Medicare Aims to Expand Coverage of Cancer Care. But Is It Enough?

Apr 13, 2019

  1. Northeast Agent

    Northeast Agent Guru

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    Medicare Aims to Expand Coverage of Cancer Care. But Is It Enough?

    Cancer patients, doctors and drug companies are urging the Trump administration to remove the restrictions and broaden coverage so more patients can benefit from the treatment, known as CAR T cell therapy, or CAR-T. But insurance companies are pushing for the restrictions.

    The Food and Drug Administration has approved two CAR-T products to treat certain blood cancers: Kymriah, made by Novartis, with a list price of $373,000 or $475,000, depending on the type of cancer, and Yescarta, made by Gilead Sciences, with a list price of $373,000.

    There is no national Medicare policy for covering CAR T cell therapy. The request for a Medicare coverage decision came from one of the nation’s largest insurers, UnitedHealth Group, which expressed concern that “CAR-T therapies could create significant financial risks” for the government and for private Medicare Advantage plans.

    UnitedHealth is the largest provider of Medicare Advantage plans, with about five million people enrolled in its plans. The private plans receive a fixed monthly payment from the government to provide the full range of services covered by Medicare.

    America’s Health Insurance Plans, a trade group for insurers, also urged caution, saying, “There is currently limited evidence for CAR-T therapies.”
  2. somarco

    somarco GA Medicare Expert

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    CMS and private carriers look at cost EFFECTIVE treatment, not just cost alone.

    Most (if not all) of the newer, high priced treatment protocols are often used with advanced stage cancers. These medications and treatments are "last resort" and will not CURE the illness but MAY prolong life for a few months.

    The average is around 3 months in most cases.

    Sometimes patients seeking newer treatment protocols can be admitted to a research program where the cost of the medication is more affordable.

    And many times older, less expensive med's can be just as effective.
    somarco, Apr 13, 2019