Apr 24, 2019

CMS proposes new payment rate for pricey, personalized CAR-T cancer treatments

A biologist works on immunotherapy for HPV+ cancers at the National Cancer Institute. Photo: Saul Loeb/AFP/Getty Images

The Centers for Medicare & Medicaid Services issued a proposed rule yesterday addressing Medicare hospital payments in 2020, including how hospitals will be reimbursed for CAR-T therapies.

The big picture: These are medical procedures that use a patient's own cells to fight cancer — a treatment that also comes with a high price tag.

Details: The proposed rule narrows the gap between what Medicare pays for CAR-T and what the drug companies that make it charge, but there's still a substantial gap.

By the numbers: Hospitals can lose upwards of $100,000 when they administer CAR-T therapies to Medicare beneficiaries today, because of the way payment is structured.

  • The 2 CAR-T therapies on the market have a price tag of $373,000 per procedure.
  • Right now, hospitals receive varying payment rates, which can include an add-on of up to 50% of the manufactures' price, or $186,500. Yesterday's proposal increases that add-on to 65%, or $242,450.

Between the lines: Hospitals would obviously rather be made whole for the cost of the procedure. There'd been talk of increasing the base payment by creating a new billing code for CAR-T, but CMS decided not to do that, at least not yet.

  • Outpatient reimbursement for the procedure is much more generous, as it's structured completely differently, but comes with added risk.

CMS is also considering raising Medicare rates to hospitals by 3.7% on average next year, by far the largest proposed pay hike in several years. Penalties for too many readmissions or poor quality will be opportunities for wiggle room in the Medicare price hike.

Go deeper: Stat News dug into hospitals' payment dilemma in March.

— Correction: An earlier version of this story said hospitals all get paid the same amount for CAR-T therapy. That's incorrect. Their payments vary.

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Wisconsin may be the start of the 2020 election wars

Illustration: Aïda Amer/Axios

Wisconsin voters braving lines in face masks — after a last-minute Supreme Court ruling against extending the absentee deadline — could foreshadow a nationwide legal struggle over how to conduct elections during the coronavirus outbreak, election experts say.

Why it matters: "It's a harbinger of what's to come in the next skirmishes in the voting wars" from now through November, Richard Hasen, a professor and national election law expert at the University of California, Irvine, told Axios.

New Zealand sets sights on coronavirus elimination after 2 weeks of lockdown

Prime Minister Jacinda Ardern gives a coronavirus media update at the New Zealand Parliament in Wellington. Photo: Mark Mitchell - Pool/Getty Images

AUCKLAND -- New Zealand has flattened the curve of novel coronavirus cases after two weeks of lockdown and the next phase is to "squash it," Professor Shaun Hendy, who heads a scientific body advising the government on COVID-19, told Axios.

Why it matters: The country imposed 14 days ago some of the toughest restrictions in the world in response to the pandemic, despite confirming only 102 cases and no deaths at the time.

Go deeperArrow51 mins ago - Health

Coronavirus dashboard

Illustration: Sarah Grillo/Axios

  1. Global: Total confirmed cases as of 2:30 a.m. ET: 1,431,375 — Total deaths: 82,145 — Total recoveries: 301,543Map.
  2. U.S.: Total confirmed cases as of 2:30 a.m. ET: 399,886 — Total deaths: 12,910 — Total recoveries: 22,461Map.
  3. Federal government latest: Acting Navy secretary resigns over handling of virus-infected ship — Trump removes watchdog overseeing rollout of $2 trillion coronavirus bill — Trump said he "didn't see" memos from his trade adviser Peter Navarro warning that the crisis could kill more than half a million Americans.
  4. States latest: California Gov. Gavin Newsom is confident that more than 200 million masks will be delivered to the state "at a monthly basis starting in the next few weeks."
  5. Business latest: America's food heroes in times of the coronavirus crisis. Even when the economy comes back to life, huge questions for airlines will remain.
  6. World updates: China reopens Wuhan after 10-week coronavirus lockdown.
  7. 2020 latest: Polls for Wisconsin's primary elections closed at 9 p.m. ET Tuesday, but results won't be released until April 13. Thousands of residents cast ballots in person.
  8. 1 Olympics thing: About 6,500 athletes who qualified for the Tokyo Games will keep their spots in 2021.
  9. What should I do? Pets, moving and personal healthAnswers about the virus from Axios expertsWhat to know about social distancingQ&A: Minimizing your coronavirus risk.
  10. Other resources: CDC on how to avoid the virus, what to do if you get it.

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