Payers and Providers Map the Path to Community CAR T Access

Chimeric antigen receptor (CAR) T-cell therapy access was built for tertiary academic centers, but the patients who need it increasingly live far from one. At the Community Oncology Alliance Payer Exchange & Innovation Summit, a panel of payer, practice, and network leaders examined what it will take to close that gap: how to define success, what payers need to see, and how community practices can build programs that both patients and payers trust.

Moderator Kiana Mehring, MBA, CSPR, CRCT, LION, PPMC, senior vice president, payer strategy, revenue cycle operations and value-based care, Florida Cancer Specialists & Research Institute (FCSRI), led the discussion “Breaking Down Barriers to Cellular Therapy: Payers, Providers & the Path to Patient Access.” Mehring asked the panelists, “What does successful coordination and collaboration look like among the different stakeholders?” Joining her were Anthony Bonagura, MD, who recently retired from his role as senior medical director at Optum; Aaron Lyss, MBA, director, strategic payer relations, OneOncology; and Ameet Patel, MD, MMHC, director of cell therapy at FCSRI. Mehring set an optimistic tone, noting that “there’s a lot more than we agree on than we disagree on.”

Definitions of Success

Lyss described success as a “3-legged stool.” Outcomes must be on par with those in other care settings, access must be faster and better, and the financial burden on practices must be manageable, he said, adding that access is “core to the value proposition of community oncology.”

Patel approached the question clinically, focusing on “brain-to-vein” time, a measure he called unique to cellular therapy. Shortening it matters because approximately 20% to 25% of patients become ineligible during the complicated CAR T-cell therapy journey, he explained. “How do you get that brain-to-vein time to essentially zero or close to it is really a phenomenal goal from the perspective of patients,” he said. He also highlighted the behind-the-scenes work of navigators and care coordinators, noting that “you don’t have codes to be able to show that effort.”

Bonagura stressed that success looks different depending on who is asked. Some patients prioritize convenience, whereas others will seek multiple opinions far from home, and self-insured employers often see these therapies as among their largest line-item expenses. All of those expectations, he said, must be balanced.

He traced many of today’s barriers to the therapy’s origins. Early on, CAR T-cell therapy was viewed as analogous to stem cell transplantation, delivered as an inpatient procedure at academic centers that already ran transplant programs. Centers soon told payers that inpatient delivery was not viable, he explained.

“From a financial standpoint, it is not a viable entity to keep it as an inpatient [offering],” he said. “They need to be able to do it as an outpatient.”

But payer systems move slowly, he cautioned. “Turning around UHG [UnitedHealth Group] is like turning around an aircraft carrier with an oar,” he said.

Lyss said he is optimistic that data will favor community delivery. “When we have the data on health care resource utilization and the health economics of delivering these therapies in the community oncology physician practice setting, in coordination with hospital providers, apheresis providers, we are going to see that the cost is significantly less than making these payers travel to tertiary centers,” he said. “If the quality is there, and the outcomes are there, then why are payers going to still make this so hard?”

He pointed to a familiar assumption. “It is the dogma that commercial cell therapies are like transplants, and they are managed like transplants,” he said.

What Do Payers Want to See?

Bonagura outlined several expectations. First, CAR T-cell therapy must be treated as a complete “vein-to-vein” episode. He said that payers were initially concerned about centers that wanted to infuse the product and send patients back home, and he said a community practice will likely need to take control of the case for a period of time. “The whole thing needs to be considered as a full event,” he emphasized.

Second, outcomes matter, but data are limited. “Our outcome data are developing, but it is very limited,” he said. Third, certification carries weight. “Third-party certification is going to become important,” Bonagura continued. “It is extremely important to a lot of our customers.”

He cited the Foundation for the Accreditation of Cellular Therapy as the best-known example. Manufacturer programs are a harder sell. “A lot of the pharma companies have very good quality programs, but they’re not going to be perceived by the customer as being totally disinterested; they have some skin in the game,” he said.

Patel said practices should bring evidence to payers. “There are a lot of studies in the outpatient setting showing that both accredited sites and nonaccredited sites are capably able to deliver CAR T,” he said. Practices can also commit to longitudinal follow-up and be selective, referring complex patients to academic centers. But the dialogue must continue. “It’s not a 1-time conversation that you may have with your local [or] regional payer. It’s an ongoing discussion,” he said.

Building a Program Amid Pushback

Lyss, expressing respect for Bonagura’s opinion, took the other side on 2 points. He said the practices beginning to consider CAR T-cell therapy are those already managing T-cell engager patients outside the clinic walls. “It’s only the practices that have gotten these training wheels of doing outpatient management of T-cell engager patients in earlier ramp-up dosing phases that are even getting to the start line of thinking about doing CAR T-cell therapy,” he said.

On outcomes, he cited results of a study presented at the 2026 American Society of Clinical Oncology Annual Meeting that found no meaningful difference in outcomes between Foundation for the Accreditation of Cellular Therapy (FACT) and non-FACT centers.¹ “There was a meaningful, observable difference in access to FACT and non-FACT centers, but not in outcomes,” he said. “We’re starting to get some early signals that the community practices that are doing this are doing it in the right way.”

Bonagura did not dispute the logic but explained the payer mindset. “We have one chance to treat this patient,” he said. “We don’t hear about the good outcomes. We hear about the bad outcomes.” He acknowledged, however, that the field is moving. “What we think today about what is acceptable for a center delivering CAR T may be totally wrong,” he said.

Lyss described how OneOncology, which has 6 practices certified by at least 1 manufacturer to administer CAR T-cell therapy, is speeding up the process. Building on the experience of Tennessee Oncology, which treated its first patients with commercial CAR T more than 2 years ago and later achieved FACT accreditation, the network created standard operating procedure (SOP) templates for postinfusion toxicity management, quality management plans, guidance for engaging hospitals and apheresis providers, and contract templates with legal support.

“They’re not staring at a blank page from the standpoint of development of SOPs, and they can take a template and customize it for their practice, their staff, etc,” he said.

Patel offered a simple framework. “There’s a triumvirate of variables: There’s time, there’s money, and then there is labor. In an ideal situation, you want to pick 2 out of the 3. But CAR T is unique in that you’re developing a program and you require all 3,” he said.

What Does the Future Hold?

Asked how to simplify payer expectations, Bonagura was unsure. “I don’t know that simplifying it is necessarily something we can realistically expect right now,” he said. “We have to accept that there’s going to be disagreements. We have to work through them.”

Lyss expects change sooner. “I don’t think it’s going to be 5 to 10 years,” he said. “We’re going to potentially see FDA approval of the safest CAR T-cell product we’ve seen yet in this calendar year.” As products approach the safety of bispecifics, the system will need to adapt, he noted. “When we start having CAR T-cell products that have the safety profiles of the bispecifics that we’re administering in the physician’s office today, then it’s going to accelerate some of these questions around why do we have these 2 completely different systems,” he said.

An audience question addressed the projections of more than 200,000 patients eligible for bispecifics vs approximately 10,000 eligible for CAR T-cell therapy, suggesting that easier access to bispecifics could draw clinicians away from CAR T. Patel responded that curative potential is the point. “That’s always been the value proposition of CAR T-cell therapy, that this is a curative treatment modality,” he said.

Bonagura said the perception that CAR T-cell therapy belongs only at elite centers is a hurdle. “That perception needs to change over time, but that is a real perception that we have to deal with,” he said. “Education doesn’t necessarily happen overnight.”

Lyss closed with a challenge to the room. “So, are you all ready to build your CAR T programs now?”

Reference

1. Raj RV, Beer TC, Liu FF, et al. Real-world patient characteristics, outcomes, and resource utilization of chimeric antigen receptor (CAR) T cell therapy across Foundation for the Accreditation of Cellular Therapy (FACT) and non-FACT treatment centers in large B-cell lymphoma (LBCL). J Clin Oncol. 2026;44(suppl 16):7023. doi:10.1200/JCO.2026.44.16_suppl.7023