Assessing cost-effectiveness of GLP-1 drugs in a changing market

People who have had a previous heart attack or stroke are at the highest risk for recurrent events. Taking the GLP-1 agonist semaglutide lowers the risk for cardiac events and could become cost-effective as prices decline, said cardiologist Dhruv S. Kazi, M.D., MSc, MS, associate director of the Richard A. and Susan F. Smith Center for Outcomes Research and medical director of the Cardiac Critical Care Unit at Beth Israel Deaconess Medical Center (BIDMC).

Kazi and his colleagues conducted an analysis to understand the impact of semaglutide (Ozempic and Rybelsus for diabetes and Wegovy for weight loss) at different price points on population health, specifically in patients who have had a previous heart attack or stroke.

Wegovy is approved both as an oral and as an injection for weight loss and to reduce the risk of major adverse cardiovascular events in adults who are obese or overweight. The injection form of Wegovy is also approved to treat metabolic dysfunction-associated steatohepatitis (MASH).

The model used an annual semaglutide cost of $8,604 (2023 U.S. price net after rebates and discounts, as well as the incremental cost for each quality-adjusted life-year, or QALY, gained. Kazi and his colleagues found that annual treatment with semaglutide would avoid more than 358,000 heart attacks, strokes, and cardiovascular deaths. Preventing those events is estimated to save nearly $15 billion in healthcare spending for cardiovascular care and $8 billion in spending for other care. But the drug itself would cost $344 billion over those same lifetimes.

Below, Kazi discusses various factors for cost-effectiveness and affordability of semaglutide.

Q: Your analysis was done with 2023 prices, and this is a market that is changing quickly. Would the outcome of the analysis change if today’s prices were used?

Kazi: We were aware going into this that the price of the drug is going to change pretty substantially. We had designed this study to be flexible with regard to drug pricing. There is a figure in the paper that shows as the drug price goes down, the cost-effectiveness gets better. In fact, we even make the case that if the drug prices in the U.S. were equivalent to those found in European countries, then the drug would be cost-effective.

Not only are the drug prices changing, but they’re changing unevenly in the United States. What I mean by that is that the price available to a Medicare patient might be different from the price available to a commercial insurance patient and Medicaid, for instance. What we’re trying to do is not to create a blanket go/no-go decision on whether semaglutide is cost-effective or not cost-effective, but rather to inform the value of this therapy across a range of prices that we think will be available in the United States over the next couple of years.

Q: Are GLP-1 medications now affordable for patients?

Kazi: "Affordable" is a tricky word because affordable to whom? Increasingly, semaglutide is affordable, especially for the group of patients that we’ve studied in this model: people with heart disease. Usually, an insurer will cover this therapy for heart disease prevention, and a patient’s copay might be $25 or $50. That is affordable for many, but not all.

I’ve always thought that copayments are funny. If the drugs are effective, we want people to take them. They should be free so that people are using them. But I think as a health system, it’s a different conversation. Here’s what I mean by that: something can be very high value in the long term but unaffordable in the short term. If every patient who would benefit from semaglutide for weight loss, for instance, were to be on the therapy, we’d be spending a very large amount of money on these drugs. We could argue that as a health system, we may not be able to afford them, even with the lower prices in the long run.

One of the challenges for a lot of health systems is to figure out how to prioritize. Who are the people who you want to have access to this therapy early because it produces the maximum health benefit? The sweet spot is the individuals who are at high risk for heart disease but not so high risk that they have other health challenges. Finding the balance based on the payers’ priorities and our societal priorities is going to be important.

Q: Would your analysis change for oral GLP-1 therapies?

Kazi: Historically in the United States, when we have a brand-name drug that has both an injectable and oral formulation, the prices are not very different. What changes is how people interact with the therapy. People are more likely to miss doses of oral therapies, especially if they’re daily medications. And there are also a lot of people who have a needle phobia and may not be willing to start an injectable. For the oral therapies, it's unclear if the side effect profile is similar to the injectable.

At least initially, our analysis would be similar for the oral therapies. If the oral therapies were much less expensive than injectables, which is the intuition people have, then the value would be better. But if more people are willing to take oral therapies than injectables, then maybe the total spend is higher.