New weight loss medications that cost more than $1,000 a month will be made available to millions of Americans and their insurance companies. Yet, the majority of insurance policies don’t pay for these procedures.
Once a shortage eases and numerous new drugs are introduced to the market, the demand for anti-obesity medications is anticipated to increase dramatically this year.
The medications must be taken indefinitely, but they cost $1,000 or more per person per month.
How much prevention can individuals and the nation afford when more than 40% of Americans are overweight enough to be eligible for these meds and the majority are currently ineligible for coverage?
Dr. Marcus Schabacker, president, and chief executive of ECRI, a nonprofit organization working to advance healthcare, said, “We appreciate that (the pharmaceutical sector) continues to explore” anti-obesity drugs. If most patients who require it cannot afford it, it simply does not assist.
More than 2 million prescriptions for Wegovy, the brand name for the Novo Nordisk drug liraglutide, and for tripeptide, an Eli Lilly diabetes medication that hasn’t yet been licensed for weight reduction, were written in the past year, according to health technology startup Komodo Health.
This year, it’s anticipated that these medications will be more widely accessible due to rising prescription demand.
It has been demonstrated that liraglutide and tripeptide can reduce extra weight by an unheard-of 15% and 20%, respectively. They are also anticipated to lower medical expenses and, consequently, health repercussions.
Dr. David Rind, chief medical officer for the Institute for Clinical and Economic Review, which calculates the cost-effectiveness of various medications, stated that obesity is a significant medical issue in the United States.
“We’ve been waiting a pretty long time for medications that do anything like this.”
Why it is a problem right now
Not everyone who weighs more than is regarded as healthy will desire these medications or would benefit from them. However, despite being spectacular, weight loss caused by the drugs won’t make obese people slim. Nevertheless, there were no medications available until recently that could assist people in losing that much weight.
Since it received permission in June 2021, shortages of Wegovy, caused by supply chain problems, have kept demand in check.
Nevertheless, Novo Nordisk claims to have resolved those problems, and some physicians report that their patients can now obtain the drug. The full anti-obesity dose of Wegovy costs $1,349.02 each month, or almost $16,000 per year. (The same medication, marketed under the name Ozempic, is available for less money and at a lower dosage to treat diabetes.)
Additionally this year, federal regulators will examine approving tripeptide, a drug that appears to aid in further weight loss. Tirzepatide has been available under the brand name Mounjaro since Eli Lilly received permission for it as a diabetes medication in May. It costs $1,000 per month. In the upcoming years, similar treatments may also gain approval.
Like with meds for high blood pressure and cholesterol, these new anti-obesity ones must be used permanently, so once someone starts taking them, they must continue to do so or risk the weight creeping back on.
Similarly, the American Academy of Pediatrics recently revised its recommendations for treating children who are obese, calling for more aggressive therapies and prescription drugs for kids as young as 12. Late last year, the American Diabetes Association adopted guidelines that urge individuals with diabetes to tackle obesity aggressively, including by using drugs.
According to a study by business research company Medi-Tech Insights, the global market for anti-obesity pharmaceuticals is anticipated to rise by 25% over the following five years, driven mostly by demand in North America.
Price of obesity
Per the ECRI, the treatment of obesity’s negative health impacts costs the American healthcare system $170 billion annually.
About $70 billion is spent by Americans trying to lose weight each year, mostly unsuccessfully and frequently “for solutions that are unproven and sometimes even harmful or counterproductive,” Schabacker said.
According to the value they offer, weight reduction drugs are now pricey, although “not substantially,” according to Rind.
Older-generation medications may be less effective, but according to ICER, by lowering obesity-related illnesses, they are more valuable over the long run than their cost.
For instance, Qsymia, a medication that combines phentermine and topiramate, costs $1,465 per year, but according to ICER, the benefits could make up for a cost of $3,600 to $4,800 per year.
In contrast, liraglutide typically costs customers $13,618 per year but has a value of $7,500 to $9,800, according to ICER.
According to Rind, medications should eventually provide a profit by avoiding costly treatments like hip replacement surgery and heart attacks.
But, someone with a very high body mass index—a measure of weight to height—is more likely to experience negative health effects than someone with a BMI that is closer to the 30 percentile for obesity. Hence, cost savings will primarily come from a small population, according to John Cawley, a health economist at Cornell University.
“The cost savings are in preventing excessive obesity,” he stated.
Why has weight loss therapy hasn’t received any funding to date
Insurance company’s decision to stop paying for anti-obesity treatments in the past made some sense, according to Rind. This is because many medicines only supported weight loss of approximately 5%, which is below the threshold at which health effects can be felt.
Also, several licensed weight-loss drugs were pulled off the market once they were found to be harmful. The weight-loss medication lorcaserin, marketed as Belviq, was withdrawn by the Food and Drug Administration in 2022 because of an elevated risk of cancer in long-term users. One of the medications in the fen-phen combo (fenfluramine and phentermine) was infamously removed in 1997 due to heart valve damage in patients.
If obesity therapies are found to be fatal every decade or so, Rind said, “it makes sense why someone said they wouldn’t cover them.”
Nonetheless, the absence of coverage is medically unnecessary today and there are effective treatments.
Nobody would advise someone with hypertension to exercise without also prescribing a beta blocker or another accepted medication, according to Schabacker. The cost of treating secondary diseases including hypertension, diabetes, and muscular-skeletal conditions would decrease if those Persons who qualify for treatment were covered by insurance plans or Medicare/Medicaid.
He and the others claimed that bias is another factor in the lack of coverage.
According to Cawley, “Obesity is regarded as a choice, a result of people’s choices, and as such is less worthy of coverage than even other disorders linked to nutrition, including Type 2 diabetes and high blood pressure.”
The vast majority of obese persons, according to national polls, attempt to lose weight. There was no lack of effort, he insisted.
Years of study have now demonstrated how human biology works to restore lost weight, for example by decreasing metabolism when someone loses weight. Nonetheless, the idea that patients ought to be able to help themselves persists.
“Pretending that it works makes no sense because we have ever better proof that losing weight with food and exercise doesn’t work for 95% of people,” he said.
Uneven health insurance coverage for anti-obesity treatments will probably make racial and economic inequities worse, especially for young people, according to Cawley.
“Young individuals in their teens and 20s who have parents with health insurance are covered. Some won’t, “said he.
According to him, low-income women are more likely to be obese than low-income men.
Individuals with limited dietary alternatives and poor incomes tend to eat more cheap, highly processed foods, which, according to Schabacker, tend to encourage obesity.
Even though there is an effective therapy for obesity, he claimed that doing nothing about it worsens the problem.
Who will cover the cost of these drugs?
Currently, the patient is usually responsible for covering the cost of weight loss procedures. Government programs like Medicare and the majority of health insurance policies do not pay for the cost of weight loss drugs.
In a recent presentation to investors, Novo Nordisk claimed that Wegovy is covered by insurance for at least 40 million American adults. (Approximately 108 million adults in the United States fit the criterion of obesity.)
Ted Kyle, the founder of ConscienHealth and former chair of the Obesity Action Coalition, a 75,000-member nonprofit that works to empower people living with obesity, said, “Coverage policies can be very confusing and thus lead people to give up on getting these medicines from their drug plans — even when they might be covered.”
Just 2% of obese Americans have traditionally had either weight loss drugs or surgery, which is at least partially a result of the lack of coverage.
Per the Rind, a physician at Beth Israel Deaconess Medical Center who is also an internist, once several weight loss medications are available, there will be some competition and prices may moderate slightly. But, “that one will keep costing a lot” if one drug appears to be superior and becomes the one that everyone wants.
So according to him, the introduction of these new pricey drugs may also benefit existing, less expensive, less potent medications. The usage of the least expensive medications by patients may also be attempted.
Anti-obesity drugs should start being covered by Medicare, according to Rind’s group, ICER.
Commercial insurance ought to pay for the prescriptions as well, he suggested. Although it may seem as though they would save money if they lost weight, these cost offsets won’t occur for several years, by which time the patient may have changed insurance policies.
For at least 20 years, low-cost generic medications won’t be available due to patent rights.
Maybe, suggested Rind, insurers, and pharmaceutical companies would come to a “Netflix plan” agreement, in which insurers set a dollar number and manufacturers do whatever they are prepared to in exchange for that sum.
Similar to preventive care, Cawley suggested that the government may require all health insurers to provide cost-effective weight loss procedures to lessen inequities.
Insurers frequently employ incentives, according to him, to persuade policyholders to cut back on unnecessary spending. Inexpensive weight loss drugs might be made available without a co-pay, but the more recent ones might have higher out-of-pocket costs for patients.
Consumers would “at least be forced to think twice before selecting the more expensive choice” as a result.