The Cost-Effectiveness of Obesity Meds Is a Moving Target

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INFLECTION POINT/ Is the Obesity Math Actually Mathing? 

I would like to manifest some experts taking a hard look at the underlying math behind a new cost-effectiveness assessment of obesity meds, because that’s a job that I’m underqualified to do. As I mentioned last week, there is a new analysis in JAMA Health Forum that suggests that Zepbound and Wegovy don’t meet traditional cost-effectiveness thresholds. The New York Times wrote about it here, and it includes comments from the companies. 

I’m not taking a hard look, but I’ll make two skeptical points that the New York Times didn’t seem to notice:

1. The piece’s cost information is already out of date. The authors suggest that Zepbound would have to be priced at $4,334 a year to meet a standard cost-effectiveness threshold. But Lilly is already selling Zepbound for a cash price of $4,188 a year.
   
   Caveats abound: That’s the low-dose price, insurance companies may be paying more, etc. But it’s a reminder that price is a moving target. And that target is moving down.
   

2. ICER reviewed obesity drugs three years ago, and it took a much rosier view of the medicines. At the broad level, I assume that ICER didn’t cut industry any breaks, so a competing analysis that looks even worse for the medicines feels suspect.
   
   I spent some time trying to figure out why ICER thought the impact of the medicines was greater than the JAMA Health Forum paper, and it looks looks the ICER team took a broader look at all of the ways that obesity meds might save, while the new analysis ignored some of the potential savings from the medicines.
   
   This gets to the other fundamental challenge: these medicines are being tested for all kinds of stuff, and a lot of those trials are showing remarkable, additional benefits. So the cost-effectiveness tomorrow is likely to look different -- and better -- tomorrow. 

Again, I’d love a smart take on the differences between the Health Forum paper and the ICER paper (and this Sean Sullivan-led JMCP effort). As usual, DMs are open!

QUICK TURNS/ A Double Dose of 340B and Academics Float a Wild Idea on Drug Pricing

• If you read between the lines on this legal filing from the government, it sure sounds like they’re laying the groundwork for an about-face on the 340B “rebate model.” (This is the idea that pharma companies would deliver the 340B price via after-the-fact rebates on verified 340B claims.) Yes, the government is still technically opposed to the idea. But they’re leaving a door open: “[T]he Agency has never said that rebates would not be approved under any circumstances.” Make of that what you will. (The Endpoints coverage nails this point.)

• I have no idea what to make of these dark-money attacks on 340B. The logic is that, if hospitals get 340B money, 340B can be blamed for anything a hospital does. So 340B is to be blamed for health care for undocumented immigrants, gender-affirming care, you name it. None of this helps anyone. It politicizes -- in the most extreme way possible -- an issue that is complicated enough, and it appeals to the most base impulses of the public. On the bright side, this kind of bullshit doesn’t seem to be swaying anyone. On the not-so-bright side, we’re never going to get 340B fixed if it's seen as another culture-war battlefront. 

• Talking about QALYs is a good way of getting everyone’s dander up, but this analysis from Peter Neuman at Tufts shows that QALYs remain at the center of the cost-effectiveness conversation. This is one where a picture really does tell the story, and here is the picture: 

• This piece in PNAS is kind of nuts. It starts with a fairly out-there solution to drug prices, suggesting that we try to find a single, international price that would maintain industry revenues so as not to impact revenue. That would, of course, mean lower prices in the United States and radically higher prices everywhere else. That begs the question of how one would ever make the question. And here, the authors get even more extreme: threaten to exclude from Medicare any drug that doesn’t have a single price.

• Less nuts, but more wonky, is this Health Affairs Forefront piece led by Mark McClellan, that examined how we might better integrate indirect and societal benefits into how we think about drug approvals and reimbursement.

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