TooTallTom asked a great question yesterday:
There are now multiple (pricey) weight loss medications in the marketplace, but they are rarely covered by insurance. Since weight loss helps overall wellness, and prevents onset of heart disease, diabetes, etc, when do you think the insurance industry will come around to covering these medications?
I’m going to write in fairly broad generalities.
This is a great question. We need to consider a few things from an insurer’s perspective. First, insurers usually have a contractual obligation to cover drugs that are the standard of care for known and acknowledged diseases. Insurers typically will look at Medicare for guidance/support for this determination. Medicare is not allowed by law to pay for explicit weight loss as an end in and of itself. Medicare can pay for things that aid weight loss as a means to treat something else.
So if we think that explicitly covering weight loss drugs is an optional(ish) decision, we need to think about the business case. We need to think about churn, abandonment and the number needed to treat to avoid a bad event.
We know that quite a few people will start on these drugs and stop taking them within a year. We also know that insurers routinely don’t see people for more than a few years at a time if the policy is fully insured and employers routinely see turnover in their ranks. This limits the length of time that health gains can be internalized as reduced claims. Finally, losing weight is likely a good thing in preventing other bad events but not everyone who does or does not lose 10% of their body mass will have a negative and expensive event in the next X years. Figuring out how many people are needed to initiate treatment and then how many months of treatment need to happen for a population to avoid one bad event is a tough challenge.
Now if these drugs were as expensive as 81mg aspirin, the insurers would be more than happy to pay for anyone with a BMI over 30 to take these drugs if they want to. But these drugs are expensive. So there is substantial reluctance.
However, Ben Ippolito and Jospeh Levy make a very good point in this month’s Health Affairs as they analyze the estimated costs to Medicare of covering these drugs for people with obesity:
Using Medicare claims, we also documented beneficiaries’ eligibility for nearly identical products approved for different indications…..
The marginal costs of this policy could fall by as much as 62.5 percent from baseline estimates if products were approved for additional indications in coming years because these additional conditions are common among people with obesity. This would increase Medicare spending but would occur regardless of a policy change.
People with obesity are frequently people with other health conditions. Some of those other health conditions are indicated health conditions for these drugs. We likely can apply the same logic to the commercial population where people with obesity are getting prescribed these drugs for other, approved indications and weight loss is an intended but not prescribed for effect.
piratedan
speaking as a fat dude, i need new knees. Why? So I can exercise pain free to lose weight, currently doing so leaves me in excruciating joint pain. Can’t even walk half a mile without needing a break. The docs say that you’re too heavy, you need to exercise more. I respond, sure, you got any non-addictive pain-killers so that I might do so… they say no, they’re all addictive. So I say, well how about new knees, they say no, not until you lose weight… I say how about some appetite suppressants, they say well, you’re insurance doesn’t cover it. this doesn’t cover the psychological depression that you have with being a fat person that leads to eating stuff that makes you feel good, which naturally is mostly bad stuff. I’d like fruits and vegetables more if I enjoyed them, but hey, we’re all different as to how our bodies are wired to associate pleasure with certain endorphins that get released.
I am well aware that there’s no easy answer for someone like me and I suspect that I am not the only one in this full bodied niche :-)
LeftCoastYankee
Would the business case for coverage be different if these drugs were beneficial only while taken (i.e. chronic condition medication) vs. given for a short period of time to jump start weight loss (say to help someone like piratedan get to where he could have knee surgery)?
I briefly took one to help get type 2 diabetes under control, and then it was not available. I lost some weight and didn’t gain it back, but there was definitely a change in “hunger suppression” once I stopped taking it.
Burnspbesq
The new study recently released by Lilly, that appears to show that Mounjaro/Wegovy can prevent the onset of full-blown diabetes in folks who are headed in that direction, has the potential to move the needle on this. Seems to me that insurers’ bottom lines are much better off if they can reduce the incidence of diabetes.
It’s a good time to be a Lilly shareholder (I am one). They’ve got the thing that everyone wants, it’s helping a lot of people (my A1c is down a lot since I went on Mounjaro), and it’s got several more years before the patents start to expire.
Insurers should also be much more accommodating in paying for continuous glucose monitoring. I loves me some Dexcom G7. Better data leads to better decisions leads to better overall health.
Aardvark Cheeselog
The other thing that is not mentioned anyplace yet that I have seen, is that these drugs are effective at promoting weight loss, in a way that is so far beyond any previous medical approach that it looks like a miracle.
Those obesity treatments that Medicare won’t pay for are by large not worth paying for. These drugs appear to be different.
But then we still live in the land of $30/dose Cialis because sexual health isn’t really heath, it’s just sexual. Or something.
Dagaetch
I’ve been taking Ozempic for a year now, and it is not any kind of exaggeration to say that it is life changing. A healthier relationship with food, weight loss, improved blood sugars, other downstream health (physical and mental) improvements…it really is a damn miracle drug for me and many other people. I’m lucky enough to have it covered by my insurance plan, so it’s only costing me $25 every 4 weeks. There needs to be a change to our healthcare industrial complex so that everyone can have affordable access to these things.
dendromaniac
Thank you for this assessment! Lots of value in your educated guess :-)
As a tubbo-American, it would be nice not to have to brace myself against the withering contempt of my fellow citizens. Many of us have been denied access to data-driven medical care after having been diagnosed as fat, per the same catch-22 that piratedan describes.
Weight loss drugs that actually produce sustainable results are a very new thing. Could be a game changer for a lot of people.
Tenar Arha
@piratedan: This just pisses me off. Had an aunt that had to do that to get her knees replaced, grr.
This obsession with patients losing weight, is actually counterproductive for health. Also causes doctors to dismiss other symptoms, bc all they can see is weight. And finally, there’s a lot of information out there that shows that fatness isn’t always equal to being unhealthy. (I think the podcast Maintenance PhaseMaintenance Phase explains it as part of their debunking project very well).
And on an anecdotal personal experience note: two of my uncles have been sick during the past few years, with significant internal surgeries. I honestly believe neither would have made it if they’d been thinner.
ETA: /rant
I truly hope you get whatever you think you need to get your doctors to help you.
Two rabbits
@piratedan: I probably shouldn’t be making health suggestions to anyone, but have you considered other types of exercise? Two examples might be swimming and bicycling. I was surprised to see studies that even E-bikes have a good health benefit. Sorry to butt in, good luck to you!
David Anderson: I was recently reminded of the Ornish diet. Surprised to see that aspects of the diet were being covered by Medicare for some heart health issues. (at least his book claimed)
Seemed like a sea change in the health industry/drug system.
I was drawn to it by his recent paper covering successes with his diet/program for Alzheimer/dementia/MCI issues. If you have any thoughts on this topic I would love to hear them. Thanks!
piratedan
@Two rabbits: I have a pool and I get into it when I can (still working full time) and my exercise routine frequently devolves into playing with the 100 lab who likes to swim and play fetch in the pool. I do what I can and I’ve been sloooowly dropping weight modestly by changing eating habits (less soda, more H20, no snacks late at night since I am a night owl).
WeimarGerman
Another true oddity is that commercial insurers would follow Medicare for drug benefits despite the age differences in their populations. The for-profit folks always ask to see any study repeated in their population before doing anything.
I think there would substantial delay in covering these drugs for younger people to wait for “research”. Air quotes for research done by internal actuary teams who are employed by the same profit seeking commercial insurers.
Sure Lurkalot
What a perverse health care system we have, chock full of uncalculable incentives and barriers to treatment.
Citizen Alan
@piratedan: I’m sorry, but did I accidentally post this perfect description of my weight and exercise issues under piratedan’s nym by mistake?
Citizen Alan
@Burnspbesq: Have you noticed any gastrointestinal issues with Monjaro? I’m about to take my first shot today, but I stopped taking Ozempic because it made me constipated for 6 days and then gave me explosive diarrhea on the 7th (sorry, TMI I know).
Sandia Blanca
@Dagaetch: My experience with Wegovy is similar. It is now covered by our insurance (UHC) at $25 per four weeks. My original prescription was for a compounded semaglutide, because Wegovy had a supply shortage. After a couple of months the supply issue disappeared and it’s now a non-issue. Very thankful for this game changer!
piratedan
@Citizen Alan: knew that I wasn’t alone out there. I understand the frustration of the battle. I’m good for pushing a cart on a Costco run and loading up the truck and unloading it, but after that, it’s a pair of ibuprofin and a nap :-)
Shana
@Citizen Alan: I felt tired and a bit nauseous the day after my shot but no other effects.
JoyceH
@piratedan: Have you seen a physical therapist? Your knee pain could very well be due to the arthritis but not necessarily. I have bone-on-bone osteoarthritis, and a knee surgeon was willing, indeed eager, to perform two knee replacements as soon as I gave the word. But I didn’t really want that. I limped for five years, with my right knee giving a very painful pop whenever it went from bent to straight and vice versa. But first I tried physical therapy and I learned that the popping had nothing at all to do with the arthritis- it was due to a tight IT band. She worked on that for several months to work out the tightness and I haven’t limped since. Sometimes, when I’m good about doing my stretches and not eating inflammatory food, I have no knee pain at all. I’ve adopted my therapist’s motto – not every knee pain is a joint pain.
Back to the topic of the new weight loss drugs. I hope anyone who’s tried them or is still using them will chime in, because I’m curious but quite hesitant. A couple years ago I lost 50 pounds on Weight Watchers but have more to lose and WW seems to have stopped working. I know two people who take Monjauro, one for diabetes and one for weight loss. The weight loss person is thrilled with it, but her food portions are so tiny! The diabetes person takes forever to get used to a new dosage and if she eats a bite more than her body wants her to eat she experiences nausea and vomiting. So…. Anyway, I’d like to hear some personal stories because I’d really like to get my weight down to something more manageable.
Jane2
@Dagaetch: Couldn’t agree more. As a Canadian, I find that there’s a big moral aspect to which drugs are not covered under the Drug Formulary – weight loss aids are never covered. “You need to lose weight, but only in the approved way.” “Look at all those women who just want to be a size 0.” I’m lucky enough to have a plan that covers all but 40CAD which is about what you’re paying – otherwise, it’s 250CAD – who can afford that?
It is life-changing in the way you describe. It’s not the easiest drug to take, but it’s a revelation how a body loses weight when left to do it without the diet industry. It’s not fast, but it sure is effective.
Jane2
@JoyceH: I second the recommendation of a physical therapist. My arthritic knee was so bad that I could barely walk, and two visits with a physio and following their recommended program has me pretty much pain-free. They’re not weight-bearing, but instead build up the muscles around the knee – game changer.
Lums Better Half
Another aspect that should be considered is the effect of the use of these drugs for weight loss has on their availability for those patients using them for more immediate medical issues, like diabetes.
It has been difficult to obtain the Trulicity I am prescribed for my diabetes because of shortages attributed to expanded use of the medication.
Dagaetch
As I said above, I’ve been taking Ozempic for just over a year now, for weight loss and blood sugar control. My experience has been extremely positive.
For me, this is a life changing thing. I’m very willing to tolerate the trade offs for that. It’s a personal decision! There are several communities out there with people who share their experiences, sympathize when people have a bad day, and offer advice on strategies that helped them.
Hope this helps!
JoyceH
@Dagaetch: I think that’s the problem I have with the notion. If WW still worked for me, I could easily stick with the program for say 46 weeks out of the year, but I want to be able to indulge when I travel and over the holidays. I’m going to ITALY in November! Tiny portions in Italy?!
JoyceH
@Lums Better Half: I suspect those shortage issues will level out as the market adjusts. Some of these drugs are coming out specifically for weight loss – I think Wegovy is prescribed for weight loss rather than diabetes. (And I think my insurance covers it.)
lee
I took Wegovy for a month then a supply shortage hit and I’m waiting for it to be filled.
I’m not particularly fat (gained a bit of weight during a stressful period) but technically pre-diabetic (A1C at 6.0).
Insurance would not cover it. Luckily we have the financial ability to pay for it. I also signed up thru the wegovy website for half off.
As others have said it is life changing. Your appetite just disappears (during the first week I had to remind myself to eat). I found that each shot lasts a shorter period of time. Myra-lax every other day really kept the worst constipation away so I didn’t have to suffer thru that.
Dagaetch
@JoyceH: I hear you. I was in Spain and France earlier this summer. The amount of delicious things I didn’t eat!! I’m still kind of sad haha. But I’m so much healthier and happier overall that it’s worth it.
Ella in New Mexico
As a primary care provider I can absolutey attest to the fact that morbid obesity is a metabolic disorder that causes inflammation and contributes to chronic, life limiting diseases and disorders that are almost ALL ameliorated or cured whent the patient attains healthy body weight.
A single payer healthcare system would see the investment the use of these drugs are in reducing future medical costs, morbidity and mortality. lt would aslo be able to negotiate pricing with the pharmal companies making them.
The fact that so many insurers depend on passing on treating a patient’s chronic conditions with ideal medications, imaging and treatments because they hope they’ll move on to another insurer is what is destroying American’s health.
TooTallTom
David,
Thank you so much for this informative post.
Jane2
@Ella in New Mexico: I am in a single payer health system that works pretty well and covers most medications, except when it comes to these drugs. And most insurance plans won’t cover them either if they’re used for weight loss. It’s amazing how “morbid obesity is a health crisis” has been reframed as “cosmetic weight loss”.
Ella in New Mexico
@Jane2: I think the tide will turn over the next couple of years as the research pouring in on the incredible benefits of these medications starts to be widely accepted evidence base care. I think the exorbitant costs right now will definitely prolong the whole “weight loss is cosmetic so not covered” even in single payer systems. But I expect those prices to fall as newer, more powerful GLP-1 meds are developed and put on the market.
Again, an aggressive and cost effective health care system should incorporate prevention into its cost considerations, which is not going to happen without significant government pressure on Pharma and insurance companies.and that will ultimately have to come from the citizens they serve.
Kayla Rudbek
@Burnspbesq: yes, I would love to have the continuous glucose monitor that I saw in a European cycling magazine instead of having to try to stick my finger manually in the morning. But 1) my glucose and A1C aren’t bad enough to meet the insurance threshold for continuous monitoring and 2) FDA didn’t want to approve that particular device so that company is going out of business as a result. (Personally I want my smartwatch to be able to measure my glucose without piercing my skin and I’m sure that Apple and Garmin are working on it)
Kayla Rudbek
@Tenar Arha: I saw a Facebook video where the doctor was upset that her current patient had been told that she needed to lose weight to treat her carpal tunnel syndrome. The doctor making the video pointed out that there’s not even any fat inside the carpal section so weight loss would be totally irrelevant in actual treatment for carpal tunnel syndrome.
Kayla Rudbek
@Citizen Alan: I’m on Mounjaro and metformin, had a little bit of digestive issues when I was on 2000 mg of metformin per day, but dialing the metformin back to 1000 mg per day seems to have fixed that. I’m still working on the optimal time for the weekly shot of Mounjaro; Saturday morning can be a bit of an issue for going out on long bike rides Saturday and Sunday as I can drain my reserves too far if I don’t eat enough. Sunday evening seems to be better as the bike rides are done.
Burnspbesq
@Citizen Alan:
No issues for me. Hope it works for you!
Burnspbesq
@Kayla Rudbek:
Apple has been working feverishly on that for several years, and has reportedly spent a billion dollars on the project, but they’re not close. I barely notice I have the G7 on.
Burnspbesq
@Kayla Rudbek:
I’ve been off metformin for a couple of years because it was messing with my kidneys. Insulin, Farxiga, and Mounjaro.
SteverinoCT
@Citizen Alan:
I have Type II diabetes and my doctor put me on Trulicity. It really wasn’t having much effect, so he switched me to Mounjaro. I’ve lost maybe 35 lbs so far (oddly enough, I started from a high of 330 and lost 15 when I got a two-day Covid bout, and kept that off before beginning the drugs).
But to your question, my regularity was upset; not to your extreme but my morning/evening routine became a sometimes once a day, sometimes middle of the night deal. I stopped eating breakfast except for a small bit (piece of toast, say) to ameliorate all the drugs I take. After lunch then is when I’ll get the urge. Nothing dire; but then, WFH hath its advantages.
Blue Galangal
@Citizen Alan: Make sure you hydrate with electrolytes, not just water. Liquid IV works great for me. It’s a game changer.
Also keep up with fiber and protein. The Kirkland brand protein bars (170 calories, fiber+protein – recommend the cookies & cream/chocolate peanut butter pack) are also something I rely on daily.
Renie
Since I’m on Medicare they don’t pay for the drug but they do pay for weight loss consultation. So my endocrinologist only charges me what she pays for the drug – $400/month. She files a claim with Medicare for consultation. I started on Ozempic and after the first treatment my cravings for chocolate completely disappeared along with my appetite. My weight problem has always been the chocolate. I was elated. But I did suffer from constant constipation and wound up taking laxatives every week. I also had days where my stomach bothered me alot. I started in May and in July my doctor switched me to Zepbound. The stomach problems disappeared and the constipation reduced. But now I’m back to the initial dosage of Zepbound and have slight cravings again. My doctor said they will disappear as my dosage increases. It does though suppress my appetite. Before I started I thought I would lose weight faster. I’ve lost 23 lbs since May now I am at 1lb a week. Though I believe I will probably have to be on one of these drugs forever, losing slowly is better.
I follow a group on Reddit and am amazed at the amount of people who get the drugs and little guidance from their doctors. I think they lose faster cuz they may eat too little. Eating too little will have a bad effect on your metabolism. My doctor has me on a calorie count of no less than 1100 a day and breaks down how much protein, fat & carbs I need a day. Being a 67 year old women the protein is very important.
I already have Ozempic face which is similar to the expensive Buccal fat removal people pay for. LOL. Good luck to all of you!
rikyrah
Been trying to get on one since February. I am almost giving up. Will see the doctor again next week.
Chris T.
@Dagaetch:
That’s pretty good: mine is $55/pen with insurance (vs list price which was $1k and is now $750ish I think). First time in many years my A1c got down into the sixes! Side effects are becoming annoying, but I’ll stick with it for blood sugar reasons.
Chris T.
@Kayla Rudbek:
Everyone’s different, but for me, when I was on metformin (pre-semaglutide) I had these “issues” with regular metformin but the XR (extended release) formula fixed it, until they put me up at 2000 mg/day; 1500 was fine. Once I was finally approved for the Ozempic pen, they took me off both the glipizide and the metformin. Next A1c test is at the end of the year but the ones so far were finally down into the 6s, and the last one was 6.0.