Making The Decision: Providing Access to/Coverage For Weight Loss Medications…Or Not?

Nurse Deb Ault President, AIMM

Full disclosure: I am (and have been most of my adult life) an obese individual. I am also a self-funded employer health plan sponsor. Additionally, I am a medical professional. Some would say that this combination gives me a unique perspective. Thus, I have done my best to provide things for consideration by employers, and I have attempted to limit my “opinion” to the end of the article. Please do note that while I am many things as listed above, I am not an attorney and this article should not be taken as legal advice. You should obtain guidance from an attorney.

Understandably, a common question employers have related to their employee healthcare plan is whether or not to include access to weight loss medications for their employees. According to the 2017-2020 National Health and Nutrition Examination Survey, 41.9% of American adults have obesity. As obesity is an epidemic across the U.S., it is a situation rightfully of concern to business leaders and of course, to those individuals who suffer with their weight and the related health challenges that often accompany obesity.

In this article, I’ll review a variety of considerations as well as my own perspectives to help informed leaders make an appropriate and responsible determination on whether or not to provide access to weight loss medications for their employees/health plan members. Of course, every situation is unique and every organization is different, so accept these comments as they are intended – for a broad audience across the U.S.; your specific situation may dictate and encourage a different approach than what is presented here.

Let us begin by considering any potential legal requirements.

What Does The Law Say?

Not much.

To my knowledge, there is not currently any U.S. legislation that mandates coverage of treatment(s) for obesity. However, there may be state laws pertaining to obesity. Whether or not a particular employer sponsored health plan is subject to state laws is something that legal experts should be involved in addressing. There also may be some instances in which the ADA laws apply.

Finally, there is also a movement afoot to have obesity recognized by the Office of Civil Rights. I’ve not been able to locate any current articles around this topic, but this one from Fisher Phillips in 2020 is a good starting point: https://www.fisherphillips.com/news-insights/current-trends-in-combating-weight-discrimination-in-the-workplace.html

What Does The Science Say?

There are not currently any MCGs or other evidence-based clinical criteria developed that would show when (clinically) the benefits of the treatment with the newer GLP-1 medication outweigh the risks associated with those drugs. More broadly, as of this writing, there are not MCGs for any of the weight loss drugs.

Therefore, for anyone to perform a solid prior authorization process will require that they first develop a clinical criteria detailing when they will cover those drugs and when they will deny those drugs so that they can ensure that they are treating all members of the plan equally. Absent any clinical criteria being applied to requests for weight loss medications, one would have to rely on the plan’s definition of medically necessary & appropriate and experimental/investigational.

What should be included in the prior authorization requirements should a plan or vendor chose to create one is a good topic for debate. Should it mimic the requirements for gastric surgery for weight loss (an MCG does exist for surgery)? Should it be less restrictive? Should it be strictly or loosely interpreted?

With a lack of objective evidence and clarity around the benefits vs. risks of such weight loss medications, it’s currently very challenging to determine how (from a scientific perspective) to decide who would receive access to these drugs and under what conditions.

What Are The Financial Implications?

Given that the prevalence of obesity in the US is 41.9%, and given that the cost of the newer weight loss medications is typically $1,000+ per month (according to GoodRx) and that currently doctors are saying that weight returns when the medications are discontinued (meaning that it is anticipated that patients could be on these drugs for the rest of their lives), it is easy to see how covering these medications could quickly add up to a massive spend for a self-funded health plan.

Just take 40% times the number of people covered by your plan, then multiple it by $12,000, and you’ll get a quick “back of the envelope” calculation of the potential financial implications to your self-funded plan.

It’s reasonable to assume that over time, costs will come down and as they do, this part of the question should rightfully be reevaluated, but for now, the prices of these medications, in and of themselves, would make this offering a challenging one even if the scientific evidence proving them to be effective without serious or long-term risks was available.

Making The Decision – An Informed Opinion

While obesity is recognized by the CDC as a disease, and there are ICD10 codes for obesity, whether or not to provide coverage for the obesity and it’s treatments (or which of its treatments to cover or not) is ultimately a self-funded group level and company cultural level decision. (NOTE: Interestingly there IS a code for obesity due to excessive calorie intake, but NOT a code for obesity due to lack of exercise.)

Thus, given the cost associated with most of the newer weight loss medications, at a minimum it would likely be prudent to have a rigorous prior authorization process for any coverage to be available for them, assuming of course that your PBM is capable of performing such a process.

One key question that to ask is “Does the plan currently cover weight loss surgery?” Weight loss surgery DOES have a clinical criteria that details when the benefits outweigh the risks. It costs between $7,400 and $33,000 (according to GoodRx again). Related, another question that I would ask is “Does the plan currently cover nutrition counseling and supervised exercise programs or even offer something like Weight Watchers at work?” (See https://healthsolutions.ww.com/ )

The point is that “buzzworthy” medications may ultimately prove effective and safe and come down in price. However, until that time, objectively it’s reasonable to prioritize offering other proven, less costly methods to combat obesity. Covering medications without covering any other treatments for weight loss treatment would be akin to supporting the erroneous idea that these medications are a “silver bullet.” They are not, and the group would be much better served by encouraging both diet and exercise behavior changes within their population than they would be by covering medications.

Should a plan decide to cover the newer weight loss medications in addition to rigorous prior authorization process and providing coverage for other weight loss programs, I would suggest that they look at international procurement as a way to control costs. The exact same medications can be obtained for about half of the cost through these types of programs.

Finally, there is a philosophical question that I personally like to ask when confronted with this topic: Does your health plan currently cover prescription stimulants used for the purpose of weight loss? The answer is NO because the FDA has not approved prescription stimulants to be used for the purpose of weight loss even though we know that these medications do often lead to losing weight. Even though we know that lack of physical activity is a major contributor to obesity, and a recent study indicates that lack of exercise is THE main contributor to the rise in obesity, we chose to not use stimulants for the purpose of weight loss. (See https://med.stanford.edu/news/all-news/2014/07/lack-of-exercise--not-diet--linked-to-rise-in-obesity--stanford-.html)

Why do we (in the U.S.) think that it’s appropriate to cover drugs that are designed to decrease caloric intake, but not think it is appropriate to cover drugs that increase physical activity?

Viewing the issue holistically, questions to ask of your organization are the following: Does your work environment support physical activity? Do you have stand-up desks? Do you REQUIRE people to take their break and move around or move away from their cubicle? Have you ever hosted a “stand-up meeting”? Does your work environment support good nutrition? What is in the vending machine?

These questions all lead to…

The Real Question Worth Asking

Unfortunately, the REAL question is not “Should my plan cover the new weight loss medications that are hitting the market?” The REAL question that should be asked is “What do I, as an employer, do to support healthy balance in terms of both nutrition and exercise, and then what do I do to support those individuals who DESPITE GOOD NUTRITION AND EXERCISE are still obese?”

This issue is both scientifically and mathematically, as well as humanistically, a deeper challenge. To cover the drugs without prioritizing the other methods seems like trying to treat the symptom without focusing on the real cause. Covering these drugs without first attempting to successfully implement the less risky behaviors could be irresponsible. Case in point: we all remember the Fen Phen debacle of the 1990s right? (See http://www.cnn.com/HEALTH/9707/08/fen.phen.pm/)

Two other relevant articles worth reviewing are:

https://www.mayoclinic.org/healthy-lifestyle/weight-loss/in-depth/weight-loss-drugs/art-20044832

https://www.npr.org/sections/health-shots/2023/01/31/1152491692/scant-obesity-training-in-medical-school-leaves-docs-ill-prepared-to-help-patien