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. 2025 Sep 24;12(10):ofaf596.
doi: 10.1093/ofid/ofaf596. eCollection 2025 Oct.

Budget Impact of Adopting Nirmatrelvir-Ritonavir for Treating COVID-19 in a Large Integrated Healthcare System

David P Bui  1 , Denise M Hynes  1   2   3 , Edwin Wong  4   5 , Robert Vergun  6 , Lei Yan  6   7 , Yuli Li  6   8 , Nallakkandi Rajeevan  6   8 , Kristin Berry  4 , Hung-Mo Lin  6   7 , Yuan Huang  6   7 , Diana J Govier  1   9   10 , Mihaela Aslan  6   11 , George Ioannou  4   12 , Kristina L Bajema  13   14
Affiliations

Budget Impact of Adopting Nirmatrelvir-Ritonavir for Treating COVID-19 in a Large Integrated Healthcare System

David P Bui et al. Open Forum Infect Dis. .

Abstract

Background: Understanding the budget impact of prescribing nirmatrelvir-ritonavir (NR) for COVID-19 can inform procurement and allocation strategies in large healthcare systems.

Methods: We assessed the budget impact of providing NR in the Veterans Health Administration (VHA) for all treatment-eligible Veterans (laboratory-confirmed COVID-19 illness from April 2022 through March 2023) and by clinical subgroups, including predicted hospitalization/death risk quartile. We used decision tree models that included 30-day emergency department (ED) visits, hospitalizations, and death to assess the budget impact of NR. Transition probabilities were derived from a target trial emulation of NR effectiveness in the same population. We priced NR at $1031/course and used cost accounting records to estimate ED ($1420), hospitalization ($22 419), and hospitalization with ICU ($59 918) costs.

Results: Among 138 261 treatment-eligible Veterans, 18% (n = 24 892) were prescribed NR. Treating all patients compared with treating none reduced healthcare costs by -$20 million (uncertainty bound [UB]: -70-0.23) but increased total budget costs by +$122 million (UB: 73-143) due to NR purchasing costs. Targeted treatment of patients in the highest risk quartile (n = 19 406) achieved healthcare cost savings of -$17 million (UB: -49 to -3) and a modest total budget increase (+$3 million, UB: -29-17).

Conclusions: NR may reduce 30-day COVID-19 healthcare utilization costs, but the high cost of purchasing NR is likely to exceed those savings. Price reductions are necessary for NR to be a financially viable treatment for healthcare systems. Risk-informed allocation strategies can help maximize treatment benefits and minimize budget increases.

Keywords: COVID-19; antiviral; budget impact; cost; decision tree.

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Conflict of interest statement

Potential conflicts of interest: None.

Figures

Figure 1.
Figure 1.
Tree model setup to evaluate the budget impact of (A) treating versus (B) not treating all treatment-eligible patients (N = 138 261) in the Veterans Health Administration with nirmatrelvir-ritonavir (April 2022–March 2023).
Figure 2.
Figure 2.
Estimated cost per hospitalization, ICU admissions, and deaths prevented if all Veterans in each subgroup are treated versus not treated.
Figure 3.
Figure 3.
Estimated budget impact (cost differences) and estimated break even cost per course of nirmatrelvir-ritonavir. Budget impact figures are color-coded from greatest increases (red) to greatest reductions (blue) to highlight variation.
Figure 4.
Figure 4.
Estimated budget impact (cost differences) on healthcare costs and total costs, including purchasing cost of nirmatrelvir-ritonavir, and uncertainty bounds based on 10 000 decision tree simulations for each subgroup.
See this image and copyright information in PMC

References

    1. U.S. Food & Drug Administration . FDA approves first oral antiviral for treatment of COVID-19 in adults. 9 August 2024. Available at: https://www.fda.gov/news-events/press-announcements/fda-approves-first-o.... Accessed 13 February 2025.
    1. Hammond J, Leister-Tebbe H, Gardner A, et al. Oral nirmatrelvir for high-risk, nonhospitalized adults with COVID-19. N Engl J Med 2022; 386:1397–408. - PMC - PubMed
    1. Bajema KL, Berry K, Streja E, et al. Effectiveness of COVID-19 treatment with nirmatrelvir–ritonavir or molnupiravir among U.S. veterans: target trial emulation studies with one-month and six-month outcomes. Ann Intern Med 2023; 176:807–16. - PMC - PubMed
    1. Dryden-Peterson S, Kim A, Kim AY, et al. Nirmatrelvir plus ritonavir for early COVID-19 in a large U.S. health system. Ann Intern Med 2023; 176:77–84. - PMC - PubMed
    1. Lewnard JA, McLaughlin JM, Malden D, et al. Effectiveness of nirmatrelvir-ritonavir in preventing hospital admissions and deaths in people with COVID-19: a cohort study in a large US health-care system. Lancet Infect Dis 2023; 23:806–15. - PMC - PubMed