The lower price for semaglutide established by the Center for Medicare and Medicaid Innovation's (CMMI's) Better Approaches to Lifestyle and Nutrition for Comprehensive Health (BALANCE) model, taking effect in January 2027, could produce savings that would offset the cost of treating an additional 550,000 to 3.6 million Medicare beneficiaries who qualify for expanded obesity-indication coverage, according to a Research Letter published April 2 in JAMA.

Stacie B. Dusetzina, PhD, et al., sought to estimate the impact of recent drug price agreements determined through CMMI's BALANCE demonstration project and the Inflation Reduction Act's Medicare Drug Price Negotiation Program maximum fair price (MFP) on total Medicare spending on semaglutide in 2027. They used National Health and Nutrition Examination Survey (NHANES) data from 2021 to 2023 to estimate prevalence of Medicare beneficiaries using semaglutide along with Medicare-reported semaglutide use in 2024 to calculate expected Medicare spending on semaglutide in 2027 both under participation in the BALANCE model, and then separately under the negotiated MFP.

After assuming no supplemental rebates and 2024 use based on NHANES eligibility estimates, the authors found that full plan participation in the BALANCE model would result in an estimated $932.7 million in savings compared to the MFP in 2027 alone. These savings could offset the cost of treating an additional 549,473 beneficiaries.

Additional sensitivity analyses that doubled baseline semaglutide use and further reduced prices found that an estimated 1.1 million to 3.6 million people could be treated without increasing program spending.

The authors acknowledge several study limitations, including its exclusion of tirzepatide, reliance on 2024 utilization data and assumptions regarding qualifying indications under the BALANCE model. They add that the sensitivity analyses were designed to try and account for the fact that "the estimates do not consider additional indications for which coverage under Medicare Part D and under the BALANCE model is uncertain."

In an accompanying editorial comment, Hamlet Gasoyan, DS, PhD, MPH, and Michael B. Rothberg, MD, MPH, note that participation in the BALANCE model is voluntary for drug manufacturers, Part D plans and state Medicaid agencies. They urge these parties to participate since "the program has the potential to address health disparities and extend the benefits of novel obesity medications, in concert with lifestyle interventions, to more U.S. residents living with obesity."