Medicare Expands Health Insurance Coverage for Cancer Patients

April 20, 2019

Medicare Expands Health Insurance Coverage for Cancer Patients

Health Insurance Coverage – Cancer treatment is an expensive part in every health insurance. The good news is that the US government plans to expand the Medicare coverage to cancer care. Of course, some restrictions are still applied to keep the costs under control. As reported by Robert Pear for New York Times, cancer patients, healthcare professionals and drug companies are asking the Trump administration to reduce the restrictions associated with cancer treatment coverage.

Medicare Health Insurance and CAR-T Therapy

Many people are urging the US government to overage CAR T cell therapy, or popularly known as CAR-T. The problem is that most insurance companies are insisting in keeping the restrictions applied due to the costs of CAR-T. This treatment is personalized. Therefore, each patient received different treatment and the costs vary widely, depending upon each treatment.
However, CAR-T treatment is costly only at the beginning. The benefits could last for several years. In other words, the treatment costs may be decreasing in the following years, despite higher up-front costs. Medicare is considering the option to shift to CAR-T coverage. The decision is expected in the coming few weeks. Medicare’s decision is predicted to influence how other insurers will respond to the option.
Actually, the Food and Drug Administration has listed two CAR-T product in its approved coverage. The products, called Kymriah produced by Novartis and Yescarta produced by Gilead Sciences, target certain blood cancers. Many patients have reported that the treatments are effective. Moreover, studies are being conducted to find out other uses of CART-T treatment for cancer patients.
Actually, the US government has proposed CAR-T treatment into health insurance coverage. The option has been available for Medicare patients, whose disease does not respond to other treatment options, like radiation and chemotherapy. If Medicare agrees to cover CAR-T treatment, it will also cover relapsing cancers after certain period of improvement.

The Challenges for Covering CAR-T Therapy into Health Insurance

Simply speaking, Trump Administration responds positively to the proposal for covering CAR-T therapy. A representative of Centers for Medicare and Medicaid Services noted that CAR-T is a breakthrough in the treatment for life-threatening diseases like cancers. Of course, the costs associated with CAR-T therapy is still a challenge.
CAR-T therapy is personalized, since every patient needs specialized preparation of cells. The costs are quite expensive. As a result, many health professionals question the ability (or willingness) of insurers to pay for the treatment costs. The Trump Administration certainly needs to make sure that health insurance beneficiaries have access to the latest and effective treatment options. If CAR-T is really effective, it must be accessible to every cancer patient at affordable costs.
It is estimated that the total cost of CAR-T treatment may exceed $750,000. What makes it so expensive? The cost is actually related to the procedure itself, as described below:
  • The T cells are removed from the patient’s blood.
  • Then, the removed immune cells are sent to a laboratory.
  • The laboratory procedures involve identifying the cancer cells and attacking them once recognized.
  • After the cancer cells are killed, the immune cells are sent back to the hospital for infusion into the patient’s blood.
The estimated cost above included the CAR-T infusion, the costs of hospital stays, and medical services.  It may sound like a big price tag, but the benefit is very meaningful for someone’s lifetime.

How Advocates for Patients Respond to CAR-T therapy

Due to the high costs of CAR-T therapy, a group of health insurers are still objected to the option. They claim that there is still limited evidence for the therapy. Advocates for patients said that the proposal for widening the coverage from Trump Administration is still too restrictive. Such restriction could delay lifesaving efforts for cancer patients.
The current proposal only covers patients with relapsing cancers. The coverage criteria proposed by the US government is more restrictive compared to the actual use of CAR-T therapy as approved by the FDA. The coverage should not be limited to patients with relapsing cancers, who are treated at a hospital. Why?
  • Many cancer patients are moving to outpatient setting, where they can receive treatment under a serene environment.
  • Outpatient treatment can be more effective for patients and the insurers.
  • Many community oncology practices are actually capable of administering CAR-T treatment
Therefore, if covering CAR-T therapy aims at saving more lives, the health insurance coverage for cancer treatment should not be too restrictive. The government needs to consider payment mechanisms for outpatient treatment options, which can be more effective, actually. The decision on whether Medicare and other insurers will cover this treatment option is still in few weeks. We certainly hope that a coverage mechanism is available to save more lives.

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