Semaglutide Coverage Could Raise Medicare Costs by Billions

TOPLINE:

Around one in seven Medicare beneficiaries with a high body mass index (BMI) may perhaps per chance well merely be newly eligible for semaglutide therapy after Medicare allowed Fragment D plans to duvet the drug for sufferers with a BMI ≥ 27 and a history of cardiovascular illness (CVD), no topic their diabetes plan.

METHODOLOGY:

• In March 2024, Medicare licensed the coverage of semaglutide by Fragment D plans for sufferers with a high BMI and existing CVD, no topic their diabetes plan. This resolution follows the SELECT trial results, showing that semaglutide reduced the probability for cardiovascular events in some sufferers with out diabetes.
• This see aimed to picture the Medicare beneficiaries most likely to be newly eligible for semaglutide therapy and estimated most costs to Medicare Fragment D.
• The researchers integrated 5111 individuals used ≥ 65 years with self-reported Medicare enrollment in the National Well being and Nutrition Examination Recognize between 2011 and 2020, all of whom had a BMI ≥ 27 and had been susceptible to support from semaglutide therapy.
• They evaluated the next ability definitions of established CVD that would be belief about by the Fragment D notion:
  • Doctor-equipped prognosis of myocardial infarction, stroke, coronary artery illness, or angina
  • A 10-three hundred and sixty five days probability for atherosclerotic CVD between 7.5% and < 20.0%
  • A 10-three hundred and sixty five days probability for atherosclerotic CVD of ≥ 20%
  • Success of any of the above three standards
• Files on interview responses, remedy exhaust, medical examinations, laboratory results, and diabetes diagnoses had been obtained from the individuals.

TAKEAWAY:

• This see stumbled on that 3.6 million individuals (14.2%) had been deemed extremely susceptible to qualify for semaglutide therapy for the main time, and broadening the factors for established CVD may perhaps per chance well enhance this number to 15.2 million individuals (60.9%).
• If all newly eligible beneficiaries had been to catch semaglutide therapy, Medicare spending may perhaps per chance well enhance by $34-$145 billion every three hundred and sixty five days.
• Even with more conservative definitions of CVD and a most well-known fragment of individuals now not conserving long-term adherence to semaglutide therapy, costs may perhaps per chance well unruffled enhance by $10 billion every three hundred and sixty five days.
• Youthful, usually more healthy, female Medicare beneficiaries had been unruffled susceptible to stay ineligible for semaglutide therapy in step with the coverage equipped by Fragment D Medicare plans.

IN PRACTICE:

“Even supposing roughly one in seven Medicare beneficiaries with elevated BMI is susceptible to be newly eligible for semaglutide, the majority will stay ineligible if a slim definition of established CVD is used by Fragment D plans. Weight support an eye on has advantages for sufferers with elevated BMI, so the definition of established CVD used by Fragment D plans for coverage of semaglutide may perhaps per chance well have outsized public neatly being implications,” the authors wrote.

SOURCE:

The see become led by Alexander Chaitoff, MD, MPH, Center for Healthcare Birth Sciences, Department of Medication, Brigham and Girls’s Clinical institution, Boston. It become printed on-line on August 27, 2024, in Annals of Internal Medication.

LIMITATIONS: 

This analysis relied on self-reported cases of CVD. The see become also miniature to absolute top neighborhood-space adults. It estimated most budgetary impacts but didn’t fable for price reforms launched by the Inflation Reduction Act or for absolute contraindications to semaglutide.

DISCLOSURES:

This see didn’t expose any sources of funding. Some authors declared receiving grants, serving as consultants, and having diversified ties with some institutions.

This text become created utilizing quite a lot of editorial instruments, including AI, as share of the direction of. Human editors reviewed this dispute sooner than newsletter.