Semaglutide Coverage Could Raise Medicare Costs by Billions

TOPLINE:

Around one in seven Medicare beneficiaries with a high body mass index (BMI) may be newly eligible for semaglutide treatment after Medicare allowed Part D plans to cover the drug for patients with a BMI ≥ 27 and a history of cardiovascular disease (CVD), regardless of their diabetes status.

METHODOLOGY:

• In March 2024, Medicare approved the coverage of semaglutide by Part D plans for patients with a high BMI and existing CVD, irrespective of their diabetes status. This decision follows the SELECT trial results, showing that semaglutide lowered the risk for cardiovascular events in some patients without diabetes.
• This study aimed to describe the Medicare beneficiaries most likely to be newly eligible for semaglutide treatment and estimated maximum costs to Medicare Part D.
• The researchers included 5111 individuals aged ≥ 65 years with self-reported Medicare enrollment in the National Health and Nutrition Examination Survey between 2011 and 2020, all of whom had a BMI ≥ 27 and were likely to benefit from semaglutide treatment.
• They evaluated the following potential definitions of established CVD that could be considered by the Part D plan:
  • Physician-provided diagnosis of myocardial infarction, stroke, coronary artery disease, or angina
  • A 10-year risk for atherosclerotic CVD between 7.5% and < 20.0%
  • A 10-year risk for atherosclerotic CVD of ≥ 20%
  • Fulfillment of any of the above three criteria
• Data on interview responses, medication use, clinical examinations, laboratory results, and diabetes diagnoses were obtained from the participants.

TAKEAWAY:

• This study found that 3.6 million individuals (14.2%) were deemed highly likely to qualify for semaglutide treatment for the first time, and broadening the criteria for established CVD could increase this number to 15.2 million individuals (60.9%).
• If all newly eligible beneficiaries were to receive semaglutide treatment, Medicare spending could increase by $34-$145 billion annually.
• Even with more conservative definitions of CVD and a significant portion of individuals not maintaining long-term adherence to semaglutide treatment, costs could still increase by $10 billion annually.
• Younger, generally healthier, female Medicare beneficiaries were still likely to remain ineligible for semaglutide treatment according to the coverage provided by Part D Medicare plans.

IN PRACTICE:

“Although approximately one in seven Medicare beneficiaries with elevated BMI is likely to be newly eligible for semaglutide, the majority will remain ineligible if a narrow definition of established CVD is used by Part D plans. Weight control has benefits for patients with elevated BMI, so the definition of established CVD used by Part D plans for coverage of semaglutide could have outsized public health implications,” the authors wrote.

SOURCE:

The study was led by Alexander Chaitoff, MD, MPH, Center for Healthcare Delivery Sciences, Department of Medicine, Brigham and Women’s Hospital, Boston. It was published online on August 27, 2024, in Annals of Internal Medicine.

LIMITATIONS: 

This analysis relied on self-reported cases of CVD. The study was also limited to only community-dwelling adults. It estimated maximum budgetary impacts but did not account for payment reforms introduced by the Inflation Reduction Act or for absolute contraindications to semaglutide.

DISCLOSURES:

This study did not disclose any sources of funding. Some authors declared receiving grants, serving as consultants, and having other ties with some institutions.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.