Sending Office: Honorable Brian Higgins
Save Cancer Patients’ Lives
Sign Letter to CMS Administrator Verma to Encourage Access to Life-Saving CAR T-Cell Therapies
We urge you to join us in sending a letter to CMS Administrator Seema Verma regarding the CMS FY2020 Inpatient Prospective Payment System (IPPS) Proposed Rule – specifically, the Agency’s proposals related to reimbursement for Chimeric Antigen Receptor (CAR)
(CAR) T-cell therapy is a cutting-edge immunotherapy in which a patient’s own cells are removed, genetically modified, and infused back into the patient to fight their cancer. It is proving to be extremely successful in the battle against cancer. Unfortunately,
these therapies are very expensive for hospitals to acquire from manufacturers, and Medicare is currently reimbursing hospitals for just a fraction of the cost they incur to acquire the therapy – leaving the bulk of the drug cost and all of the associated
care delivery unreimbursed. Hospitals cannot continue to sustain losses of this magnitude; they must be reimbursed adequately for providing care to Medicare patients whose last hope is CAR T-cell therapy.
Please join us in urging Administrator Verma to provide relief to the institutions that deliver this transformational therapy to help mitigate the high cost of these therapies and to ensure access to life-saving treatments for our Medicare cancer patients.
Text of the letter is below. If you have questions, or to sign on, please your staff contact Jess Burnell with Rep. Higgins at Jessica.email@example.com or Elise Tollefson with Rep. Reed at Elise.firstname.lastname@example.org.
Representative Brian Higgins Representative Tom Reed
Member of Congress Member of Congress
May XX, 2019
The Honorable Seema Verma
Centers for Medicare and Medicaid Services
US Department of Health and Human Services
Hubert H. Humphrey Building
200 Independence Ave SW
Washington, DC 20201
Dear Administrator Verma:
We write regarding the Centers for Medicare and Medicaid Services (CMS) FY 2020 Hospital Inpatient Prospective Payment System (IPPS) Proposed Rule, and specifically, the Agency’s proposals related to reimbursement for Chimeric Antigen Receptor (CAR) T-cell
therapies. Collectively, we represent many of the most sophisticated medical centers across the country currently qualified to provide these complex and life-saving therapies, including both PPS hospitals and PPS-exempt cancer hospitals, and all of which face
challenges regarding reimbursement for these costly treatments.
The proposed rule represents an important step toward addressing reimbursement and patient access to this innovative treatment, but there is a lot more work to be done. We request further clarification on the areas outlined below. Furthermore, we urge CMS
to continue to engage with the public, Congress, and health care providers to develop solutions to ensure Medicare beneficiaries have access to currently available CAR T-cell therapies, while also paving the way to modernize the Medicare program to provide
access to future CAR T-cell therapies and immunotherapy innovation.
PPS hospitals: We are pleased that the agency recognized that hospitals cannot continue to provide these therapies to patients at a financial loss. As you know, current Medicare reimbursement for providing these therapies falls well below
the cost of providing them, which is unsustainable. This therapy has the lowest adoption rate among new cancer drugs, and it is also the most expensive cancer drug on the market. The drug cost alone is approximately $373,000, for which CMS has been reimbursing
a maximum of $186,500. We therefore support the proposal to increase the new technology add-on payment (NTAP) from 50% of the estimated costs for new
technologies to 65%, increasing the add-on payment for CAR-T to $242,450. We also support the request for comment on making a uniform NTAP payment to all centers irrespective of their billed product charge, which would remove the incentive for facilities to
mark up their costs for delivery of this therapy. Furthermore, we are encouraged by the request for comment on payment alternatives for CAR T-cell therapies. We appreciate your consideration of how to encourage value-based care and lower drug prices. However,
we do not believe these changes go far enough to improve reimbursement for the drug and associated care. We urge the agency to continue on this path to ensure that hospitals are not disadvantaged by providing this therapy and patient access is not jeopardized
both in the near- and the long-term.
PPS-exempt cancer hospitals: It is concerning to us that the agency did not provide a clear proposal to reimburse PPS-exempt cancer hospitals, which are ineligible for NTAP payments but have treated approximately half of all CAR T-cell therapy
cases to date. We urge you to develop and implement a concrete path for timely and appropriate relief for PPS-exempt cancer hospitals.
With a number of additional CAR T-cell therapies in the pipeline, the need for and benefits of this treatment will only grow. Therefore, we urge CMS to deliver relief to the institutions that provide them by further refining the NTAP formula for PPS hospitals,
and by creating an appropriate reimbursement mechanism for PPS-exempt cancer hospitals to help mitigate the high cost of these therapies. Furthermore, we urge the agency to also look beyond the immediate need for relief and develop sustainable, long-term payment
solutions to ensure that Medicare beneficiaries are able to access these kinds of treatments both now and in the future.
Thank you for your consideration of this important issue.
 This amount is also dependent on each hospital’s markup and CCR, or cost-to-charge ratio.
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