How payers can prepare for the next wave of cellular therapy patients

In recent years, cancer patients are being offered an additional option when chemotherapy and radiation treatments fail: chimeric antigen receptor (CAR) T-cell therapy. With CAR T-cell therapies, a type of ex vivo gene therapy, a patient’s T cells are genetically modified in a lab to better recognize and kill cancer cells.

The treatments are used for certain blood cancers such as leukemia, lymphoma and multiple myeloma.

Last year, the U.S. Food and Drug Administration (FDA) also approved¹ the first cellular immunotherapies for treating solid tumors, adding to the host of previously approved CAR T-cell therapies.

Known commercially as Amtagvi^TM, a one-time treatment for patients with advanced melanoma, and Tecelra^TM,² used to treat synovial sarcoma, these treatments leverage the body's own immune cells to recognize and attack cancer cells. But they come with a hefty price tag — roughly $515,000. That’s only slightly higher than existing CAR T-cell therapies for blood cancer patients, many of which cost upward of $400,000.³

These prices also don’t include the additional costs associated with these therapies, such as hospital and professional charges, invoice markups and other treatments for underlying conditions while a patient waits for cellular therapy.

Yet, the potential — and reality — of these therapies is undeniable. Since 2017, when the first CAR T-cell therapy was approved by the FDA, these therapies have become a key reason that survival rates of people with certain blood cancers have soared from 10–15% five years ago to 40% today.⁴ These results are the reason why payers must be prepared to manage the high costs of these treatments.

With hundreds of clinical trials for novel therapies underway⁵ and evidence emerging that cell-based therapies may effectively treat some autoimmune diseases,⁶ CAR T-cell therapies will continue to reshape cancer treatment in the coming years. One growth projection shows the U.S. CAR T-cell therapy market surging from $2.45 billion in 2023 to $35.1 billion in 2033.⁷

So far, more than 30,000⁸ patients in the U.S. have been treated with CAR T-cell therapies. And there’s good reason to think that these treatments will become even more accessible to cancer patients in the coming years.

As CAR T-cell therapies gain traction and become more widely accessible, they are set to have a significant impact on the healthcare landscape. And that raises pressing questions for payers. How can they prepare for an influx of cellular therapy patients? And what are appropriate strategies for managing high-cost, clinically complex cases?

1. Understand the total cost of care

CAR T-cell therapies are complex, high-touch treatments — the opposite of taking a pill. For this reason, a coverage strategy must factor in how intensive the therapies can be and the risks they present.

For example, patients often require significant support while undergoing the therapy, including close monitoring afterward for serious adverse reactions, such as cytokine release syndrome, as well as brain swelling and other life-threatening neurological events requiring hospitalization.

Direct CAR T-cell treatment costs can include apheresis (the T-cell extraction process), biopsies, CAR T-cell production, hospital stays, imaging studies and bridging therapies (treatments given to patients while they are waiting for the cells to be manufactured). And for patients who don’t live near a certified treatment center, indirect costs may include travel, housing and caregiver support.

Therapy list prices account for most but not all of the costs of care. Optum 2023 CAR T-cell cost data shows an average total billed charges of $2.2 million,¹⁰ highlighting the steep cost of the additional charges outside of the biologic itself.

A well-rounded cost-management strategy will need to factor in all aspects of the care continuum, including post-treatment monitoring, rehabilitation and any additional care related to complications or side effects.

Fortunately, there is some good news on the cost horizon. If off-the-shelf therapies come to market, they could help reduce total per-patient cost of care compared to existing approved approaches. This is because the existing processes require costly individualized CAR T-cell production, along with care administered while a patient awaits the customized therapy.

2. Develop clear coverage policies

Because CAR T-cell therapy treatments are expensive and complex, it’s important that they are covered appropriately under existing plans. Payers should develop working policies that include:

Eligibility criteria: Define the patient populations that would most benefit from cellular therapies. This could include certain cancer types, genetic conditions or rare diseases that have limited treatment options.

Reimbursement structures: Given the high costs of the treatments, payers will need to carefully consider financial factors such as reimbursement rates and copays.

Strategic contracts: Through its CAR T Preferred Provider Network, a Center of Excellence network, Optum has been able to drive down costs for payers by negotiating rates with certified treatment centers. These agreements help limit the volatility seen in CAR-T charges, providing more predictable costs and greater financial protection for payers. In addition, by working with a trusted network of providers, payers can further reduce markups on biologic costs.

3. Understand all treatment options

Any effective coverage strategy should ensure members have access to the full spectrum of treatment options. A CAR T-cell therapy may be a great option for one person but be inappropriate for another.

More broadly, payers need to determine they have a prior authorization process in place so they can identify a potential CAR T-cell therapy case — then make sure all appropriate treatment options have been considered. This can both help support optimal health outcomes and manage total cost of care.

4. Consider the value of outpatient care

University-based medical centers have been the most common sites for CAR T-cell therapy administration. The need for some patients to travel far from home has limited access and sometimes created delays in treatment, which can worsen outcomes.

While CAR T-cell therapy has historically been administered mainly on an inpatient basis, it is increasingly being offered on an outpatient basis or a mixture of both. A 2024 study⁹ of patients with lymphoma found that outpatient community hospital care was as effective as inpatient care for CAR T-cell therapies.

If outpatient CAR T-cell treatment is as safe and effective as inpatient treatment for some patients — and is more convenient for members — a coverage strategy could be designed accordingly to reduce the cost of care. Reducing inpatient care can lead to significant savings, not only on hospital facility charges but also on ancillary costs like lodging and travel for patients who must travel long distances to treatment centers.

As outpatient care becomes more common, payers could work to develop networks that facilitate these treatment options for members, optimizing both costs and patient outcomes.

The demand for CAR T-cell therapies — and other cellular and gene therapies — is only going to increase in the coming years. For payers, the challenge will be to ensure that these treatments are accessible to those who need them, while managing the financial risks associated with their high costs. By adopting a well-rounded strategy that includes cost management, outpatient care options and strategic contracts, payers can help achieve both outcomes.

Optum provides contractual protection for payers for cellular therapies, including all chimeric antigen receptor T-cell (CAR T) therapies and select gene therapies.