
We have an interesting dynamic going on in our industry. When it comes to the usage of GLP-1 for weight loss, it seems that people want to either exclude it all together or cover it unrestrictedly.
On one hand we have the state of Colorado that is looking to require state-regulated insurers and Medicaid to cover weight loss drugs for people who are obese or prediabetic. “According to legislative fiscal analysts it would cost the state Medicaid system $86 million the first year alone. An actuarial analysis by the Division of Insurance found it could also raise insurance premiums by as much as $30 million a year.”
On the other hand, North Carolina is trying to limit its coverage of weight loss drugs because of the extreme cost implications. “North Carolina’s health insurance plan for state employees recently opted to stop covering popular new weight-loss drugs amid fears that costs could balloon to more than $1 billion over the next six years.” The state wants to control the utilization of the medications by requiring that patients engage in lifestyle modifications before they would allow coverage of the weight loss medications. Not only is this a good method of controlling costs, but it is also the right thing to do. The state’s PBM, CVS, has an agreement with the drug manufacturer that if any sort of requirement is put into place the plan will not receive rebates for those products. Therefore, the state would be paying “list price” for the medication, and not be eligible for a rebate (which could reduce the cost by about 40%).
In the FDA announcement of the approval of Zepbound, they stated:
Today, the U.S. Food and Drug Administration approved Zepbound (tirzepatide) injection for chronic weight management in adults with obesity (body mass index of 30 kilograms per square meter (kg/ m2) or greater) or overweight (body mass index of 27 kg/m2 or greater) with at least one weight-related condition (such as high blood pressure, type 2 diabetes or high cholesterol) for use, in addition to a reduced calorie diet and increased physical activity.
Requiring that patients increase their exercise and modify their diet is part of the FDA approval. So why won’t Eli Lilly and Novo Nordisk allow plans to require their patients engage in these lifestyle modifications before allowing coverage? According to the Politico article, “Employers and health care economists say drug companies are more than willing to play hardball — even if it means losing some short-term business — to stop employers from imposing restrictions that could, over the long term, crimp sales.”
Just like other debates in our country, it appears that states and other decision makers are taking a black and white approach. Plans either cover it unrestricted or don’t cover it at all. The fact of the matter is that these drugs are expensive, and they shouldn’t be used as first line treatment for weight loss. Considering 40% of the US population is obese and would be eligible for these drugs, at the current cost of about $1,000 per month, the cost to the plan would be an additional $400 per member per month (PMPM), if every obese person received a weight loss medication. If only 10% of the population received these medications, the cost would be $100 PMPM. Employers do not have unlimited piggy banks, and eventually these costs will be passed onto employees through premium increases.
This debate, though, has focused mostly on cost and ignores what is the best clinical practice. Rapid weight loss, as occurs with the usage of GLP-1s, can cause patients to lose muscle mass. “However, proper well-rounded approaches to obesity treatment can mitigate the issue of muscle mass loss even when rapid weight loss occurs. When weight loss is achieved with very low–calorie dietary changes alone (without exercise), it is also associated with significant reductions in lean muscle mass; however, incorporating exercise, preferably resistance training, can mitigate the muscle mass loss.” Therefore, a form of strength training should be required to be performed while patients are using GLP-1s for weight loss.
If patients do not modify their diets, they will not lose as much weight. According to the Mayo Clinic, “studies found people using semaglutide and making lifestyle changes lost about 33.7 pounds (15.3 kilograms)”. In addition, when patients discontinue therapy and they have not established new the lifestyle habits, they are likely to put the weight back on.
We need to expect more from our PBMs and Drug Manufacturers. They need to come together and negotiate an affordable cost for these medications, while encouraging patients to engage in healthier lifestyle choices. These drugs have been proven to be effective, but how effective is a drug, if the ones that need them most cannot afford them. The only way in which expectations will change is if employers, like the state of North Carolina, come together and take a stand that we want our patients to have access to these drugs AND establish better lifestyles.
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