PBI33 CAN INNOVATIVE PAYMENT REFORM BE THE SOLUTION TO ADDRESS REIMBURSEMENT AND UPTAKE CHALLENGES FOR CAR-T THERAPIES?

Abstract

While CAR-T therapies are considered breakthrough therapies, they have experienced low uptake in real-world practice, due to challenges related to efficacy, patient accessibility, and cost. This research explored the current CAR-T utilization and reimbursement challenges as well as introduction of innovative payment systems being piloted. Data from a real-world patient record database (Global Oncology Monitor©), from 1/2018 to 10/2018 on eligible US patients (N=616) was included. Physicians randomly selected patients diagnosed with diffuse large B-cell lymphoma (DLBCL) and currently on an anti-cancer regimen, reported on their practices related to CAR-T use. Analysis of CMS reimbursement and various payment models was performed through secondary research. Primary research was also conducted via qualitative interviews with US payers (N=5). Utilization of CAR-Ts in areas such as DLBCL remains low (∼2%), due to reasons such as financial burden/lack of insurance and accessibility issues. US payers debate whether CAR-T treatment should occur in the inpatient setting, placing greater financial burden on hospitals/providers vs. in the outpatient setting, shifting the cost burden onto the patient. CMS’ current inpatient payment policy for CAR-Ts entails a DRG base payment of $39,000 and NTAP maximum of $186,500, which does not cover the total cost of care for either the therapy or hospitalization. Commercial payers are also struggling with an optimal coverage solution that will ensure access to a potentially life-saving treatment. Payers reference innovative payment models such as installment plans and outcomes-based agreements viable for CAR-T therapies. For example, a state-wide initiative in Massachusetts piloting a payment installment plan for a novel gene therapy, where payment is spread out over four years, could be leveraged for CAR-T therapies. As the CAR-T landscape evolves, it will be critical to continue to engage with payers and providers to identify solutions to address the financial toxicity, maximize patient access and improve uptake.