Module 4
Drug Spend Across Payers
GLP-1s as the affordability stress test, the federal model built to answer it and already half delayed, and why the same drug reaches three payers at three different prices.
By the end of this module, you will be able to:
- Explain why GLP-1s expose an affordability problem no payment model resolves
- Check a model's current status before citing it as how the system works
- Compare payer drug pricing mechanisms without making meaningless gross comparisons
- GLP-1s as the Stress Test A drug class that works, that a very large population is eligible for, and that no payer can afford at scale. Every tension in this course, at once. About 6 min
- The BALANCE Model A CMMI model built to get GLP-1s to Medicare and Medicaid beneficiaries at a negotiated price. Half of it has already been delayed indefinitely. About 5 min
- One Drug, Four Prices Medicaid, Medicare, and commercial payers obtain the same drug through completely different mechanisms. Comparing them without knowing which is which produces nonsense. About 5 min
Module quiz
Answer all questions to see your score.
1. What did state Medicaid programs do about GLP-1 obesity coverage as costs rose?
Gross Medicaid GLP-1 spending rose from about $1 billion in 2019 to almost $9 billion in 2024. Watching states drop coverage is watching rationing happen in real time.
2. What is the status of the BALANCE Model?
Checking a model's stage, participation, and delays before citing it is the difference between describing the system and describing a press release.
3. Why are cross-payer gross drug spending comparisons misleading?
A headline that one payer spends more per prescription may reflect nothing but different rebate mechanisms operating below the published number.