Amid increased concern about the costs of using glucagon-like peptide 1 agonists to treat obesity, some insurers are imposing further restrictions or eliminating coverage of the drugs altogether. At the same time, plans are either maintaining a certain level of access to bariatric surgery or making it easier to obtain.
As Medscape points out, while the GLP-1 drugs for obesity have a definite appeal due to their effectiveness in reducing weight and even diminishing the risk of major cardiovascular events for some, data suggests that at current prices they’re not cost-effective.
On the other hand, bariatric surgery is deemed cost-effective, particularly among persons with morbid obesity and type 2 diabetes. Current evidence shows bariatric surgery can be efficacious in reducing weight, metabolic comorbidities and mortality in people with obesity compared with lifestyle intervention alone. Specifically, sleeve gastrectomy for moderate to severe obesity and the less invasive endoscopic sleeve gastroplasty for mild obesity are both considered cost-effective strategies.
The cost of bariatric surgery ranges between approximately $17,000 and $26,000. It is estimated that insurers can recover those costs rather quickly, within two to four years, as spending on obesity-related conditions is eliminated.
According to Modern Healthcare, some insurers are now easing access to bariatric surgery. For example, Blue Cross Blue Shield of Michigan removed prior authorization requirements in September of last year. BCBS carriers in Massachusetts and Vermont have since updated their protocols as well. Similarly, Geisinger Health Plan expanded its coverage.
And, as the New York Times reported, effective the first of April the North Carolina State Health Plan no longer covers GLP-1 therapeutics for weight loss, including Wegovy and Zepbound (tirzepatide, which is a GLP-1/GIP compound). These drugs can cost around $1,000 per patient per month in perpetuity. But the plan will continue to cover bariatric surgery for morbidly obese individuals who are indicated for the procedure.
The state treasurer, Dale Folwell, stated that the move to exclude coverage of prescription drugs was driven by their high prices. He acknowledged their effectiveness, but said that expenditures on weight loss medications had ballooned in recent years and accounted for up to 10% of the plan’s pharmacy budget, with 25,000 people taking the drugs in early 2024. Accordingly, if the state were to continue to cover the products it would have to raise the cost of health insurance for everyone on the plan by “too much.”
Last year, the University of Texas health system and the hospital chain Ascension made similar decisions as they stopped reimbursing weight loss drugs. Additionally, other large payers, such as the Mayo Clinic, capped coverage at $20,000 for each employee. All these payers appear to be maintaining the same level of access to bariatric surgery.
The Medicare program universally covers bariatric surgical procedures, such as gastric bypass surgery and laparoscopic banding surgery, when a patient meets certain conditions related to morbid obesity.
However, Medicare still prohibits coverage of all obesity drugs if prescribed as weight loss medications alone. The therapeutic Wegovy secured a supplemental cardiovascular indication from the Food and Drug Administration last month. This allows limited access for certain Medicare beneficiaries who fulfill weight and major cardiovascular risk criteria. But it doesn’t follow that plans will necessarily jump to pay for the product, given the high cost and limited cost-effectiveness.
According to Cureus, bariatric surgery has demonstrated better efficacy than drugs in weight reduction, yet it also carries a higher chance of complications. By contrast, GLP-1 drugs offer a comparatively non-invasive alternative with significant decrease in weight and relatively less risk of adverse events, which explains patients’ interest in them.
As a consequence of a policy shift in which some plans decide to facilitate access to bariatric surgery while removing coverage of obesity medications, a still small number of patients may opt for surgery but a much larger group won’t be treated, at least not pharmaceutically. Though this may save payers money in the short run, if these patients remain overweight or obese there could be attendant consequences for payers’ long-term healthcare spending.