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Health & Wellness

Spring Comes – Emerging Medicine Options and Medicare Coverage

medicare coverage

When lake ice “goes out” at the end of winter, that is the first sign of big change ahead.  Spring is coming.  The same is true when big changes occur in Medicine – and within Medicare coverage.   A big change starts small.  One is happening now – and it may help older patients gain access to a path-breaking, life-saving new cancer treatment.

Here is what is afoot.  As the New York Times has reported, “Medicare is poised to cover a promising but expensive new type of cancer treatment, with significant restrictions meant to hold down the cost.”  The story was underreported, but important. 

Here are pivotal facts.  Patients afflicted with certain cancers tend to face an uphill battle – even with radiation and chemotherapy.  For these patients, new hope resides in something called “CAR-T cell therapy.”  

This new treatment is personalized to patients.  Specifically, “immune cells — T cells — are removed from a patient’s blood, sent to a laboratory where they are genetically engineered to recognize and attack cancer cells, and then sent back to the hospital for infusion into the patient.”  This begins the process.

The report adds that “treatments have been remarkably effective in some patients who had a dismal prognosis after exhausting other options,” although “450 clinical trials” are ongoing. 

This new option offers new hope.  With it comes possible new Medicare coverage – at least in some cases.  Questions remain about how effective this new treatment option will be – especially for older patients – but this development is significant. 

Unfortunately, it is also expensive.  As the New York Times noted:  “The Food and Drug Administration has approved two CAR-T products to treat certain blood cancers.”  They carry “a list price of $373,000 or $475,000, depending on the type of cancer …” Another option carries a price of “$373,000.”  The nub is – these treatments are expensive, which is why Medicare coverage will be vital.

The seminal question – based on high cost – is:  Who can get access, when and at what level?  Accordingly, the Trump team has suggested Medicare coverage of “CAR-T therapy” – for those who find chemotherapy and radiation ineffective, and for “patients whose cancer returns, causing a relapse after a period of improvement.”  That is a start.

Good too are reports that CAR-T is useful for “patients who had a dismal prognosis after exhausting other options.”  The open question is: Could a larger number of older Americans be covered for this “entirely new approach to treating serious and even life-threatening diseases?”  Maybe. 

That seems to be the question under consideration now.  The Centers for Medicare and Medicaid Services is considering that question now.  It may take a while, but ice is moving … spring is coming.  The Trump Administration is pressing coverage for one group – and possibly a wider group.  And that is good news.

Some think we are entering a “brave new world,” others are cautious.  Net-net, good things are afoot.  The Administration is helping make them happen.  Spring is on its way.  

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Read more articles by Robert B. Charles

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