Photo: Kseniya Ovchinnikova/Getty Images
Weight loss drugs such as Wegovy and Zepbound are clinically effective but not cost effective at their current prices, according to a study published in JAMA Health Forum.
Tirzepatide and semaglutide, the generic names for the medications, generate improvements in quality-adjusted life expectancy when they’re paired with lifestyle modification, according to the study. But neither medication was cost effective at the $100,000/quality-adjusted life-year (QALY) benchmark due to their high lifetime treatment costs.
The threshold analysis indicates that a substantial price reduction (30.5% for tirzepatide and 81.9% for semaglutide) would be needed to make the medications more cost effective.
WHAT’S THE IMPACT?
Most state Medicaid programs and Medicare do not cover anti-obesity medications, and private insurance plans restrict access by requiring prior authorization, authors found. Due to the lack of additional discounts and inadequate coverage through state, federal and private insurance programs, many patients are unable to afford these medications, resulting in higher premiums and cost-sharing.
These high net prices will likely exacerbate obesity disparities, disproportionately affecting racial and ethnic groups with unequal healthcare access, the study posited.
Policy solutions are crucial to improve anti-obesity medication affordability and access, authors said. Under the Inflation Reduction Act, the Centers for Medicare and Medicaid Services has initiated price negotiations for selected drugs with an effective date of January 2026. Although the newer anti-obesity medications were not part of the initial 10 drugs for the inaugural drug price negotiation program, semaglutide is likely to be selected for Medicare price negotiation as early as 2027 under the IRA, given its significant clinical and fiscal effects, according to the analysis.
Although the exact discount from Medicare price negotiation is uncertain, this will likely affect the future prices of anti-obesity medications. Moreover, a recent CMS proposal to include anti-obesity medications under Medicare Part D and Medicaid could expand access to millions of people, though the Congressional Budget Office estimates that such coverage would increase federal spending by $35 billion between 2026 and 2034.
Authors said exploring alternative weight maintenance approaches – such as lifestyle modification programs, food-is-medicine interventions, and lower-dose maintenance GLP-1 receptor agonists (GLP-1 RAs) – after the initial use of GLP-1 RAs to achieve maximum weight loss could offer cost-effective alternatives while helping patients sustain meaningful clinical benefits.
Although these alternatives potentially yield fewer health gains than anti-obesity medications alone, they may result in substantial long-term savings in healthcare expenditures, the study said.
THE LARGER TREND
Expanding Medicare coverage of anti-obesity medicines could increase annual spending by $3.1 billion to $6.1 billion, according to an August Health Affairs study.
The authors forecast that if anti-obesity drugs were covered in 2025, and if 5% percent of newly eligible patients were prescribed one, annual Part D costs would increase by $3.1 billion annually. If the percentage of patients was doubled to 10%, the price tag could rise by $6.1 billion.
Given that more than 70% of U.S. adults had obesity or were overweight as of 2021, the potential market for these products is large, Health Affairs said.
Jeff Lagasse is editor of Healthcare Finance News.
Email: [email protected]
Healthcare Finance News is a HIMSS Media publication.
link