'Tsunami of exclusion': Patients shut out while payers cut obesity drug coverage

As health plans drop costly GLP-1 drugs, controversially leaving people without access to potentially life-changing therapies, health companies are hoping to fill the marketplace void to provide better access to care for patients.

Demand continues to remain high, with prices reflecting that interest. Customers can expect to outlay $936 for Ozempic and $1,349 for Wegovy in the U.S., the highest cost for the drug in the world.

On Sept. 1, the University of Texas System will eliminate coverage for weight loss drugs on its employee health plan and Medicare plan for retirees, pointing toward a 233% total cost increase for the drugs on the payer’s end. The university said it would need to increase premiums by at least 2.5% to accommodate the growing number of customers taking the drug. St. Louis-based Ascension also dropped coverage in July, requiring employees to pay out-of-pocket for drugs like Wegovy.

Critics argue the trend will have severe impacts on people who truly need the drugs, as they may not be able to afford the prescription any longer.

“People don’t want to take medicine,” Brooke Boyarsky Pratt, a former GLP-1 patient and CEO of knownwell, a clinic focused on providing better care for individuals that struggle with their weight, told Fierce Healthcare. “The people decide they need to take medicine when the problem becomes such that it’s going to help them have better health outcomes.”

Patients left with few options

The University of Texas System suggested to those that will lose coverage to contact manufacturers directly for a discount, but knownwell Chief Medical Officer Angela Fitch, M.D., said that isn’t much of a solution at all.

“There are online coupons where you can get $300 off … it’s a little bit of a rebate but it’s not enough,” she said.

Brooke Boyarsky Pratt
Brooke Boyarsky Pratt (knownwell)

Payers deciding to no longer offer the drugs, despite the American Medical Association declaring obesity a disease in 2013, is a significant setback to a subset of the population that finally was finding success in losing weight. For Pratt, she co-founded knownwell because she knows traditional primary care offices give meager treatment advice for heavier people. Her organization sets patients up with a dietitian, support staff and health coaching to help people address problems they are facing, regardless of whether that involves losing weight.

She said that too often doctors, who already have limited time in their busy schedules to look holistically at a patient’s struggles, will fall back on generic advice that is simply not helpful.

“The typical experience for a patient who’s overweight or has obesity is you go to the primary care doctor, and they say ‘Do you know you’re overweight? It’s really unhealthy. Have you tried eating well and exercising?’” recalled Pratt. “It’s a very stigmatizing conversation that tends to be patronizing. They're asking people who have obesity if they've ever dieted. The vast majority of us have been on a diet since we were 11 years old.

“It’s not just that it hurts your feelings when you go to the doctor and have those conversations,” she added. “It’s leading to worse health outcomes.”

Many medical professionals are not trained to provide obesity care. In the U.S., less than 100 actively practicing doctors have completed a fellowship in obesity medicine, obesity education is infrequent in many medical curriculums and many providers historically have had a built-in bias against patients with obesity as they believe they lack willpower, Stat reported.

“Our view with employers starting to say, ‘we’re not going to cover GLP-1s’ is because of the bias and stigma,” said Pratt, acknowledging that it’s common for insurance policies to require patients to wait on prior authorization for drugs as cheap as $10. “It’s a disease where you can kind of do that. It would be really hard to say we’re not covering chemotherapy anymore, it’s too expensive. Part of what you’re seeing is a negotiation … between payers and pharmaceutical companies.”

More data support GLP-1 effectiveness

Several studies and surveys in recent months have underscored the promise, and current reality, of GLP-1 drugs.

Earlier this month, global pharmaceutical company Novo Nordisk released results from a five-year-long clinical trial showing Wegovy slashes the risk of heart attacks, strokes and cardiovascular deaths by 20% versus participants who took the placebo.

Cardiovascular studies are standard practice for diabetes medicines and are increasingly common for obesity drugs. While obesity is a risk factor for cardiovascular disease, there is debate as to whether trials should be required, or if it’s evidence of obesity bias since trials often aren’t needed for other diseases.

“There’s a few ways to look at it,” Rekha Kumar, M.D., chief medical officer at obesity care provider Found, told Fierce Healthcare. “One view is this is a version of obesity bias that these drugs are held to a higher standard than other medicines that just meet their treatment endpoint. But also, the history of anti-obesity medications in the U.S. has a negative track record as many medicines were pulled of the market because of adverse cardiovascular outcomes … so I understand why the FDA is asking for this.”

In July, Found shared data with Fierce that showed 69% of its patient population does not have coverage for drugs treating weight loss, a 50% decrease since December. Experts at Found said insurers have been relying on pharmacy benefit managers as their support for GLP-1s weaken.

ECRI Institute, an independent nonprofit in the healthcare technology and safety space, said that payers denying weight loss drugs will “expand health inequities” in marginalized populations—especially as Black and Hispanic people experience obesity and associated conditions at higher rates than white people—and that it could be costly to treat underlying conditions for all people in the future.

“In their attempt to avoid covering these drugs in favor of short-term financial interests, insurance companies may be setting themselves up to pay for exponentially more expensive treatments down the road in a nation where nearly half of adults are living with obesity,” said ECRI President and CEO Marcus Schabacker.

Another study published in The New England Journal of Medicine found that Wegovy led to larger reductions in symptoms and physical limitation as well as weight loss for patients that have been diagnosed with heart failure with preserved ejection fraction, Fierce Pharma reported.

Could saliva tests mend the payer-patient relationship?

So, payers say the drug is just too expensive for the number of people that desire the drug, and the drug’s utility is limited because those who stop taking the drug can quickly put the weight back on. Other critics contend that drugs like Ozempic and Wegovy don’t always help people lose weight, further incentivizing them to not cover the drugs.

Mark Bagnall, CEO of Phenomix Sciences, said his company’s saliva-based tests can be part of the solution. The tests identify one of four obesity phenotypes: hungry brain, hungry gut, emotional hunger and slow burn. He said the tests can tell which category your body best aligns with by measuring 6,000 gene variants.

Mark Bagnall
Mark Bagnall (LinkedIn)

“This is a disease that affects 100 million Americans,” he explained to Fierce Healthcare. “You would not expect the disease to work the same way for every patient.”


Phenomix launches first of 4 obesity phenotype tests amid weight-loss drug boom

GLP-1 drugs have been shown to work well with individuals struggling with hungry gut—or people who don’t feel full, so they snack between meals—and not hungry brain, which are people that overeat, but don’t snack, during meals because they don’t feel satisfied. Those who eat to cope with negative emotions or inherently possess a decreased metabolic rate are less likely to have positive experiences with GLP-1 drugs, discouraging both the insurance company and patient from starting a costly new medication.

People who have an emotional component to their eating can benefit from other types of treatment like counseling or surgical techniques and devices.

Bagnall said insurance companies are stuck in the “unenviable” position where they’re expected to pay for all drugs, including weight loss drugs that millions of people suddenly want, when that is not financially realistic. He said Phenomix’s products are getting interest from pharmaceutical companies, patients and payers alike. Ideally, he hopes the saliva test can be uploaded into the electronic health record prior authorization process.

It could prove the right approach if it is cost-effective for all groups. Ellen Kelsay, CEO of the Business Group on Health, said in a recent press briefing that all parties involved in the GLP-1 coverage debate need to “make sure the patient population who needs them most is taking them.”

Will payers soften their approach?

As companies continue innovating to provide adequate care for customers, insurers have yet to reverse their decisions and reoffer GLP-1 drugs under its coverage. Positive clinical trials and saliva-based tests aside, patients will likely have to wait longer.

“We’re going to see more of this now,” said Pratt. “You’re going to see this tsunami of exclusion as they (the pharmaceutical companies) are trying to put pressure on the payers to bring in the price.”

“For the insurance companies that have had a hard stance on not covering this, I don’t think that will change yet,” said Kumar. “I think what insurance companies will want to see is how do you optimize adherence to these medications.”

She noted that people still like to lose weight for purely cosmetic reasons as well, so both sides will likely need to come together to differentiate between various motivating factors.

“I mean, it’s clear that obesity is a disease and in the severe form it can’t be solved with just diet and exercise,” Kumar added. “But where does that blurry line where somebody is just struggling to lose five, 10, 15 pounds? When do we decide that they do or don’t qualify for that medicine? Unfortunately, it’s going to depend on a patient’s ability to pay out-of-pocket.”