CAR-T, CRISPR, and More Updates in Cancer Care and How to Pay for Them

Cancer remains a leading cause of morbidity and mortality in the United States, and the cost of cancer care is projected to reach $156 billion in 2020. Since 2013, more than 45 novel cancer therapies have been approved, with more than 600 molecules in late-phase clinical trials. During a presentation at AMCP Annual Meeting 2018, Christina Link, PharmD, and Jake Chaffee, PharmD, both clinical managers at Blue Cross Blue Shield of Michigan, gave an overview of oncology treatment innovations.

Last year, the U.S. Food and Drug Administration approved the first two chimeric antigen receptor (CAR) T-cell therapies (tisagenlecleucel and axicabtagene ciloleucel), which collect patient immune cells, reengineer them, and reintroduce them into the body to target tumor cells. Another novel treatment option is CRISPR—a gene therapy technique in which genes in living cells can be modified or corrected to treat genetic causes of disease.

The goal of CAR-T therapy is complete remission (CR). Tisagenlecleucel led to 83% of patients achieving CR/CR with incomplete hematologic recovery. All patients achieved minimal residual disease-negative status. Axicabtagene ciloleucel resulted in 51% of patients achieving CR. The median duration of treatment was not reached for either therapy. Both CAR T-cell therapies have boxed warnings for cytokine release syndrome—a systemic inflammatory response syndrome—and neurological toxicities. The cost of CAR T-cell therapies can range from approximately $523,000 to $795,000 per case.

These innovative therapies with large price tags result in payment strategy challenges and require different management and payment models. Some of these payment models for innovative oncology agents include:

• Bundled payments: Include single payments for defined episode of care or set of services; used in transplants, inpatient clinical episodes, and select oncology programs
• Accountable care organizations and patient-centered medical homes: Payment is linked to effective management of population or episode of care
• Value-based and outcomes-based contracting: Payment terms are tied to clinical circumstances, patient outcomes, or agreed-upon measures
• Annuity payments: A series of payments are made at equal intervals

Site of care, biosimilars, and drug competition are areas to consider in oncology management. Alternative sites of care to the hospital outpatient setting are the member’s home, physician’s office, and ambulatory infusion center. Site of care consideration can lead to an $8,000 decrease in per-person, per-month costs; fewer emergency department (ED) encounters—including 18% fewer ED visits at 10 days and 28% fewer ED visits in 72 hours—and decreased physician visits. Biosimilars are providing competition at lower costs, and two agents have already been approved: tbo-filgrastim and filgrastim-sndz, which are used to treat neutropenia. Other biosimilar agents in the pipeline are for reference drugs trastuzumab, rituximab, bevacizumab, and pegfilgrastim.

Presentation S3: Digesting Cancer’s Alphabet Soup: Managing CAR-T, CRISPR and other Innovation in Oncology. AMCP Annual Meeting 2018.