Does long-term use of GLP-1 (Glucagon-like peptide-1) receptor agonists decrease costs for insurance companies?

Long-Term Cost-Effectiveness of GLP-1 Receptor Agonists for Insurance Companies

Long-term use of GLP-1 receptor agonists does decrease costs for insurance companies through reduced incidence of diabetes-related complications, despite their higher initial acquisition costs.

Mechanism of Cost Savings

GLP-1 receptor agonists provide significant cost savings through multiple pathways:

1. Cardiovascular Benefits:

   • GLP-1 RAs significantly reduce major adverse cardiovascular events (MACE) in patients with type 2 diabetes and established cardiovascular disease 1
   • The LEADER trial showed a 13% relative risk reduction in cardiovascular death, non-fatal myocardial infarction, or stroke with liraglutide compared to placebo 1
   • SUSTAIN-6 demonstrated a 26% relative risk reduction in cardiovascular outcomes with semaglutide 1

2. Reduced Diabetes-Related Complications:

   • Long-term projections show GLP-1 RAs reduce the incidence of diabetes-related complications 2, 3
   • These avoided complications translate directly to cost savings that offset the higher acquisition costs of these medications

3. Quality-Adjusted Life Year (QALY) Improvements:

   • Semaglutide 1 mg improves quality-adjusted life expectancy by 0.06 QALYs compared to liraglutide 1.8 mg 2
   • Oral semaglutide provides 0.18 additional QALYs compared to liraglutide 3
   • These QALY improvements represent substantial economic value to healthcare systems

Economic Evidence from Cost-Effectiveness Studies

Multiple economic analyses demonstrate the cost-effectiveness of GLP-1 RAs:

• UK Analysis: Once-weekly semaglutide 1 mg was found to be dominant (more effective and less costly) compared to liraglutide 1.8 mg, with £280 lower direct costs per patient, even when liraglutide's price was reduced by 33% 2

• Italian Setting: Liraglutide 1.8 mg compared to lixisenatide 20 μg showed an incremental cost-effectiveness ratio of €2,001 per QALY gained, well below typical willingness-to-pay thresholds 4

• Oral Formulations: Oral semaglutide remained cost-effective compared to injectable liraglutide even with liraglutide price reductions of up to 50% 3

Implementation Challenges

Despite clear economic benefits, GLP-1 RA utilization remains suboptimal:

• As of 2019-2020, only 6.8% of patients with diabetes and CKD were prescribed a GLP-1 receptor agonist in the CURE-CKD Registry 1
• Persistent use (≥90 days) was only 6.3%, indicating significant discontinuation issues 1
• Even in commercial health insurance as recently as 2020, GLP-1 RA initiation was reported in only 17% of patients with diabetes and CKD 1

Real-World Effectiveness Considerations

Real-world studies show important differences from clinical trials that affect cost-effectiveness:

• High discontinuation rates (20-50%) within the first year 5
• Use of lower doses than those evaluated in clinical trials 5
• Weight reduction tends to be lower than in randomized controlled trials, though outcomes approach trial results in highly adherent patients 5

Pitfalls and Caveats

1. Adherence Issues: Poor adherence significantly reduces real-world effectiveness and therefore cost savings. Insurance companies should consider adherence support programs to maximize return on investment.

2. Dosing Challenges: Suboptimal dosing in real-world settings diminishes potential benefits. Step-up dosing protocols and side effect management strategies should be implemented.

3. Gastrointestinal Side Effects: These are the primary reason for discontinuation, which limits long-term cost-effectiveness. Proactive management of these side effects is essential.

4. Initial Cost Barrier: The high upfront cost may deter coverage decisions despite long-term savings. Insurance companies should consider value-based contracts that account for long-term outcomes.

Conclusion for Insurance Decision-Making

When evaluating the long-term financial impact of covering GLP-1 receptor agonists, insurance companies should consider:

1. The substantial offset of initial medication costs through reduced complications
2. The improved quality of life and productivity of covered members
3. The need for adherence support programs to maximize real-world effectiveness
4. The potential for generic GLP-1 RAs (like liraglutide potentially in 2024) to further improve cost-effectiveness 1

By focusing on the total cost of care rather than just medication acquisition costs, insurance companies can realize the economic benefits of long-term GLP-1 RA coverage.