GLP-1 drugs are effective in treating obesity.
The ultimate solution is for drug prices to come down — whether through the development of generics or pressure from Congress on drugmakers.
In the meantime, public and private insurers need to look for ways to ensure the drugs are available to those who need them and are likely to be helped — but not those without proven medical need. Connecticut pioneered a unique model with its employee health plan that involves a third-party organization crafting personalized weight loss plans. Some insurers, including MassHealth, are planning to experiment with requiring a cheaper drug to be used first. All these models are worth learning from.
The first GLP-1 drugs were approved to treat Type 2 diabetes in 2005 and to address weight loss in 2014. Newer version are stronger and more effective, and their popularity is skyrocketing. In Massachusetts, in the first nine months of 2023, 3.2 percent of commercially insured people were prescribed a GLP-1 drug, up from 0.5 percent of members during the same time in 2018, according to an analysis by the Massachusetts Health Policy Commission. There were approximately 313,000 prescriptions for GLP-1 drugs written to commercially insured individuals (those not on Medicare or Medicaid) in 2023.
While GLP-1 drugs are approved for Type 2 diabetes and weight loss, prescriptions for weight loss are growing fastest, and the drugs approved by the Food and Drug Administration for weight loss are more expensive. A monthly supply of the weight loss drug Wegovy had an average commercial price of $1,303 in 2023, not counting rebates the drugmaker gave insurers. (The average amount the consumer paid was $85 for a one-month supply.)
Those prices add up fast. Total spending by private insurers on GLP-1 drugs in 2023 in Massachusetts was projected to surpass $270 million, according to the Health Policy Commission, up from $125 million in 2022. Already in 2022, GLP-1 drugs accounted for 5 percent of pharmacy spending among people with commercial insurance.
The potential for extraordinarily high costs has led some insurers to limit coverage, and policies vary widely. Medicare Part D plans, which are private plans that cover prescription drugs for seniors, are prohibited from covering weight loss drugs. MassHealth began covering weight loss drugs when medically necessary in January 2024 after negotiating manufacturer rebates. But starting in January 2025, MassHealth will begin requiring patients with obesity to first try an oral appetite suppressant before being approved for a GLP-1 drug. Private plans have imposed a range of requirements: prior authorization, enrollment in a diet or exercise plan, trying a less expensive drug first, or proof of weight loss for continued coverage.
North Carolina’s state employee health plan stopped covering GLP-1 drugs for weight loss, saying continued coverage would have required a premium increase of $48.50 per subscriber per month. (Massachusetts’ state employee health plan has also noted an increase in spending but is still covering the injectables.) Blue Cross Blue Shield of Michigan this summer decided to stop covering GLP-1 drugs for weight loss, and the University of Texas stopped covering the injectables for weight loss for its employees in 2023.
The problem with eliminating coverage is these drugs work against a real health threat. According to the Centers for Disease Control and Prevention, nearly 42 percent of American adults were obese between 2017 and 2020. Obesity is a risk factor for health problems including Type 2 diabetes, hypertension, and heart disease. Dr. Hugh Taylor, president of the Massachusetts Medical Society, said for many people, preventative measures like diet and exercise are insufficient. “GLP drugs are remarkably effective, in many cases as effective as surgery,” Taylor said. The Massachusetts Medical Society — and the national American Medical Association — have urged greater insurance coverage for weight loss treatments, including GLP-1 medications.
There is not yet sufficient research on whether the cost of GLP-1 drugs could be recouped through fewer long-term health complications.
One innovative approach is a program Connecticut started for its state employee insurance plan. The state contracts with Flyte, which employs obesity specialists that see patients virtually (and soon in-person). Specialists create personalized weight loss plans for enrollees that often include non-medication interventions and lower-cost medicines before prescribing a GLP-1 drug. Flyte also provides education and support to patients on the drugs. According to Connecticut officials, the program has shown positive health effects while limiting the growth in prescriptions. However, some Connecticut doctors have complained about having their patients taken away and sent to out-of-state virtual clinicians.
The ultimate solution is for the cost of these drugs to come down — which shouldn’t be impossible. Currently, GLP-1 drug prices in the United States can be four or five times higher than in other countries. According to health policy research organization KFF, Ozempic had a list price of $936 in the United States in August 2023 but less than $200 in countries including Japan, Canada, Switzerland, and Germany, and less than $100 in the United Kingdom and Australia. (To be sure, there are tradeoffs. The New York Times, citing industry-funded analyses, notes that Americans can often get medicines faster and with fewer restrictions than residents of countries with cheaper prices.)
Senator Bernie Sanders, who chairs the US Senate Committee on Health, Education, Labor, and Pensions, has been pushing drug manufacturers to lower their prices. Research suggests generic versions could be manufactured at lower prices if legal, regulatory, and business hurdles are overcome.
“The key is how is the federal government going to handle drug prices going forward,” said Ron Mastrogiovanni, CEO of health care software company HealthView Services and an expert on health care costs. “Are we going to give the authority to the government to actually negotiate those prices?”
Until that happens, state policymakers and insurers must do their best to craft policies that balance access with fiscal sustainability.
Read the original article in the Boston Globe here.
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