CAR-T therapies are a type of innovative cancer therapy that tweaks a patient’s immune system cells to attack cancer. The National Cancer Institute explains:
A type of treatment in which a patient’s T cells (a type of immune system cell) are changed in the laboratory so they will attack cancer cells. T cells are taken from a patient’s blood. Then the gene for a special receptor that binds to a certain protein on the patient’s cancer cells is added in the laboratory. The special receptor is called a chimeric antigen receptor (CAR). Large numbers of the CAR T cells are grown in the laboratory and given to the patient by infusion.
This treatment regime has good clinical results and the attack path is expanding to more diseases. However it is (to use a technical term) wicked expensive. Novartis charges a list price of $475,000 for their CAR-T regime. This is one more example of something that we’ve looked at with Hep-C last March. Hep-C cures generate two true statements with a significant tension.
1) They are really freaking expensive on both a per-patient basis and total spending basis
2) They are really effective and thus high value
JAMA Pediatrics just published a cost-effectiveness study on CAR-T for a particular type of childhood cancer .** This paper raises the same points as the Hep-C cures:
In this decision-analytic modeling study using deidentified data, cost-effectiveness analysis generated an incremental cost-effectiveness ratio between $37 000 and $78 000 per quality-adjusted life-year gained over a patient lifetime horizon, with more than 40% of those initiating tisagenlecleucel treatment becoming long-term survivors.
Currently, the next best alternative to CAR-T treatment has a survival rate of 5% to 10%. So there are huge survival gains. Secondarily, those survival gains are cost effective gains. Most health policy analysts in the United States assume that a quality adjusted life year price of under $100,00 is a reasonable deal. Very few analysts will argue that a treatment with an upper bound price per QALY well below $100,000 is unreasonably priced.
A policy problem is that these are huge cash outlays for an insurer that has to assume that a patient won’t be covered by them for the rest of their life. The insurer will pay for the treatment and won’t get any of the gains of the new, high cash outlay treatment. If there is perfect risk adjustment with a technological innovation plus-up, this could remove some incentives for insurers to either not cover CAR-T facilities at in-network rates or to try to drown a patient and their family in paperwork and pre-authorization purgatory.
We need to figure out ways to pay for treatments that are both incredibly expensive and incredibly cost-effective within the insurance model that we are committed to.
** Whittington M et al, “Long-term Survival and Value of Chimeric Antigen Receptor T-Cell Therapy for Pediatric Patients With Relapsed or Refractory Leukemia”, JAMA Pediatrics, October 8, 2018