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When hematologic malignancies are ineffective in repeated chemotherapy, CAR-T therapy has undoubtedly provided hope for this type of patient as a new option in recent years. However, clinicians and analysts in the United States have said that the current two new varieties of CAR-T products listed in the United States, due to the price tag of hundreds of thousands of dollars, have disrupted the insurance approval process, resulting in delays in the process, not excluding certain In case of refusal to underwrite.

CAR-T therapy is also known as a “living drug”. This therapy kills cancer cells by collecting the patient’s own immune T cells and transforming them into the patient’s body. Kymriah and Yescarta are two CAR-T products approved for sale in the United States last year for the terminal treatment of patients with advanced hematoma. Some critically ill patients who have been treated with CAR-T cells have not developed cancer for up to five years. But the cost of treatment is high.


Yi Lin, who is tracking CAR-T therapy at the Mayo Clinic, said: “CAR-T is the product that patients really need. This treatment can benefit those who are desperate. I don’t want the right patient to be excluded for some reason. Outside the scope of treatment.” The Mayo Clinic has not received any financial assistance related to CAR-T therapy until the media disclosure.


The cost of a single infusion for Kymriah and Yescarta in the treatment of advanced lymphoma in adults was $373,000, while the cost of Kymriah in treating children and young adults with acute lymphoblastic leukemia was $475,000. This is the cost of the drug itself; in addition, many patients have serious side effects that can cause them to stay in the intensive care unit of the hospital for several weeks, increasing the cost of treatment to more than $1 million.


But the US government and insurance companies are indifferent to this phenomenon. Oncologists said: “Although most insurance companies in the United States currently include CAR-T products in the insurance list, most of them are based on individuals and require the insured person to sign an agreement with the insurance company. The big insurance company Prior to the insured experience of stem cell therapy, the insurance process for CAR-T technology was processed very quickly. However, in smaller insurance companies or in individual regions, this is not the case. The extension of the approval process caused by delays often lasts for several weeks. ”


Stephanie Fania, director of health policy and strategic relations at the American Society for Blood and Bone Marrow Transplantation, said that the application documents for CAR-T therapy are likely to be delayed by the payment authorization team. They are not aware of the urgency of the request. Sex, usually these patients may only have a few weeks of survival.


Farnia has links to more than 50 clinics with CAR-T therapies. She said that it is still necessary to go to the treatment center for treatment evaluation in the current situation, but it is undoubtedly frustrating because the relevant copywriting work is not timely.


Insurance experts say that health insurance and Medicaid often face greater underwriting challenges than private insurers. Dr. Michael Bishop, director of the Hematology/Oncology Cell Therapy Program at the University of Chicago, complained that some Medicaid programs do not include treatment, although Medicaid covers children and some adults in low-income families, Medicaid Redemption has always been difficult, and some states simply deny coverage—even in states with balanced budgets. ”


Matt Salo, executive director of the National Association of Medicaid, said that Medicaid funding is very limited and the system is still fragile, and states must assess costs and the effectiveness of drugs.

Clinicians say that despite the fact that people who have benefited from Medicare or Medicare and Disability Health Insurance benefits are not currently covered, the government’s reimbursement rate has also raised concerns among technology providers. Last spring, Medicare announced that it would pay for the implementation of the medical service providers in Yescarta and Kymriah on an outpatient basis. However, this amount will exceed the cost of the drug.

The agency said that including the beneficiary’s Part B deductible (if not already met), the federal health insurance beneficiary’s out-of-pocket limit is $1,340.


But the flaw in this plan is that the facilities for CAR-T treatment are usually in the inpatient department rather than in the outpatient department, otherwise the patient may have serious, systemic side effects. Gary Goldstein, business manager for the Blood and Bone Marrow Transplant Program at Stanford University Medical Center in California, said that most outpatient clinics are unable to guarantee the safety of patients receiving CAR-T treatment.


Officials at the Centers for Medicare & Medicaid Services said that the cost of hospitalization is likely to be significantly lower than that of open clinics. The agency is currently conducting research on CAR-T therapy inpatient care programs to prepare for the upcoming annual financial review. So far, many patients admitted to medical centers have not been included in the scope of medical insurance services.


Goldstein said: “It is ridiculous to explain to a 66-year-old patient that his lymphoma was at the age of 64. But the current system is like this. If today’s health insurance system does not improve, So sooner or later there will be problems.”

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