Obesity is often seen as a failure of willpower, but is, in fact, a disease: one caused by everything from socioeconomic conditions and family history to metabolic factors. For the 42% of US adults affected by obesity, the cost is high in every facet of their lives. The condition is linked to increased risks of cancer, infertility, sexual dysfunction, and Alzheimer’s disease — not to mention increasing rates of depression and anxiety partly linked to social stigma. But for health plans covering anti-obesity medications, the cost is also high.
As new anti-obesity medications like glucagon-peptide agonists (GLP-1s) hit the market, many doctors are prescribing them off-label to patients clamoring for relief. But prescribing these medications to every patient with obesity would cost health plans $150 billion a year — another additive cost before we have enough data to support the related savings. Already, direct and indirect expenses tied to obesity amounted to $1.4 trillion in 2014 — and could easily exceed $4 trillion by 2035 without major interventions. This amounts to a whopping half of all healthcare spending — no small cost for insurers, employers, and governments alike.
In response, health plans are cracking down on what could be life-saving medications. Major insurers are restricting access to off-label prescriptions and auditing pharmacies and doctors who offer these medications to patients — and some are even restricting access to less expensive medications. Only 22 percent of employer health plans cover anti-obesity drugs due to sticker shock, and Medicare doesn’t cover obesity medication at all, considering it a lifestyle issue. Many health plans might want to cover the drugs, but are stymied by a patchwork of rules and regulations that prevent them from knowing which patients need the more expensive drugs and which would benefit from other, less expensive lifestyle and medication approaches. And many others are afraid of having to raise premiums — a very real fear, with research predicting that the price of anti-obesity medications could raise costs by up to 3 percent. Meanwhile, people struggling with obesity are forced to go off medications that have been working for them — or pay a shocking $900 out of pocket each month.
I have met with health plans across the country over the past few months and have heard everything from “there is no bigger impact to premiums than GLP-1s” to “this is the most complicated issue I’ve seen in 27 years” to “we don’t feel exposed at the moment.” I tend to agree that this is the most complicated issue in decades. These medications have the potential to materially impact long-term health outcomes in our society, particularly in the largest Medicare-eligible population of baby boomers we have ever seen. Combine that with the consumer demand generated by social media for weight loss and the political and equity questions on every health plan and employer team’s mind, and we have a recipe for higher costs and further confusion.
Before employers and health plans jump to the easiest solution that promises near-term cost savings in a harsh economic environment, we should be very careful about shutting off the faucet. Instead, they should consider a more nuanced approach that could meet the needs of both providers and patients without breaking the bank.
The entire industry is moving toward reducing friction and administrative burden for prior authorization, and we as an industry must evolve our cost management strategies for these medications too. Cigna recently announced the removal of prior authorization for twenty-five percent of medical services, and United announced it will remove prior authorization for twenty percent of its total prior authorization volume starting this fall. In an environment where health plans and providers are battling consumer-focused new entrants, obesity treatment provides an opportunity to design a consumer-driven solution that can meet the needs of those footing the bill.
Recently, we’ve seen an increasing number of obesity management solutions hit the market. These companies offer patients a robust approach to alleviating obesity, providing an array of approaches that range from behavior change to nuanced medication management. When they take on a new patient, they are able to use their arsenal of tools and experts to determine what kind of interventions will work best for them. Many struggling with obesity will benefit from behavior management alone, working with dietitians and doctors to consider all the factors influencing a patient’s health and create a sustainable, step-by-step plan that works for their life. If the patient needs more assistance in losing weight, doctors can recommend a myriad of less expensive, less intensive anti-obesity medications that work for many people. If the patient is part of the 10% of an organization’s population that needs the help of GLP-1 medications, they can prescribe that alongside behavior change support to help a patient succeed in their health goals. Instead of half the obese population opting immediately for expensive medications, obesity management programs can help filter people to the right level of care, saving everyone time while also being cost-effective.
In this approach — known as step therapy — obesity management solutions act as clinical gatekeepers, helping patients and doctors escalate care as needed. Gatekeepers in healthcare can be bad words, sending shivers through some who still remember the early HMOs. Instead, these clinical designers (as I like to call them), and tools, provide the consumer with the connectivity and detailed discussion that is lacking in many provider officers who are struggling to see each patient for more than 15 minutes. It also ensures that people who truly need GLP-1s can access them while ensuring that everyone gets the most effective, cost-conscious care possible.
Obesity management solutions offer a middle path for patients and providers. They help mitigate cost trends for payers and employers while maintaining access and providing equitable care to members and employees. And, they help patients get access to a full spectrum of care that otherwise may not be available in traditional provider settings or with traditional prior authorization processes.
Photo: Peter Dazeley, Getty Images