[Ip-health] Yikes! U.S. Medicare sets outpatient rate for CAR T reimbursement.

[James Love]

​The NIH won't enforce oblgiations to make its NIH funded inventions
"available to the public on reasonable terms, including the new CAR T
treatments.

Reuters reports Medicare reimbursement policies for Yescarta and Kymriah.

* The minimum patient co-payment for Yescarta is $79,076.

* For Kymriah the co-payment is $100,168.


https://www.reuters.com/article/cancer-medicare-yescarta/u-s-medicare-sets-outpatient-rate-for-yescarta-reimbursement-idUKL2N1RI17D


U.S. Medicare sets outpatient rate for Yescarta reimbursement
Deena Beasley

April 5 (Reuters) - Medicare, the U.S. government healthcare program for
the elderly and disabled, will pay hospitals close to its standard mark-up
rate for administering cell therapy Yescarta for cancer outpatients, who
will have a co-payment of nearly $80,000, according to the Centers for
Medicare & Medicaid Services (CMS).

Additional Medicare reimbursement for inpatients has been requested by
Yescarta maker Gilead Sciences Inc and Novartis AG, which makes Kymriah, a
similar therapy. Both therapies were approved last year by the Food and
Drug Administration and are being used by growing number of major cancer
centers.

The CMS has not made a decision on the requests, it said in an emailed
statement on Thursday.

Reimbursement has been a major issue for investors because the high costs
of the so-called CAR-T therapies could affect usage, especially for the
Medicare population.

The therapies involve drawing white blood cells from a patient, processing
them in the lab to target cancer, and infusing the cells back into the
patient.

Most patients are first admitted to the hospital because the treatments may
have life-threatening side effects, and inpatient services can bring the
total cost to as much as $1.5 million.

For outpatient drugs, Medicare typically reimburses providers at the net
price (after discounts and rebates) plus 6 percent. New drugs are paid at
the manufacturer’s wholesale acquisition cost plus 6 percent for the first
three quarters.

As of April 1, CMS said it would pay $395,380 to health providers who use
Yescarta, with a list price of $373,000, on an outpatient basis. The
minimum patient co-payment for Yescarta is $79,076.

For Kymriah, with a list price of $475,000, the Medicare payment rate is
$500,839, and the co-payment is $100,168.

For inpatients, Medicare bundles CAR-Ts into the payment for a hospital
stay. Gilead and Novartis have filed for additional “new technology add-on
payments” from Medicare to cover the cost of cell therapies in the hospital.

Yescarta is approved for patients with a type of lymphoma who have failed
to respond to other therapies, while Kymriah is approved for children and
young adults with acute lymphoblastic leukemia that has not responded to
other treatments.

Novartis has also filed for use of Kymriah in lymphoma patients and a
decision from the FDA is expected by mid-year. (Reporting by Deena Beasley;
Editing by Richard Chang)