As Published in Healthcare Business Today

By Ed Liebowitz

As the debate over access to Ozempic and other GLP-1 drugs for weight loss heads to the courts, the broader issue of equitable access is back at the forefront.

On June 5, a Maine woman filed a class action lawsuit against Cigna for not covering drugs that can be used to treat obesity. She claims her doctor prescribed the GLP-1 drug Zepbound for her obesity, and Cigna denied coverage. The lawsuit claims this violates the Affordable Care Act’s anti-discrimination law, which prevents discrimination on the basis of disability.

How the suit will play out remains to be seen, but it highlights a broader issue: the need for the health insurance industry to address access to GLP-1s to treat obesity. Complicating the already delicate balance between equitable access to GLP-1s and personalized weight-loss management is the opaque influence of rebates. Employers are caught in the crossfire, forced to choose between step-therapy programs that ease individuals into costly pharmacotherapy and the threat of forfeiting substantial PBM rebates tied to GLP-1 prescriptions.

This dynamic creates a perverse incentive, undermining efforts to build a balanced, economically sustainable framework that offers access to GLP-1s alongside alternative treatments. The result? It undercuts shared decision-making in obesity care, prioritizing financial gain over patient-centered outcomes.

The Current GLP-1 Landscape

The disparity in coverage between people with diabetes and those struggling with weight management for GLP-1s is well-documented. An October survey by the International Foundation of Employee Benefit Plans found that 76% of companies provide GLP-1 drug coverage for diabetes, while only 27% cover the drugs for weight loss. Another 13% of plans said they’re considering coverage for weight loss.

Meanwhile, KFF finds that 12% of adults say they’ve used a GLP-1, including 43% of those who have been diagnosed with diabetes and 22% of those who have been told by a doctor they’re overweight or obese. The survey also found that public awareness is growing sharply, with 32% of adults saying they’ve heard “a lot” about GLP-1s, up from 19% in July 2023.

Finally, adherence is a major concern. While clinical trials have shown over 90% adherence, one study found that just 51% of patients were adherent at 12 months. Strategies surrounding GLP-1s should take adherence into account because using them for just two months, for example, can lead to patients essentially wasting thousands of dollars.

Who Should Be Using GLP-1s?

Identifying who should receive GLP-1 drugs is a crucial part of the equation. The criteria for prescribing these drugs is generally based on medical guidelines considering factors such as BMI, comorbidities, and patient history. Personalized assessments are also essential to determine who would benefit most from GLP-1 drugs and ensure they’re reserved for those who truly need them. Health policy expert Ezekiel Emanuel, M.D., Ph.D., points to a potential shortage of GLP-1 drugs and other weight-loss medications, saying that measures should be taken to allocate them to those who have exhausted all other options.

While GLP-1s have significantly advanced our understanding of weight loss and weight gain and provided a real solution for many people, too many patients are convinced they’re the first or best option. In reality, many patients who start GLP-1s for weight loss are unaware of options that may work better for them at a lower cost. Most are misinformed of the long-term implications, effort required for adherence and financial burdens associated with a GLP-1 for weight loss.

With a better understanding of the mechanisms of weight loss and all the options available to them, patients will be better equipped to make the serious decision of whether to start taking medication.

Building Health Literacy to Empower Patient Decisions

Engaging patients across populations and conditions is critical. Educating them transparently on the weight-loss options available is key to building confidence and trust. Providing patients with information on the pros and cons of treatment and supporting their evaluation of a personal healthcare journey helps them have more meaningful conversations with their provider and more deeply believe in the efficacy of their treatment plan.

Each weight-loss journey is personal. While GLP-1s may work great for some, non-pharmacological options may work just as well for others. A comprehensive plan that addresses the individual’s multidisciplinary needs is critical for sustainable outcomes.  

Considering Economics and Sustainability

Balancing access to GLP-1 drugs with economic sustainability is critical for the industry. GLP-1 costs generally run between $900 and $1,350 per month. According to the New England Journal of Medicine, if all 19.7 million Medicare beneficiaries with obesity were prescribed a GLP-1, it would cost the U.S. healthcare system $268 billion.

Developing a framework for economically sustainable GLP-1 coverage will require policy changes, adjustments to insurance plans, and likely various cost-sharing mechanisms. There is currently tension between cost-effectiveness and reducing waste (payer responsibility) compared to efficacy and societal gains (medication-induced gains). A balanced approach is required to prevent the healthcare system from being flooded with excess costs while ensuring patients who need these treatments have access.

The recent lawsuit against Cigna has highlighted this much broader issue, underscoring the need to address fair and thoughtful access to GLP-1s for obesity treatment. Regardless of how the debate plays out, engaging patients, educating them about alternative treatments, and creating a balanced and economically sustainable framework for GLP-1 coverage are all major steps toward providing equitable access to weight loss treatments. Healthcare providers, payers, and policymakers must collaborate to create responsible and equitable access to obesity treatments and create a more clearly defined role for GLP-1s.

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Source: https://www.healthcarebusinesstoday.com/equitable-access-glp1-drugs-obesity/