"Pay for the Care, Not Only the Vial": The Hidden Costs of Cancer Care

Practices are absorbing staffing, training, and monitoring costs that payers don't reimburse when delivering novel cancer therapies, a gap panelists said can limit patient access, according to oncology leaders who spoke on a cost and capacity panel.

The session at The American Journal of Managed Care^®’s annual Patient-Centered Oncology Care® conference, moderated by Wade Iams, MD, MSCI, director of lung cancer research of Tennessee Oncology, examined how drug costs, operating expenses, and capacity limits determine which patients can receive therapies such as chimeric antigen receptor (CAR) T-cell therapy and bispecific antibodies. Panelists from academic, community, and hospital-affiliated cancer networks agreed that drug price is only the starting point and that the staff, beds, and infrastructure needed to deliver it are often harder to scale.

Hidden Operational Costs of Novel Cancer Therapies

Melody Chang, RPh, MBA, BCOP, vice president of pharmacy operations at the American Oncology Network (AON), said her organization tracks drug acquisition costs and operational costs very differently. Acquisition costs sit on the invoice and can be benchmarked, but operational costs, including training, monitoring time, and other expenses that never show up on the books, are far harder to capture. For some novel therapies, she said, reimbursement falls short of the cost of delivering care, and practices are left to cover the difference.

The start of the cost conversation at Memorial Sloan Kettering Cancer Center (MSK) is what the wholesale acquisition cost is and how MSK is going to pay for it, according to Scott Freeswick, PharmD, MS, vice president and chief pharmacy officer at Memorial Sloan Kettering Cancer Center. The center’s pharmacy and therapeutics committee looks for FDA approval or National Comprehensive Cancer Network Category 1 or 2A status and tries to keep drugs in the outpatient setting.

“We basically lose the money that we spend on inpatient dose,” Freeswick said. “So anytime a drug is added to formulary, we actually challenge the person bringing it to formulary [to show] that the drug can be given safely in an outpatient environment, and our goal is to move as many drugs as we can from [inpatient] to [outpatient].”

Yale Podnos, MD, MPH, FACS, chief medical officer and president of the practice at Starling Oncology, formerly The Oncology Institute of Hope and Innovation, said his organization sits on both sides of the payment question because about half of its business is capitated and half is fee-for-service.

“Half of the time the payer’s the payer, and then the other half of the time we’re kind of the payer,” he said. “We do have to look at it from both perspectives, which causes a lot of really interesting conversations and constructive arguments between the finance and clinical teams.”

Podnos said Starling keeps payer status hidden from treating physicians so it doesn't influence care. He said the organization defines value as effect divided by cost and later said a therapy no better than what's already available is unlikely to be used.

Staffing and Training Limit CAR T and Bispecific Capacity

On capacity, panelists kept returning to people rather than equipment. Chang said outpatient CAR T-cell therapy is a chain of dependencies, including apheresis slots, manufacturer turnaround, site activation, and certification, but staffing is the hardest to scale. Her organization began administering outpatient CAR T in June.

“You can add the chair next day, you just cannot have the trainers on demand the next day,” she said. Programs that see a patient only every few months don’t get enough repetitions to build proficiency, she added, and nursing turnover forces retraining.

Iams said his network saw the same thing when rolling out the bispecific T-cell engager tarlatamab (Imdelltra; Amgen)^1,2 across its 35 clinics. “The human element is the most difficult piece, making sure we have that expertise that we want across the board,” he said.

Jonathan Tinker, MBA, MHA, vice president of oncology services of the Sarah Cannon Cancer Network, the oncology enterprise of HCA Healthcare, agreed that the workforce is the biggest barrier to expanding capacity. His network has 10 sites providing CAR T-cell therapy, 3 of them built in the past 2 years. Staff from newer sites visit mature sites to build competencies.

“Because those first couple patients are so important, experienced individuals from the mature sites will go to the newer sites and be there for the first couple infusions,” he added. “It definitely takes a partnership for training to expand that workforce.”

For Freeswick, the top constraint is inpatient beds. Institutions did not anticipate how toxic newer therapies would be, he said, and MSK is often at or beyond capacity because of CAR T-cell therapy and bispecific antibody therapy. MSK partners with area hospitals, moves CAR T and bispecific step-up dosing to the outpatient setting when it is safe, and has outsourced some apheresis to a third party.

“It's not for every patient, but whenever we can do it, we will do it,” Freeswick said.

MSK has also expanded suburban sites, which have grown in popularity since the COVID-19 pandemic, and now brings clinical trials to them. That is expensive and tedious, he said, because some investigational drug vials can be distributed from only one site, requiring temperature-controlled transport under regulatory requirements. He said it is worth it because enrollment increases and patients are happier getting care closer to home.

“Last thing you want to do when you’re sick is to get in the car and drive for a couple hours in traffic,” he said.

Expanding Novel Therapies Beyond the Flagship Site

Tinker said his network decides where to add a therapy based on community need, local clinical expertise for which the therapy is a priority rather than a side project, and facility assessments for managing adverse events (AEs). Of the 190 hospitals in the network, not all are equipped to manage AEs. Iams said local hospital capacity is the biggest hurdle his practice faces with bispecific rollouts across Tennessee.

Podnos said Starling’s fully decentralized model, spread across thousands of square miles in Southern California, makes it hard to build a center of thought leadership without a flagship. The organization relies on physicians with particular interest and expertise.

“If I don’t have a zealot, I look for a champion,” he said. “And then if I don’t have a champion, I look for somebody who owes me a favor.”

Chang said AON tested its outpatient workflow at 2 pilot sites in 2024 and, because the rollout went well, is pushing it out to more sites. She said the network expects to be able to deliver bispecifics entirely in the outpatient setting across almost 87% of its system. Physician champions, the pharmacy and therapeutics committee, and centralized pharmacy operations share the work. She said the biggest investments are clinical education and central pharmacy support, which spare individual sites from building infrastructure independently.

What Panelists Want From Payers: Reimburse the Care, Not Just the Drug

The single change that would most expand access is something payers can help with, the panelists agreed.

Freeswick called for holistic reimbursement, with Podnos agreeing and looking for reimbursement that goes beyond average sales price plus 6% to the resources needed to build new programs. Tinker asked for more predictable payments and pointed to long-term workforce investment through HCA Healthcare’s graduate medical education programs.

Chang said closing the capacity gap comes back to cost, because underpayment leaves too little funding to invest in staff.

“I would plead maybe to the payers, if there are payers in the audience, pay for the care, not only for the vial,” she said.

References

1. Joszt L. Tarlatamab receives accelerated approval for extensive-stage SCLC. AJMC^®. May 16, 2024. Accessed September 29, 2026. https://www.ajmc.com/view/tarlatamab-receives-accelerated-approval-for-extensive-stage-sclc

2. Joszt L. FDA shortens tarlatamab monitoring, widens access to SCLC care. AJMC. September 14, 2026. Accessed September 29, 2026. https://www.ajmc.com/view/fda-shortens-tarlatamab-monitoring-widens-access-to-sclc-care