge happens in real time rather than through precedence. Costly mistakes in key access areas will need to be adjusted quickly — a difficult endeavor given the tight control from C-suite decision makers.
Plan sponsors managing high-cost therapies like CAR T need insights from manufacturers to assess cost benefit. Payers are open to strategic ideas around mitigating or sharing overall risk.
Clinical innovation in healthcare is only a first step toward lasting change. When we analyze the performance of CAR T in the real world, the value of optimized market access strategies rings loud and clear. The lessons learned from this experiment will help other manufacturers marketing complex therapies better navigate the market.
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