Costly and Effective versus Cheap and Ineffective

ICER – the Institute for Clinical and Economic Review – has released its final report on the effectiveness and value of obesity meds and set a public hearing for September 16. Let’s say it right up front. This private nonprofit is trying to do something that is almost impossibly hard. Making objective sense from the mess that is drug pricing in the U.S. So good for them. They do it carefully, though perfection is not an option. But in the end, they’ve come down to an unsatisfactory verdict – that cheap and relatively ineffective drugs are preferable to costly and much more effective ones.

It’s not a terrible answer. However, though might it be the best answer available, we’ll suggest that a better one would be to bring down the cost of the effective and presently unaffordable drugs.

In other words, the best answer would be to fix the awful mess of drug pricing in the U.S.

The Final ICER Report

Though the work of ICER on this subject is quite complex, their bottom line is relatively straightforward. After a meticulous process of developing a cost effectiveness model of obesity meds that are presently available, they’ve issued a report that says Qsymia (phentermine and topiramate) is the most cost effective obesity med available. More costly and effective drugs – specifically Saxenda (liraglutide) and Wegovy (semaglutide) – are just not worth the high prices they carry in the U.S.

They note the semaglutide is markedly better than liraglutide, but the Wegovy price would need to come down by roughly half to offer good value. Contrave gets a partial pass. Because they believe it offers a bit less effectiveness than Qsymia, they say that it offers less value but enough to satisfy a less challenging standard than Qsymia does.

Is Modest Efficacy Good Enough?

For years, all we had were obesity meds with modest effectiveness. Few doctors prescribed them and few patients took them. This was a shame, because even with modest effectiveness, those drugs can improve a person’s health and quality of life. And not everyone has only a modest response. A few patients respond quite dramatically and are thrilled with the results. All good.

But now we are moving into an era with much more effective drugs that can be life changing for many more people living with obesity. We know the personal stories of friends who have experienced this. In the comments on the ICER draft report, one patient wrote:

“To put it simply, this drug has changed my life. My A1C is now 4.7 and my blood sugar is back at normal levels. My blood pressure hovers around 110/70, which is where it was for most of my life until the last couple of years. More importantly, I have been able to lose 36 pounds in less than 7 months. I no longer have insatiable cravings. I no longer feel hungry or not full. I eat normal amounts and can make healthy choices without feeling deprived.

“I now experience hunger and satiety in a way that I can only assume people with normal metabolism do.”

Discounting Lives in a Broken System for Drug Pricing

Some people will get a satisfying response with Qsymia or Contrave. Many more will get good outcomes with newer options like Wegovy. Before long we will have even more options that bring similar or better outcomes and more competition. That’s good, because one size does not fit all.

But for now, the verdict from ICER is to tell payers that the transformed lives of people who need the most effective obesity drugs are not worth it because those drugs are too costly. In this sense, the criticism that ICER discounts human lives might be justified. Patricia Goldsmith and Carole Florman wrote:

“It seems to us that ICER is protecting the insurance companies that pay for treatments. If the organization truly wants to become the watchdog for the nation – which includes the people who use health care – it needs to research and quantify the value of treatments as they relate to the people who need them.”

Negotiating Prices and Withholding Access

Plainly and simply, people need better access to more effective drugs for obesity AND prices must come down on these costly drugs. It’s simply not OK that Wegovy costs only $100 per month in the U.K. and $1,350 in the U.S. Nor is it OK to hold the lives of people with obesity hostage in order to drive those prices down. So both drug companies and payers are going to have to shape up. Otherwise they will face a very uncomfortable backlash.

Playing shift the blame will no longer work.

Click here for the ICER Report, here for public comments, and here for responses to those comments. for further perspective, click here, here, here, and here.

The Golden Cell, painting by Odilon Redon / WikiArt

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September 3, 2022