HealthPulse AdvisorsCAR-T & Advanced Therapy Reimbursement

The payer has modeled your contract.

For hospitals and cancer centers evaluating payer contracts, single-case agreements or outcome-linked terms for advanced therapies.

What you receive: an assessment of the proposed terms, applicable payment rules, program costs and financial exposure, with assumptions and unresolved terms made explicit.

Discuss a decision Read the FY2027 analysis

Supporting analysis: FY2027 CAR-T per-case economics.

FY2027 CAR-T per-case economics
FY2027 illustrative national IPPS base payment for MS-DRG 018, effective October 1, 2026CMS FY2027 final-rule Tables 1B, 1D and 5. Up 6.1% on FY2026.
$333,445
FY2027 IPPS fixed-loss amount, effective October 1, 2026Up 22.2% on FY2026.
$49,346
Median drug acquisition costManufacturer WAC data, all 7 FDA-approved products
$530K
Total cost of care, academic programs, medianDi et al., JNCI Cancer Spectrum, Aug 2024
$608,100
Effective clinical trial payment, FY2026Adjustment factor cut from 0.33 to 0.16. FY2026 historical value. FY2027 treatment requires separate analysis.
$50,277
Published per-case loss after outlier paymentsPenn/JCO 2020; Avalere Health 2025
$63K to $304K
How these figures are calculated

Illustrative national operating-plus-capital base payment for MS-DRG 018, calculated using the FY2027 final MS-DRG relative weight of 45.1272, national operating standardized amount of $6,848.98, capital federal rate of $540.03, and assumed wage index and capital geographic adjustment factor of 1.000. Assumes submission of quality data and meaningful EHR use. Excludes hospital-specific wage and geographic adjustments, IME, DSH and uncompensated-care payments, NTAPs, transfer adjustments, quality-program adjustments, and outlier payments.

What gets tested first.

Single-case agreements

Whether an agreement was in place before the first infusion, and on what terms.

Outlier payments

Where the outlier threshold sits relative to this program's actual per-case cost.

Revenue Code 891

How the drug cost is reported on the institutional claim, examined as evidence of whether payment follows the contract and the Medicare rule.

These are mechanisms HealthPulse tests for where they apply. None of them is asserted to be present in any specific program.

Capability

Advanced Therapy Reimbursement Architecture

CAR-T, TIL and HSC transplant payer-contract structures analyzed against current CMS baselines.

Read the capability
Platform

Analytical approach

How the firm's analysis is done, including H4, its internal analysis system.

The analytical approach

A payer, a product and a per-case number.

That is enough to start. If the gap is smaller than it looks, we will say so on the first call.

Discuss a decision