Novartis’ Kymriah reimbursement continues to involve outcome-based provider contracts but payer engagement ambivalent with complicated reimbursement dynamics

19 Jul 2018

Novartis’ (VTX:NOVN) outcome-based contracts (OBCs) for reimbursing its CAR-T therapy Kymriah (tisagenlecleucel) for acute lymphoblastic leukemia (ALL) remain a viable option for treatment centers, despite recent conflicting media reports saying otherwise, experts said. But private payer enthusiasm for engaging in OBCs and how the arrangement can overall reduce healthcare costs is unclear in light of nebulous financial logistics, they noted.

Despite recent news reports about the Centers for Medicare and Medicaid Services (CMS) pulling out of demonstrations to reimburse Kymriah based on performance, OBCs between Novartis and treatment centers remain part of Kymriah’s reimbursement procedures, both parties to the contract have confirmed to this news service.

OBCs were touted as a major step in value-based reimbursements by CMS and other stakeholders when Kymriah was approved approximately a year ago. However, their adoption has been limited to ALL alone, and not extrapolated for the drug’s subsequent approval in B-cell lymphomas. Furthermore, regardless of outcomes-based arrangements, private payers are negotiating Kymriah’s ALL reimbursement rates on a case-by-case basis, considering the relatively low number of ALL patients eligible to receive Kymriah coupled with its high cost.

Since payment rates revolve around single-case agreements, the far-reaching financial impact of this value-based model is not clear, said experts. They were also unclear about the logistics revolving around upfront and ancillary costs for these therapies in the larger community.

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