Wegovy (semaglutide) is a prescription subcutaneous obesity medication that has helped people with … (+)
There is high demand for anti-obesity drugs called glucagon-like peptide-1, or GLP-1, agonists. However, 58% of patients stop using it before achieving a clinically significant level of weight loss, according to a recent study by the Blue Cross Blue Shield Association.
When combined with an appropriate diet and exercise program, GLP-1 can provide substantial health benefits for patients. These are not limited to weight loss. GLP-1s have been used for nearly two decades in the treatment of type 2 diabetes. And a GLP-1 called Wegovy (semaglutide) obtained an additional cardiovascular indication from the Food and Drug Administration this spring.
The drugs are also being studied in late stages of clinical development for chronic kidney disease and non-alcoholic fatty liver disease, where they have shown promise. Additionally, in their filing, BCBSA researchers listed sleep apnea and increased wear and tear on joints as health conditions likely to improve with weight loss, which GLP-1 may help to reach.
To achieve these health benefits, it is essential that people who are prescribed GLP-1 continue to take them at least long enough to achieve clinical success, and preferably longer to avoid possible weight rebound. once they stop taking the medication. In the BCBSA study, patients with coexisting conditions such as peripheral vascular disease and diabetes were more likely to take their medications persistently. However, the study shows that 58% of all people whose claims were analyzed stop taking their medications before reaching a clinically significant level of weight loss, defined as a weight reduction of at least 5% per year. compared to the basic level. Additionally, 30% of patients discontinued use within the first month.
The problem of lack of persistence on GLP-1 is not new. A peer-reviewed study published earlier this year indicates that only 40% of obese patients taking semaglutide-based GLP-1 products were persistent after one year. And a real study published last year found that 68 percent of people who started taking GLP-1 for weight loss stopped taking it after a year.
The abandonment problem is compounded by high list prices. An article in Medical landscape points out that although GLP-1 obesity drugs have some appeal due to their effectiveness in reducing weight and even lowering the risk of major cardiovascular events for some, data suggests that at current prices they are not profitable.
Estimates of net prices for GLP-1 drugs indicate that they are significantly below list prices. These are the price levels most relevant to payers. Despite this, the latest survey conducted last month shows that only 34% of U.S. employer health insurance plans offer coverage of GLP-1 medications for diabetes management and weight loss. Although the percentage of plans covering medications has increased, it’s a modest increase that doesn’t suggest they’ll all be on board anytime soon.
Medicare still prohibits coverage of all obesity medications if they are prescribed solely as weight loss medications. Congress is unlikely to lift this ban in the near future. A report released in May by the Senate Committee on Health, Education, Labor and Pensions, saying high prices for GLP-1 drugs, combined with growing use, could “bankrupt the entire our health care system,” does not help advance legislation that would allow Medicare to cover obesity. drugs.
Nonetheless, after the FDA added an indication for Wegovy in March as a treatment to reduce the risk of serious heart problems in obese or overweight patients with pre-existing cardiovascular risk, the Centers for Medicare and Medicaid Services authorized the plans to cover the drug for qualified Medicare. beneficiaries.
But this does not mean that the majority of plans will necessarily embark on paying for the product, given its high cost and limited profitability. Rather, it is likely that those covering Wegovy will have prior authorization protocols in place as well as other usage management tools.
The plans are likely aware that the data supporting Wegovy’s additional indication imply a 1.5% absolute risk reduction 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 taking Wegovy and 8% of those in the placebo group. This translates to a number needed to treat of 67 to avoid a serious cardiovascular event, which is not necessarily a good value proposition from an insurer’s perspective. Additionally, the data did not show that Wegovy reduced the risk of cardiovascular death in a statistically significant way.
Reimbursement problems extend to Medicaid, where only 28 percent of plans currently cover weight-loss drugs.
As payers are hesitant to reimburse in the commercial, Medicare, and Medicaid markets, we are seeing some insurers make bariatric surgery more accessible than GLP-1 medications.
This is not just an American phenomenon. Even when list and net prices are much lower, reimbursement authorities act cautiously. A Danish medicines monitoring committee is now advising doctors to restrict Wegovy prescriptions, given the limited cost-effectiveness. He cites the $870,000 cost of preventing a cardiac event as a factor in his decision.
Combined with cost-effectiveness concerns, BCBSA data suggesting that many patients are not taking their obesity medications long enough to experience a clinically meaningful benefit presents challenges for insurers making payment decisions regarding GLPs -1 for weight loss.