Wegovy (semaglutide) is a sub-cutaneous prescription obesity medicine that has helped people with … [+]
There is high demand for obesity medications known as glucagon-like peptide-1 agonists, or GLP-1s. However, 58% of patients discontinue use before reaching a clinically meaningful level of weight loss, according to recent research from The Blue Cross Blue Shield Association.
In conjunction with an appropriate diet and exercise regimen, GLP-1s can provide substantial health benefits to patients. These aren’t confined to weight loss. GLP-1s have been used for almost two decades in the treatment of Type 2 diabetes. And a GLP-1 named Wegovy (semaglutide) secured a supplemental cardiovascular indication from the Food and Drug Administration this spring.
The medications are also being studied in late stages of clinical development for chronic kidney disease and non-alcoholic fatty liver disease, where they’ve shown promise. In addition, in its issue brief, BCBSA researchers listed sleep apnea and increased wear and tear on joints as health conditions that may improve through weight loss, which GLP-1s can help attain.
To achieve these health benefits, it is critical that people prescribed GLP-1s continue to take them at least long enough to realize clinical success, and preferably longer to avoid possible weight rebound once they come off the medications. In the BCBSA study, patients with coexisting conditions such as peripheral vascular disease and diabetes were more likely to be persistent taking their medications. However, the study shows that 58% of all individuals whose claims were analyzed stop taking their medications before reaching a clinically meaningful level of weight loss, which is defined as at least a 5% reduction in weight from the baseline level. Moreover, 30% of patients discontinued use within the first month.
The problem of lack of persistence on GLP-1s isn’t new. A peer-reviewed study published earlier this year indicates that only 40% of obese patients taking semaglutide-based GLP-1 products were persistent at one year. And a real-world study released last year revealed that 68% of individuals who started on GLP-1s for weight loss were no longer taking them after one year.
Compounding the problem of discontinuation are high list prices. An article in Medscape points out that while 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.
Estimates of the net prices of GLP-1 drugs indicate they’re considerably lower than list prices. These are the price points most relevant to payers. Even so, the latest survey conducted last month shows that only 34% of United States employer health plans offer coverage of GLP-1 drugs for both diabetes management and weight loss. While the percentage of plans covering the medications has been rising, it’s a modest increase and not one which suggests they’re all going to be on board anytime soon.
Medicare still prohibits coverage of all obesity drugs if prescribed as weight loss medications alone. Congress is unlikely to lift the prohibition in the near future. A report issued in May by the Senate Health, Education, Labor and Pensions Committee claiming that high GLP-1 drug prices combined with rising uptake could “bankrupt our entire healthcare system” isn’t helping move legislation along that would authorize Medicare to cover obesity drugs.
Nevertheless, after the FDA in March added an indication to Wegovy as a treatment to reduce the risk of serious heart problems in obese or overweight patients with preexisting cardiovascular risk, the Centers for Medicare and Medicaid Services did allow plans to cover the drug for qualified Medicare beneficiaries.
But it doesn’t follow that the majority of plans will necessarily jump to pay for the product, given the high cost and limited cost-effectiveness. Rather, it’s likely that those who do cover Wegovy will institute prior authorization protocols as well as other utilization management tools.
Plans are presumably aware that the data supportive of Wegovy’s supplemental indication imply an absolute risk reduction of 1.5% of significant cardiovascular events among clinical trial participants, which is relatively small. Namely, during the trial, major adverse cardiac events occurred in 6.5% of patients on Wegovy and 8% of those in the placebo arm. This translates into a number needed to treat of 67 to avoid one severe cardiovascular event, which isn’t necessarily a good value proposition from an insurer’s perspective. What’s more, the data didn’t show Wegovy decreased the risk of cardiovascular death by a statistically significant margin.
The problems with reimbursement extend to Medicaid, where just 28% of plans currently cover weight loss drugs.
Amid payer hesitancy to reimburse in the commercial, Medicare and Medicaid markets, we observe that some insurers are making bariatric surgery more accessible than GLP-1 drugs.
This isn’t solely a U.S. phenomenon. Even where list and net prices are much lower, reimbursement authorities are treading cautiously. A Danish drug oversight panel now advises doctors to restrict prescriptions of Wegovy, given the limited cost-effectiveness. It cites the cost of $870,000 to prevent one cardiac event as a factor in its decision.
Coupled with cost-effectiveness concerns, the BCBSA data suggesting that many patients don’t stay on their obesity medications long enough to experience clinically meaningful benefit present challenges for insurers making payment decisions regarding GLP-1s for weight loss.
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