Financial Considerations, Policies for Antiobesity Medication Coverage

The United States is facing a growing obesity epidemic, while the widespread use of antiobesity medications and prescription trends are also increasing, particularly in the context of managing chronic conditions like diabetes.

At the AMCP Nexus 2024 conference, experts discussed financial considerations and policies for medication coverage from the clinician and payer perspective. | Image Credit: Corona Borealis - stock.adobe.com

As obesity and related health concerns become increasingly prominent, it is important to evaluate the effectiveness of these medications across various populations to better understand their benefits and challenges. Additionally, with more medications being approved and new combination therapies on the horizon, it is also important to consider the cost-effectiveness and accessibility of these medications.

At the AMCP Nexus 2024 conference, experts discussed financial considerations and policies for medication coverage from the clinician and payer perspective, as well as the need for comprehensive and long-term treatment strategies for obesity.

Overview of the Weight Loss Drug Market

The National Health and Nutrition Examination Survey (NHANES) reported that 42.5% of US adults aged 20 years and older are obese and another 31.31% are overweight. In 2021, national spending for semaglutide totaled $10.7 billion and increased 300% between 2020 and 2022, according to the CDC. Moreover, 53.8% of patients taking a glucagon-like peptide-1 (GLP-1) have a history of type 2 diabetes, although indications have been expanded beyond the disease.

Current guidelines by the American Gastroenterological Association (AGA) recommends pharmacological therapy in addition to lifestyle interventions, including long-term medication management with semaglutide, liraglutide, phentermine-topiramate, naltrexone-bupropion, phentermine, and diethylpropion. Additionally, the American Diabetes Association (ADA) recommends that people with diabetes who are overweight or obese use a GLP-1 or dual glucose-dependent insulinotropic polypeptide (GIP)/GLP-1 agonist, due to additional weight-independent benefits.

Patient Selection

When it comes to clinical considerations for prescribing antiobesity medications, Angela Fitch, MD, chief medical officer, Knownwell, explained that most patients have tried lifestyle interventions multiple times before seeking medications, emphasizing the need for pharmacotherapy.

“We have patients who have tried to be successful with lifestyle intervention, and unfortunately, they have lost 5 pounds or so but have gained it back,” said Fitch. “I had one patient who told me she’s lost 100 pounds, but that was the same 10 pound, 10 times across her lifetime.”

Fitch also highlighted the importance of significant weight loss for patients with a high disease burden, such as those needing knee replacement surgery.

From a payer perspective, clinical considerations include previous nonpharmacological and pharmacologic intervention, comorbid conditions, baseline body mass index, and concurrent medications. Other payer considerations include disparities in obesity rates, which are significant across racial and ethnic groups, obesogenic food environments, and avoidance of health care due to weight stigma.

Comprehensive Lifestyle Modifications

Despite the importance of lifestyle modifications in weight loss interventions, most patients see limited results. Challenges to lifestyle modifications include time required, which can take 6 months to 1 year, as well as difficulty maintaining significant weight loss.

Additionally, lifestyle modifications have been found to help sustain weight loss and have shown clinical improvements in blood pressure, lipid levels, and glycemic control. Furthermore, comprehensive lifestyle interventions address all components of obesity treatment, such as behavioral, nutritional, physical, adjunct pharmacotherapy, and surgery.

Navigating Drug Shortages

While drug shortages are not a new concept, shortages for GLP-1s are somewhat unique, as they have been propelled into the eyes of the public.

“If you look at obesity alone, [there’s] close to 140 million people who qualify for treatment for obesity, and there is not 1 or 2 or potentially even 3 drug companies that can supply that [much] treatment, or are inclined to be able to do so,” said Fitch.

Fitch suggested working with pharmacies to manage waitlists, as well as staying informed about medication availability is important when navigating drug shortages. She also believes these medications should be a standard benefit on insurance policies.

“I live in Boston, Massachusetts, and we’ve found it very helpful very early on to work with pharmacies directly,” said Fitch. “Obviously, they can only do as best as they can with the supply in the market, but really working together has been critical for us.”

Monitoring Outcomes and Comorbidities

In addition to weight loss, it is also important to consider patient-centered outcomes, such as improved mobility and quality of life. Weight loss is measured monthly and then every 3 months, and guidelines recommend continuing therapy if a patient has more than a 5% reduction in baseline weight within 3 to 6 months. Other outcomes that should be measured include adherence and persistence, improvement in secondary outcomes, and morbidity and mortality.

Drug Coverage

Antiobesity medications also have a significant financial impact, including high costs and the need for coverage to manage costs. It is also important to identify patients who may be successful on lower-cost alternatives, as well as ensuring they have coverage.

From a payer perspective, it is important to evaluate cost containment strategies such as implementation of step therapy, utilization management, and preferred product designation.

Despite evidence demonstrating the effectiveness of GLP-1s for weight loss, many commercial, employer groups, and commercial state health plans have walked backed or stopped providing coverage.

Payers can ensure continued coverage by analyzing potential costs including potential health care cost offsets to optimize efficiency and financial impact, choose lowest net cost products inclusive of any supplemental manufacturer rebates, and promote comprehensive lifestyle management programs.

A financial impact assessment found that International Classification of Diseases, Tenth Revision codes may not be directly correlated to patients that will receive the drug. The assessment also considers requiring medical record documentation instead of provider attestation, as well as the possibility of an oral medication trial and/or lifestyle intervention before more costly anti-obesity medications are introduced. Furthermore, the assessment suggests timing for monitoring persistence/adherence or other clinical outcomes and monitoring how drug shortages affect uptake and adherence.

“All of these efforts help to develop a new budget impact model decrease some of the expenses in the future,” said Mckenzie McVeigh, PharmD, MS, clinical pharmacy manager, Massachusetts Medicaid, UMass Chan Medical School – ForHealth Consulting. “That’s helpful, considering tracking drugs and indications, as well as analyzing what this means for not only budget, but also member access and treatment.”

Reference

Anderson E, Fitch A, McVeigh M. “Pound for pound” assessment of anti-obesity medications, coverage policies, and financial considerations. Presented at: AMCP Nexus 2024; October 14-17, 2024; Las Vegas, NV.