Medicare’s recent decision to cover semaglutide treatment for patients with a BMI of 27 or higher and a history of cardiovascular disease could raise costs by billions of dollars. A new study found that 3.6 million Americans, or 14.2% of Medicare beneficiaries, could become newly eligible for the weight loss drug. The study analyzed data from 5,111 individuals aged 65 and older who participated in the National Health and Nutrition Examination Survey between 2011 and 2020.
Researchers defined established cardiovascular disease through physician diagnosis, a 10-year risk for atherosclerotic cardiovascular disease, or fulfillment of any of these criteria. If semaglutide treatment is fully adopted by these newly eligible beneficiaries, Medicare spending could increase by $34 to $145 billion annually. Even with conservative definitions of cardiovascular disease and considering that many may not adhere to long-term treatment, costs could still rise by $10 billion per year.
“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,” stated the authors, led by Dr. Alexander Chaitoff of Brigham and Women’s Hospital.
Medicare eligibility impacts for semaglutide
Wegovy, the brand name for semaglutide, has a list price of about $1,350 for a 28-day supply. The drug functions as a GLP-1 receptor agonist, which helps to increase insulin secretion and decrease blood sugar levels. It has gained prominence for its effectiveness in managing type 2 diabetes and promoting significant weight loss.
The study’s findings highlight the importance of precise health policy guidelines when expanding Medicare eligibility for weight loss drugs based on cardiovascular criteria. The number of patients who will qualify for semaglutide coverage will depend on how broadly cardiovascular disease is defined by Medicare Part D plans. The analysis relied on self-reported cases of cardiovascular disease and was limited to community-dwelling adults.
It estimated potential maximum budgetary impacts but did not factor in payment reforms introduced by the Inflation Reduction Act or absolute contraindications to semaglutide. The study did not disclose any sources of funding, but some authors declared receiving grants, serving as consultants, and having other connections with various institutions. The findings were published in the Annals of Internal Medicine on August 26, 2024.
- Medscape.”Semaglutide Coverage Could Raise Medicare Costs by Billions”.
- UPI.”Under new Medicare rules, 3.6M Americans could be covered for Wegovy”.
- SciTechDaily.”Semaglutide: A Diet Drug Dilemma for Medicare With a $145 Billion Price Tag”.