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The Prohibitive Economics of Weight Care

How we discuss overweight and obese diagnoses and how we treat those patients is slowly starting to improve. However, there’s still a lot of work to be done – in how we manufacture, market, and manage life-changing weight care medications, as well as how we expand access and improve adherence to them.

The U.S. has a well-known, well-documented weight care problem that our healthcare system isn’t equipped to solve – yet. For decades, limited resources, misaligned incentives, and one too many blind spots across our systems and stakeholders have gotten us to where we are today: a near-constant battle in acknowledging and effectively treating obesity as a complex chronic disease.

But that’s all starting to change.

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The prevalence of obesity has increased by 40% over the last 20 years, with severe obesity cases almost doubling. Meanwhile, there are fewer than 100 doctors in the U.S. who have completed an obesity medicine fellowship and are presently practicing obesity medicine. Primary care providers also don’t have the time, resources, or expertise to manage overweight or obese patients beyond the standard ‘diet and exercise’ directive, which doesn’t take behavior change or the individual’s unique biology into consideration.

This gap in care means many high-cost health conditions associated with overweight and obesity diagnoses, including heart disease, musculoskeletal pain, diabetes, and hypertension, continue to impact patients at high rates and put further strain on employers, insurers, and the healthcare system. It has also left room for blockbuster weight care medications to step into the spotlight this year.

The rise of blockbuster weight care medications 

GLP-1s are a class of type 2 diabetes drugs that improve blood sugar control and typically lead to weight loss by signaling a feeling of fullness. Reports show that nearly 1.7% of people in the U.S. were prescribed semaglutide this year, up 40-fold over the past five years – an unsurprising increase given the steady news coverage that’s led to widespread awareness of these medications.

This class of drugs is also proving effective in managing other health risks. Novo Nordisk, manufacturer of GLP-1s Ozempic and Wegovy (semaglutide), recently released results from its SELECT cardiovascular outcomes trial, which demonstrated a 20% reduction in major adverse cardiovascular events for overweight or obese people in the absence of diabetes treated with Wegovy. Heart attack was reduced by 27%, stroke by 7%, and cardiovascular mortality by 15%, and some of these benefits are seen practically within weeks of starting the medication. Additionally, all-cause mortality was reduced by 19% for patients taking Wegovy versus the placebo group.

It’s incredibly promising to see that this GLP-1 medication can help reduce cardiovascular events, but two major issues remain: who can afford these medications, and will they adhere to them? For blockbuster drugs to perform as intended, we have to fix the economics and prioritize adherence.

The problem with access and adherence 

Let’s be frank: GLP-1s are incredibly expensive, costing nearly $10,000 per year without insurance. As such, employers have been pulling back coverage of these drugs, and insurers are putting pressure on providers’ off-label prescribing, which has limited the availability of these medications for people qualified to have them.

Found data shows 69% of patients did not have insurance coverage as of June 2023 for GLP-1s for anti-obesity, a 50% decline since last December. Dramatic cost increases are also anticipated if these medications continue to gain FDA approval, putting coverage for this class of drugs at further risk.

Disease forecasting company Airfinity ran an analysis based on the SELECT trial results and found that the treatment cost for 63 patients over three years to prevent one heart attack, stroke, or cardiovascular death was nearly $1.1 million. Even with the positive trial results showing cardiovascular risk reduction, these high costs may leave insurers skeptical that GLP-1s can improve long-term health outcomes and save money. They could also continue to limit treatment approval—likewise for employers considering coverage of these medications for their workforce.

Beyond access and affordability, there’s also a problem with adherence. What if people don’t stick to these medications long enough to experience the intended results?

The SELECT study shows that patients on semaglutide for a few weeks start experiencing improvements in cardiovascular events; however, patients still need to be on these medications lifelong to prevent significant weight gain and other comorbidities because there’s scant research on obesity maintenance dosing. So, how do we get people to remain on medication for the long term? Only 50% of people adhere to long-term treatment plans from their provider, including taking medication, following a diet, and executing lifestyle changes. Prime Therapeutics also analyzed patients who are obese, prediabetic, or have a body mass index of 30 or higher and taking a GLP-1 medication for weight loss, which found that only 32% of patients were still taking their medication one year after starting their prescription.

Nonadherence to any medication can happen for a variety of reasons, such as adverse events, inability to continue paying deductibles or copays, or difficulties adopting new behaviors. While adverse events depend on each person’s biology, access and behavior change challenges are two critical pieces of the puzzle that should be better acknowledged and addressed for this class of drugs to deliver on its promises.

Making the economics work 

While there’s been significant progress with GLP-1s assisting with weight loss and helping reduce cardiovascular events, these medications are only one of many tools that should be considered within a broader toolkit for weight care.

To create truly effective treatment paths at the individual level – where the economics actually work – insurers and employers should consider coverage for other effective weight care medications beyond GLP-1s. Providers should adopt a step therapy approach, and patients must be open to behavioral change and coaching support in addition to medication or combination therapies. 

  • More affordable anti-obesity medicines: Off-label generics and non-GLP-1 branded anti-obesity medications are typically covered by insurance and are more affordable and accessible. While it is unknown if these medications on their own achieve the same cardiovascular benefits as semaglutide, they can help people lose weight and resolve high-cost comorbidities. Studies have shown that even a small amount of weight loss, such as 5-10% of an individual’s total body weight, can decrease blood pressure, stabilize blood sugar, improve blood cholesterol, and give people energy.
  • Step therapy: Step therapy means practitioners have tried established treatments that are commonly used, affordable, and considered first-line options. This approach doesn’t exist within obesity medicine yet, meaning no guardrails exist around a patient demanding an aggressive, expensive weight care medication like a GLP-1. Before prescribing GLP-1s, providers should assess which first-line medications might work based on the patient’s biology and try those first.
  • Behavior change and coaching: The lack of behavioral intervention in the SELECT study can be attributed to its 8.5% weight loss which is less than the 15% weight loss in Wegovy obesity trials. Care plans that include medication coupled with a supportive community and health coaching help reinforce positive habits, healthy routines, and lasting behavior change – all of which can help improve adherence to treatment plans.

How we discuss overweight and obese diagnoses and how we treat those patients is slowly starting to improve. However, there’s still a lot of work to be done – in how we manufacture, market, and manage life-changing weight care medications, as well as how we expand access and improve adherence to them.

In the meantime, effective weight care approaches are available today that acknowledge and treat obesity as a chronic disease, offer affordable medication-assisted integrative care, and provide support and guidance focused on lasting behavior change—in other words, these approaches work.

Photo: Jason Dean, Getty Images

Rekha Kumar, MD, MS is a practicing endocrinologist, obesity medicine specialist, and the chief medical officer of Found, an evidence-based weight care platform. She also served as the former medical director of the American Board of Obesity Medicine and has authored papers and textbook chapters on the medical management of obesity.

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