Insurance

• Single-case agreement / out-of-networkHigh

  Medicaid out-of-state billing and enrollment are notoriously slow, stretching the time before treatment can start

• Insurance coverage & prior-authorizationHigh

  Medicaid rules vary by state and plan — some don't clearly cover CAR-T, so approval can be slow or contested

• Coverage lag after approvalWatch

  State Medicaid can take months after FDA approval to add a new therapy, so coverage may not exist yet when it's needed

• Equity / disparity riskHigh

  Medicaid patients meet more coverage restrictions and site limits, which lowers the chance of reaching treatment

Home community

• Geographic access / distance to a centerHigh

  Rural homes sit far from the few certified centers, so the nearest option may be hours away

• Equity / disparity riskHigh

  Rural residence layers distance, workforce, and coverage gaps on top of other disadvantages

• Travel & lodging burdenModerate

  Rural patients travel farther at every step, compounding cost and time away from work and family

• Transportation barrierModerate

  Rural areas have little public transit, so the long drives fall entirely on the family

Health-system navigation

• Equity / disparity riskHigh

  Harder to grasp eligibility, ask the right questions, and self-advocate — so these patients are identified and referred less often

• Health-literacy / navigation-complexity burdenHigh

  The pathway spans dozens of visits, forms, and authorizations; without hands-on navigation, steps get missed and patients fall behind

• Language & communication barrierModerate

  Dense medical explanations may not land, so key instructions and warning signs can be missed unless teach-back is used

Disease pace

• Late referral / progression before treatmentHigh

  Fast-moving disease can outrun the refer-and-work-up timeline, so any delay risks losing the treatment window

• Eligibility / patient-selection hurdlesWatch

  Rapid progression can erode fitness mid-work-up, so someone eligible today may not be by the time they are assessed

• Manufacturing / collection & vein-to-vein riskHigh

  The 2–8 week manufacturing wait is hard to survive when disease is moving fast, which makes strong bridging therapy critical

Distance to nearest center

• Geographic access / distance to a centerHigh

  At 76–150 miles each visit is a half-day trip, which quietly suppresses referral, work-up completion, and follow-up

• Travel & lodging burdenModerate

  76–150 miles means repeated paid travel and likely overnight stays around key visits

Young children / dependents at home needing care

• Caregiver & psychosocial clearanceHigh

  Children or dependents at home make a month-long relocation and 24/7 caregiving hard to arrange

• Housing insecurity / relocation burdenModerate

  Dependents at home make an extended relocation harder to sustain, both logistically and financially

Expresses hesitancy, fear of toxicity, or mistrust

• Health-literacy / navigation-complexity burdenHigh

  Mistrust can cause hesitation, missed visits, or declined steps that stall the whole process

• Awareness, understanding & hesitancyHigh

  Fear of toxicity or mistrust can lead to hesitation or outright refusal even when the patient is a strong candidate

Language

• Health-literacy / navigation-complexity burdenHigh

  A language barrier adds a translation layer to every form and instruction, slowing an already complex process

• Language & communication barrierModerate

  Without interpreters, eligibility discussions, consent, and toxicity instructions may not be understood — risking errors and delay

Household income

• Financial toxicity / out-of-pocket burdenHigh

  Copays, ancillary drugs, and travel stack up quickly and, on a limited income, crowd out essentials

• Travel & lodging burdenModerate

  On a limited income, uncovered travel and lodging can be the deciding factor in whether the patient actually shows up

Family understanding of CAR-T

• Health-literacy / navigation-complexity burdenHigh

  Brand-new to cell therapy, the family has a lot to absorb quickly just to keep decisions on schedule

• Awareness, understanding & hesitancyHigh

  New to CAR-T, the family may over- or under-estimate risk and benefit, which makes decisions harder and slower

Center in home state?

• Single-case agreement / out-of-networkHigh

  Out-of-state treatment usually requires enrolling the provider in the patient's plan or Medicaid — a slow, extra step

• Geographic access / distance to a centerHigh

  No in-state center forces out-of-state care, adding travel plus cross-state coverage and enrollment steps

Center network status

• Single-case agreement / out-of-networkHigh

  Out-of-network care requires negotiating a single-case agreement before treatment — often several weeks of back-and-forth

• Insurance coverage & prior-authorizationHigh

  An out-of-network center means standard authorization doesn't apply — a special agreement has to be arranged first

Line of therapy

• Late referral / progression before treatmentHigh

  With 2+ lines already used, the window to refer while still eligible is closing

Dedicated caregiver (~30 days)

• Caregiver & psychosocial clearanceHigh

  An unconfirmed caregiver can hold up psychosocial clearance until a concrete, named plan is in place

Caregiver & work

• Caregiver & psychosocial clearanceHigh

  If the caregiver can't take ~a month of leave without losing income, the required round-the-clock coverage can fall through

Performance status

• Eligibility / patient-selection hurdlesWatch

  Borderline performance status invites extra scrutiny that can tip a selection decision the wrong way

Financial cushion

• Financial toxicity / out-of-pocket burdenHigh

  With little savings, one unexpected bill or lost paycheck can halt participation mid-course

Currently managed at

• Late referral / progression before treatmentHigh

  Community teams see CAR-T rarely, so an eligible patient is easy to overlook or refer only after more lines are used

minority

• Equity / disparity riskHigh

  Documented referral bias and trial under-representation mean minority patients reach CAR-T less often at each step of the path

Recent bendamustine / heavy lymphodepleting chemo

• Manufacturing / collection & vein-to-vein riskHigh

  Recent bendamustine or heavy chemo depletes and tires T-cells, so collection may not yield enough healthy cells to manufacture

Referring team & CAR-T

• Late referral / progression before treatmentHigh

  A team unfamiliar with CAR-T may not spot candidacy or know when and where to send the patient

Transportation

• Transportation barrierModerate

  Depending on others or transit makes frequent, time-sensitive visits fragile — a missed ride becomes a missed step

Housing

• Housing insecurity / relocation burdenModerate

  The protocol needs a stable home base near the center; unstable housing can make that stretch impossible to arrange

Income during treatment

• Financial toxicity / out-of-pocket burdenHigh

  Weeks away from work with no paid leave cut household income at exactly the moment costs are spiking