Proposed Changes to Hospital Reimbursement Must Reflect Modern Cancer Care Regarding CAR-T, Rural Health, Quality Measures

June 25, 2019

ASCO submitted comments to the Centers for Medicare & Medicaid Services (CMS) regarding the 2020 Hospital Inpatient Prospective Payment System (IPPS) proposed rule. ASCO’s comments focus on appropriate coverage and reimbursement for Chimeric Antigen Receptor T-Cell Therapy (CAR-T) therapies, the need to address disparities between rural and urban hospitals, and implementation of meaningful quality measures to improve cancer care for patients and providers.

ASCO’s Principles for the Approval, Coverage, and Reimbursement for CAR-T Therapies

The proposed rule outlines a plan to increase the new technology add-on payment (NTAP) for CAR-T therapies from 50% to 65%, increasing reimbursement from approximately $186K to $243K. According to ASCO, that is still well below the acquisition cost of the drugs, and inadequate to ensure access to coverage. ASCO urges CMS to establish an NTAP of at least 80%, and lays out five principles for the approval, coverage, and reimbursement of CAR-T:

  • ASCO supports coverage for all Food and Drug Administration-approved indications of CAR-T therapy.
  • ASCO supports the delivery of CAR-T therapy in all manufacturer-approved, high-quality health care settings where patients can be safely and effectively treated with this very complex and demanding treatment regimen, including any and all care required for adverse events and follow-up.
  • ASCO supports CMS in their proposed National Coverage Determination approach of Coverage with Evidence Development, conditional on a minimization of unnecessary, duplicative or additional administrative requirements.
  • ASCO believes that Medicare should cover the full cost of CAR-T therapy except for any applicable patient or provider cost-sharing that would apply to any other covered drug or therapy under the Medicare program.
  • ASCO believes that all patients should be supported by the right therapy at the right time. Providers do not set list prices for drugs or treatments and should not bear the financial burden of any unpaid portion of an innovative cancer care therapy simply because a manufacturer has set a high launch price.

Addressing Disparities and Implementing Modern Quality Measures

ASCO’s comments also applaud CMS for acknowledging disparities in rural health care but expresses the society’s concerns that proposed changes to the wage index formula—which affects a hospital's overall Medicare reimbursement—may remove needed resources from urban hospitals. ASCO urges CMS to pursue ways of improving rural health care that will not put people in urban areas at risk.

Furthermore, ASCO supports CMS efforts to implement meaningful measures across its quality measurement programs and urges the agency to develop and implement measures that reflect modern oncology practice. For example, ASCO supports removing both the minimum 90-day reporting period on electronic health record use and a measure that requires verifying opioid treatment agreements, along with a.

Read the full comment letter.

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