Paying For Cancer Care– Will Medicare Soon Cover Promising CAR-T Immunotherapy?

The Trump administration has proposed that Medicare would cover CAR-T therapy if two circumstances are both met: if the treatment is prescribed by a specialist, and if patients haven’t responded to other treatments. In other words, the therapy would be approved for aggressive cancer cases, where other options have been exhausted. CAR-T would also be covered for patients whose cancer has relapsed after a period of improvement.

“We have a chance for you to go back to doing what you love to do, because we’re using new techniques like immunotherapy to get at the myeloma in a way that it hasn’t already been gotten to,” says Dr. Nina Shah, Hematologist UCSF Medical Center, about using Car-T therapy for multiple myeloma treatment.  We now have drugs that use the immune system to make myeloma go away. And one of the ones that’s really exciting is something called a CAR T cell.”

Nina Shah on using Car-T therapy for multiple myeloma treatment

In order to use CAR-T therapy, doctors take immune cells out of the patient’s body and send them to a laboratory. In the lab, doctors train the cells to attack cancer cells. Then, they send them back to the patient hospital, and re-infuse them into the patient’s blood stream so that they can attack the cancer.

“We have to change how the T cells work and reprogram them with new genes so that those T cells are able to find myeloma cells specifically and attack those myeloma cells,” says Dr. Shah. “These T cells can actually kill myeloma so much so that people who may have had their bone marrow packed with myeloma actually are able to see the bone marrow clean of myeloma, which really has been so hard to do even with all the new drugs we have.”

Insurers are less excited about the extremely costly therapy. United Health Group, the largest provider of Medicare Advantage plans, with five million people enrolled in its plans, expressed concern that these therapies could create financial risks for both the government and for Medicare Advantage plans.

Also, a trade group for insurers called America's Health Insurance Plans urges caution, citing a lack of adequate evidence on the efficacy of CAR-T therapy.

Some patient and physician advocates say that the government’s proposed coverage policy has holes, and could leave people with limited or delayed access to lifesaving treatments. Under the proposal, Medicare would pay for CAR-T therapy in patients who have "relapsed or refractory cancer" that has resisted other treatments. The government cited lack of evidence that the therapy would benefit Medicare recipients as a reason for limiting coverage.

Under the proposal, Medicare would only cover patients if hospitals monitored patients, and patients enrolled in a study to report on their quality of life after the treatment. Some doctors have expressed concerns that this would limit the group of people able to benefit from the procedure.

Car-T therapy has proven useful in multiple areas of cancer treatment, including chronic lymphocytic lymphoma. “The idea with this approach is that T-cells are taken out of the patient and educated outside of the body to recognize CLL cells,” says Dr. Matthew Davids, Associate Director, Center for CLL Dana-Farber Cancer Institute. “These cells are expanded outside the body and then re-infused to patients, where they can then seek and destroy CLL cells wherever they may be hiding in the body.”

Dr. Matthew Davids on Car-T therapy for chronic lymphocytic leukemia 

 

 

 

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