March 3 Weight Loss Products: Should Employees Cover?
That is the question currently plaguing employers and dominating many pharmacy benefit discussions. Due to growing pressure from employees and direct-to-consumer advertising, many plan sponsors ask for advice regarding a benefit that has historically been considered “cosmetic.”
Approximately 25% of employers currently provide coverage for weight loss medications. However, the question remains: should more plan sponsors cover these weight loss medications with some agents yielding results upwards of 25% weight loss? The answer is–it depends.
Obesity is a widespread problem in the U.S., and according to data from the Centers for Disease Control (CDC), obesity currently affects 4 out of 10 Americans. While weight and health are not always connected, obesity is often considered a cause of multiple comorbid and chronic medical conditions, including heart disease, several forms of cancer, and type 2 diabetes.
Typically, lifestyle interventions are recommended before drug therapy or surgery, and this includes dietary modifications, exercise, and even behavioral therapy. However, many patients do not achieve their weight loss goals with lifestyle modifications alone. With that being said, more than 10 medications are FDA-approved for weight loss, with some producing better results than others. Zepbound, the newest product to enter the market, touts clinical trial results of weight loss averaging over 22% of body weight, significantly greater than the 15% average weight loss seen with Wegovy.
These medications work by mimicking a naturally occurring hormone, GLP-1, which increases satiety, leading to reduced appetite and food cravings. Due to the epic weight loss success and assumed overall health benefits observed with the new GLP-1 weight loss medications, especially Wegovy and Zepbound, it begs the question–why wouldn’t a plan sponsor want to provide weight loss medications as a covered pharmacy benefit? Well, there are many things to consider, among them being cost, a lack of known long-term side effects, no true “exit strategy” and a dim to non-existent return on investment.
Many employers are cautious about covering these products due to costs. Weight loss medications, particularly the GLP-1 medications, average more than $1000 per month. A 2022 independent analysis completed by the Institute for Clinical and Economic Review (ICER), found that semaglutide (the active ingredient in Wegovy), was not cost-effective to treat adults with obesity. ICER estimated that an annual health-benefit price benchmark range of $7,500 to $9,800 would make the medications cost effective; however, this would require manufacturers to discount the price by 44%-57%.
Although GLP-1 medications have been on the market for over 15 years, they were initially studied, marketed, and used in diabetic patients. The more recent approval of this class for obesity purposes has a lesser-known side effect profile and little to no long-term clinical data related to the safety of these products over lengthy periods of time in obese patients. Some of the more common side effects include abdominal pain, nausea, vomiting, constipation, and diarrhea with more serious side effects including medullary thyroid cancer.
A 2023 analysis by Prime Therapeutics, found that although there were various reasons for discontinuation, with the side effect profile commonly cited, only ~32% of patients were still utilizing GLP-1 weight loss medications a year after their initial prescription.
As previously mentioned, these medications are extremely successful at helping patients lose weight. However, what happens when a patient stops taking the medication? Both the STEP-4 trial of Wegovy (semaglutide) and the SURMOUNT-4 trial of Zepbound (tirzepatide) demonstrated that weight regain after discontinuation is both common and profound. The reason behind the weight regain is related to how these medications work to suppress the appetite; thus, when the appetite suppression is removed, patients become hungrier than they once were, and caloric intake increases. Therefore, to achieve and maintain weight loss, patients must continue utilizing the ~$1000 per month medication, meaning there is no true escape plan to discontinue utilization. This furthermore amplifies the concern payers have surrounding the budgetary impact of covering GLP-1 medications for weight loss long-term.
Many conversations regarding weight loss medications have led back to the suspected potential of a return on investment (ROI) for the coverage of these products. The assumption is that coverage will lead to lower obesity rates and decreased obesity-related health issues such as lower blood pressure, cholesterol, heart attacks, and others. The concern with this assumption is several-fold.
These medications only provide a weight loss benefit while they are being utilized; once the drug is discontinued, weight is regained. Similarly, other health benefits are eroded once the drug is stopped. Not only are tens of thousands of dollars lost if a member ceases the utilization of the medication and regains the weight, but an employer must also consider their turnover rate.
Suppose a member continues the medication and keeps the weight off. The question remains: how long will that employee stay with the organization? In industries like hospitality, which have a historically high turnover rate of 70%-80% annually, the clinical or financial benefit is likely unseen by the employer.
According to a recent Wegovy-sponsored seminar, only 2% of eligible patients (based on BMI and comorbidities) are currently getting treatment for weight loss. That opens the possibility of 98% of eligible patients potentially starting these medications if weight loss drugs were available on their pharmacy benefit. When considering if the coverage of these products is a good fit for any organization, plan sponsors must understand that this decision has the potential to create healthier employees, but for how long and at what expense?
To build a plan that supports your business and employees for the long haul, connect with your RxConnection Pharmacy Consulting Team.
SOURCES:
1. CENTERS FOR DISEASE CONTROL AND PREVENTION. OVERWEIGHT & OBESITY. ACCESSED DECEMBER 12, 2023. 2. IPD ANALYTICS. OBESITY LANDSCAPE AND PAYER MANAGEMENT OPPORTUNITIES. OCTOBER 2023. ACCESSED DECEMBER 12, 2023. 3. IPD ANALYTICS. COST SAVINGS OPPORTUNITIES IN CHRONIC WEIGHT MANAGEMENT. OCTOBER 2023. ACCESSED DECEMBER 12, 2023. 4. PRIME THERAPEUTICS. REAL-WORLD ANALYSIS OF GLUCAGON-LIKE PEPTIDE-1 AGONIST (GLP-1A) OBESITY TREATMENT ONE YEAR COST-EFFECTIVENESS AND THERAPY ADHERENCE. JULY 2023. ACCESSED DECEMBER 12, 2023. 5. LINKEDIN. NAVIGATING EMPLOYEE RETENTION IN 2023: INSIGHTS AND TRENDS. JULY 2023. ACCESSED DECEMBER 12, 2023