By 2030. almost half of adults in the United States are projected to have obesity. The health and financial implications for employers cannot be overstated as direct health care costs in the U.S. have surpassed $480 billion, with an additional $1.24 trillion in indirect costs when lost productivity is considered. Adults with obesity are at greater risk for more than 200 chronic conditions and at higher risks for stroke, cancer and premature death.
As the science of obesity evolves and more treatment options become available, employers have a real opportunity to positively influence the health and well-being of their employees and covered family members. This starts with a willingness to fully address obesity as a health issue and to cover treatment for the condition — however, it must be supported by evidence. Obesity is recognized by the Centers for Disease Control, American Medical Association and the U.S. Food and Drug Administration as a multi-faceted chronic disease requiring long-term management. Unfortunately, it is often not treated the same as other chronic conditions.
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An integrated approach can be most effective. There is ample clinical data that indicates obesity cannot be managed solely by diet and exercise. It is genetic, environmental and there is a large and growing body of evidence that dying human microbiome and gut bacteria are contributing factors. As such, the obesity care continuum must be expanded to include anti-obesity medications such as GLP-1s and bariatric or other surgical interventions where required. Plan design matters.
What factors should employers consider when covering GLP-1s?
Now that glucagon-like peptide 1 (GLP-1) agonists are available and proven to be effective, employers should consider covering them if they have not already. These products have been on the market for over a year with other manufacturers currently seeking FDA approval, and new research continues to be released on the effectiveness of these medications. Most pharmacy benefit managers (PBMs) have them in a preferred Tier 2 status.
Today, most employers have placed guardrails around the use of GLP-1s. While many employers still do not cover them, others may require prior authorizations and/or proof of continued weight loss for coverage to continue. Many of these restrictions are not grounded in science.
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Obesity is a chronic disease and needs to be treated as such. For example, employers don't require plan participants to meet an HbA1C standard to continue medication/treatment for diabetes. Employers should be cautioned against using improvement in biometric measures like body weight to determine coverage of a class of medications, as this practice could put them in hot water from a legal and anti-discrimination standpoint.
The use of prior authorization for GLP-1s may also be unnecessary. Instead, using a composite of clinical indicators like the presence of other comorbid conditions including diabetes, high cholesterol, high blood pressure and other cardiovascular conditions can help ensure proper utilization management. BMI is a metric that has been used historically, but more importantly HbA1C, HDL/LDL and triglycerides as well as blood pressure values above the recommended upper limits are a better threshold for drug reimbursement approvals. The use of these metrics are supported by recent clinical trials that indicate GLP-1s help prevent heart attacks and strokes and are being prescribed for more than weight loss.
Considering these factors in designing benefits that address obesity is critical as this health issue is not going away. To help employers in making these decisions, the non-profit Midwest Business Group on Health has developed free resources and is hosting educational opportunities to help plan sponsors understand the issues at play and considerations to develop a comprehensive weight management strategy in place.
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Obesity is a chronic disease that must be treated as such and more effectively managed going forward. Rejecting anti-obesity medications and other emerging treatment options is like going back 20 years and saying we are not going to cover statins to treat cholesterol.
Following the evidence to treat obesity as a costly chronic condition will go a long way in mitigating employer health care costs and providing support to employees on their weight management journey. Employers can ill afford to not follow the emerging science of obesity.
