The National Health Service (NHS) in England has taken a significant step forward in obesity treatment by providing subsidized access to powerful weight-loss medications, while Australia maintains a more restrictive approach to these therapies.
Key Policy Differences Between Markets
England's National Institute for Health and Care Excellence (NICE) has approved subsidized access to both semaglutide (Wegovy) and tirzepatide (Mounjaro) for weight management. The coverage extends to adults with a BMI of 30 or above who have at least one weight-related condition. For tirzepatide specifically, the BMI threshold is set at 35 or higher.
In contrast, Australia's Pharmaceutical Benefits Advisory Committee (PBAC) recently declined to recommend semaglutide for inclusion in the Pharmaceutical Benefits Scheme (PBS) for weight loss. This decision leaves Australian patients facing out-of-pocket costs of approximately A$450-500 monthly for Wegovy.
Economic Analysis and Access Criteria
The divergent decisions stem from fundamentally different approaches to economic evaluation. NICE's analysis incorporated long-term health benefits, including reduced risks of diabetes, cardiovascular disease, stroke, and need for bariatric surgery. Their assessment showed a gain of 0.7 quality-adjusted life years (QALYs) per patient for semaglutide users with BMI ≥30.
PBAC's more conservative analysis, focusing on a population with BMI ≥40, calculated only 0.3 QALYs gained per patient. Notably, PBAC excluded potential benefits from preventing future weight-related conditions, considering only impacts on existing conditions.
Implementation and Restrictions
England's approach includes some access limitations. Wegovy prescriptions require specialist weight-management service oversight and are restricted to a maximum of two years. For tirzepatide, despite broader eligibility criteria potentially including 3.4 million people, initial access will be limited to 220,000 patients over three years.
Both markets require demonstrated effectiveness for continued treatment, with England stipulating a minimum 5% weight loss within six months to maintain prescription access.
Future Outlook for Australian Access
PBAC has suggested that future submissions for these medications could focus on patients with pre-existing cardiovascular disease, type 2 diabetes, or multiple cardiometabolic risk factors. However, with GLP-1 agonists absent from upcoming PBAC meeting agendas, the timeline for potential PBS listing remains uncertain.
The current situation leaves Australian patients in a challenging position, with limited access to these innovative therapies despite their proven effectiveness in weight management. The stark contrast between England's and Australia's approaches highlights the complex interplay between health economics, policy decisions, and patient access to innovative medications.
