Obesity Epidemic and its Impact on Self-Funded Employers
Contributing Authors: Collin Smith, PharmD, Augustus E. Adams, PhD, Michael J. Follick, PhD
According to the CDC, over 41.9% of citizens in the United States can be classified as obese and this number has increased by over 10% in the last two decades alone. The dramatic rise in obesity rates has also come with an economic burden, with the total cost of treating obesity-related chronic conditions estimated at $1.72 trillion in the United States alone last year; approximately 9.3% of the country’s GDP. For self-funded employer health plans, members with obesity cost more than those without obesity. Not only does obesity impact direct health care costs, but it also adversely affects productivity by increasing absenteeism and presenteeism. Decreasing the prevalence of obesity could save employers billions of dollars in both direct and indirect costs.
With the recent emergence of GLP-1 Receptor Agonists medications, or “Anti-obesity Medications” (AOMs), as clinically effective weight-loss treatments, many claim that employers can now address obesity in their insured populations. However, these newer AOMs, notably the brands Wegovy® and Zepbound®, are extremely costly, over $1,000 per month, and employers are understandably concerned about the enormous potential cost burden of these medications. Moreover, some have suggested AOM’s are suitable for long-term, even life-long, management of obesity. However, this approach would create a perpetual cost burden for private and public payors, as well as patients.
Currently, no published studies demonstrate the long-term effects of AOMs on weight loss maintenance when these drugs are discontinued. In fact, to date, no weight loss intervention of any kind has produced sustained weight loss for most users. Typically, less than 10% achieve long term weight loss at 3-year follow-up. The AOMs aren’t likely to be any different in terms of sustained weight loss unless they are used continuously, which is not financially viable. Indeed, unless the AOMs can produce economic savings in 24-36 months, it will be difficult for employers to justify the substantial cost. Further and more comprehensive assessments of long-term maintenance of AOMs for the treatment of obesity need to be conducted before a definitive conclusion can be reached on their overall cost-effectiveness. In the interim, the burning question for self-funded employers is “what are the options for balancing the potential benefits and exorbitant costs of these drugs?”
Strategies For Self-Funded Employers
What strategies can employers use now to make the decision about adding these medications to their formularies while managing their long-term impact on costs? Listed and described below are six strategies that employers can consider:
Targeting the high risk/high need population with morbid obesity who account for the highest costs.
This strategy involves a better allocation of these medications in general. Ideally, members with morbid obesity and a BMI of >= 35 are the optimal candidates. Long-term success with these members, and associated decreases in costs for obesity-related disorders such as cardiovascular disease, will likely help to mitigate treatment costs.
Cost-sharing by placing the medication on the highest tier within the formulary or setting a level that will serve to limit access to a smaller segment of the population.
The cost-share approach is a proven effective method for mitigating excess utilization of high-cost services. Cost-sharing can also be used as an incentive, through mechanisms like copay waivers contingent upon involvement in lifestyle modification interventions, to increase engagement and adherence to recommended healthy behaviors for those employees in the highest risk subgroups.
Where possible, employers can ensure that in-network prescribers better prioritize who receives these medications.
This approach can be challenging but is possible by reviewing historical and ongoing medical and pharmacy claims for risk classification and need. The use of provider-based incentives for risk stratification and engagement of high-risk patients, and disincentivize their use for non-health-related cosmetic purposes, is a viable approach for employers to consider.
Prescribers and self-funded employers can also promote coupling medication use with healthy lifestyle modifications that can assist in maintaining weight loss without medication.
Too often patients adhere to a rigid notion that GLP-1 Receptor Agonists are somewhat of a ‘cure-all’, depending solely upon the appetite suppressive properties of the medication without altering diet and exercise habits necessary to maintain sustained weight loss in absence of the drug. Implementing structured behavior change and weight loss maintenance programs as an adjunct to GLP-1 Receptor Agonist therapy is a strategy that offers potential for improving patient skills for maintaining gains after medication cessation. Success with such parallel treatment strategies thus has potential for markedly improving the cost-effectiveness of these medications.
Prescribers need to consider discontinuing these medications after patients have reached the maximum titration and achieved their targeted weight loss goal. Employers in collaboration with vendor partners can create and implement provider incentive programs to ensure compliance with this approach.
Many times, patients will be kept on GLP-1 Receptor Agonist medications months after the medication has reached a ‘plateau’ and stopped being effective in terms of further weight loss. For most patients with obesity the average duration of therapy to achieve a minimum of 10% of body weight is 8-12 months if the patient has been provided with and acquired the necessary behavioral management skills for long term success. Employers can consider setting fill limits through their PBM partners to allow employees access to AOMs for a defined period but not on an unlimited basis.
Additional strategies that employers can consider as part of a comprehensive keep-it-off component include:
- Offering weight loss and exercise support groups,
- encouraging work breaks for physical activity, and
- offering ancillary gym memberships can assist employees in maintaining a healthy weight.
Conclusion
The inception of the GLP-1 Receptor Agonist medication class of AOMs has revolutionized both diabetes and weight-loss treatments for patients, and yet poses major financial challenges to self-funded employer health plans and their members. Amidst a rapidly changing landscape, the supply and cost of these medications has become of paramount importance for employers, and requires a comprehensive and flexible approach to manage access, minimize excess cost, and yield optimal outcomes.
References:
Monitoring Report: GLP-1 RA Prescribing Trends – December 2023 Data (medrxiv.org)
Adult Obesity Facts | Overweight & Obesity | CDC
David K Ahern, PhD
Dr. Ahern is a Co-Founder and Senior Scientist for Abacus Health Solutions. He ensures that all Abacus products and programs are evidence-based and scientifically rigorous. He managed a Small Business Innovative Research (SBIR) Program at Abacus with over 15 awards and a $10 million dollar portfolio.
Over his 40-year career, Dr. Ahern has focused on the intersection of informatics and behavioral science to improve health and healthcare. Dr. Ahern was National Program Director for the Health e-Technologies Initiative of the Robert Wood Johnson Foundation from 2002-2009 where he managed a technology research portfolio of 26 grants promoting the use of technology for health behavior change and chronic disease management.
Dr. Ahern also serves as the Director of the Digital Behavioral Health & Informatics Research Program within the Department of Psychiatry at the Brigham and Women’s Hospital (BWH) and Assistant Professor of Psychology (Psychiatry) at Harvard Medical School. He has published over 100 articles, book chapters, and technical reports.
