| If there's one concept I've learned to love in a decade and a half in Germany, it's Preis-Leistungs-Verhältnis, or "cost-performance-ratio." Figuring out how to get bang for your euro is practically a national sport here, whether you're talking about the TikTok "girl math" of price per wear on a handbag or the cost-location-service calculus behind choosing a hotel. When it comes to drugs, health systems around the world take a similar approach. The question isn't just how much a drug costs, but rather how much it costs to achieve a certain health outcome — another year of healthy life, say, or prevention of one illness or death among all the people taking the medicine. Novo Nordisk Chief Executive Officer Lars Fruergaard Jørgensen will testify in the US Senate about the cost of the company's blockbuster diabetes and weight-loss shots Ozempic and Wegovy on Tuesday. The occasion is ire over Wegovy's list price in the US, currently set at $1,349 a month. As Novo has pointed out many times, few patients, insurers or employers actually pay that amount. The real question is how much benefit US payers are getting for the money they spend on the drug. And even taking potential discounts into account, the US is still on the hook for a far larger bill than European health care systems face for the same outcomes. In the UK, the National Health Service spends less than half as much as US payers to prevent one stroke, heart attack or cardiovascular death with Wegovy, I report today, based on an analysis by data analytics firm Airfinity Ltd. We published a table of the estimated costs here. "You always want to know whether, even if a medicine is effective at improving someone's health, is it cost-effective for the health system to make the medicine available," says Airfinity senior director Bhaskar Bhushan, who conducted the research. Last year Airfinity estimated the cost of preventing one bad cardiac outcome with Wegovy in the US at more than $1 million. The Airfinity calculation is generous. It assumes a 65% discount on Wegovy's list price; Bhushan tells me the discount might actually be much less. It's also based on a comparison at the highest dose of Wegovy, which is more expensive in Europe than lower doses, while in the US, the list price is the same at all doses. The Airfinity analysis uses the highest dose because that's what was used in the large study that showed heart benefit for Wegovy, but in real life, doctors are more willing to keep patients on a lower dose due to side effects. Change any of these factors, and the gap between the price tag on health in the US and in the UK, Germany and Denmark widens. Novo, for its part, argues that a simple price-for-outcome analysis is overly simplistic. It would be better to factor in the many health outcomes Wegovy can provide, from improved heart failure symptoms to less knee pain from arthritis, the drugmaker says. In an analysis it sponsored, researchers showed the drug would be cost-effective at an average discounted price if regulators were willing to spend at least $100,000 for each additional year of health. Is that a good cost-performance ratio? That's going to be at the heart of Tuesday's hearing. — Naomi Kresge | 
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