Medicare coverage of costly drug being debated

Will Trump administration drop the restrictions on new type of blood cancer treatment? Stay tuned!

Will insurance companies be able to block expanded Medicare coverage of cancer care?

The answer is a positive maybe.

According to a story last week by by Robert Pear in The New York Times, insurers are pushing to keep existing restrictions against an expensive new type of treatment, CAR-T cell therapy. 

"Cancer patients, doctors and drug companies are urging the Trump administration to remove the restrictions," the story says.

The restrictions are intended to hold down costs of the treatment, which Pear explains "is manufactured specifically for each patient." 

Many more "such 'personalized medicines' are in the pipeline," he adds.

Medicare's final decision is expected in the next few weeks. 

According to the Times, the federal "Food and Drug Administration has approved two CAR-T products to treat certain blood cancers: Kymriah, made by Novartis, with a list price of $375,000 or $475,000, depending on the type of cancer, and Yescarta, made by Gilead Sciences, with a list price of $373,000."

Although CAR-T treatments "generate high costs up front…the benefits could last for years," Pear contends.

The treatments, he notes, "have been remarkably effective in some patients who had a dismal prognosis after exhausting other options."

Dr. Francis S. Collins

Pear's story quotes Dr. Francis S. Collins, director of the Centers for Medicare and Medicaid Services, as saying that "harnessing the power of a patient's immune system in this way was a 'marvel of modern medicine."

And Pear attributes to Kirsten A. Sloan, vice president of the American Cancer Society Cancer Action Network, the notion of favoring people having access to the treatment and letting "the doctor decide which patients should be eligible."

In CAR-T therapy, immune- or T-cells are removed from a patient's blood, sent to a lab to be "genetically engineered  to recognize and attack cancer cells, and then sent back to the hospital for infusion into the patient."

The problem is the over-all cost: The infusion, doctors' fees and hospital stays can add up to $750,000 or more.

A statement from one of the nation's largest insurers, UnitedHealth Group, expresses concern that CAR-T therapies could create significant financial risks for both the government and private Medicare Advantage plans.

More information about controversies over new treatments or drugs can be found in "Rollercoaster: How a man can survive his partner's breast cancer," a VitalityPress book I, Woody Weingarten, aimed at male caregivers.