As Medicare expands its coverage to include weight loss medications like semaglutide, questions arise about eligibility, costs, and the potential impact on the healthcare system. A new study examines these issues, focusing on who can access these drugs and what it might cost Medicare.
Key Findings:
Eligibility Criteria: The study estimates that up to 3.6 million Americans with obesity and pre-existing cardiovascular conditions (like a history of heart attack, stroke, or coronary artery disease) could qualify for Medicare coverage of semaglutide. This number increases significantly when including those with elevated cardiovascular risk but no major diagnoses, potentially reaching 5.1 million more people with high-risk scores and 6.5 million with intermediate-risk scores.
Medicare Coverage and Costs: Medicare’s recent move to cover semaglutide for enrollees with established cardiovascular disease could be expanded to include more at-risk individuals. However, this expansion will depend on how Medicare plans define “established cardiovascular disease” and the cost-sharing structures they implement. Current estimates suggest that if only 30% of those eligible under this criterion start and adhere to the medication, the annual cost to Medicare could exceed $10 billion at current prices.
Broader Implications: The study, led by Dr. Alexander Chaitoff and published in the Annals of Internal Medicine, highlights the need for clear definitions and guidelines on eligibility. While current coverage focuses on those with specific cardiovascular diagnoses, there is a push to consider preventive measures based on cardiovascular risk scores, which could potentially benefit millions more.
Policy and Practice: Medicare Part D and Medicare Advantage plans could set various criteria for semaglutide coverage, which may include higher costs or requirements for patients. The study advocates for a more inclusive approach, arguing that sustained weight loss should be considered a valid outcome for coverage, akin to other preventive treatments.
This analysis underscores the complexity of expanding drug coverage under Medicare and the need for thoughtful policy design to balance accessibility, efficacy, and costs. The full impact on patients and the healthcare system will become clearer as policies are implemented and negotiated.
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