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Newly available anti-obesity drugs are safe, effective but pricey

KFF, CNN publish results of the Mental Health in America survey

By Jeff Levin-Scherz, MD, MBA | November 17, 2022

Our population health leader weighs in on anti-obesity drugs, mental health crisis, and provides a follow-up on maternity care in this monthly update.
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The prevalence of obesity is growing in the U.S., and we increasingly understand that it is often not simply a matter of “bad habits.” Rather obesity is a metabolic disease that has many serious adverse outcomes that may require intensive medical intervention to address. We also know that most of those with severe obesity cannot sustainably achieve their target weight through diet and exercise alone.

In the U.S. (2018), 33.2% of adults have a body mass index (BMI) in the obesity range of 30 to 35 and 9.2% have BMI in the severe obesity range of over 35. An additional 30.7% of the adult population is overweight – leaving only a bit over a quarter of the population at normal weight, BMI of 18 to 25.

For those with severe obesity, bariatric surgery helps lead to sustainable weight loss and can reverse diabetes and dramatically decrease the risk of obesity-associated complications. Bariatric surgery is generally limited to those with a BMI over 40, or those with BMI over 35 and diabetes. Most employers cover bariatric surgery, but they often require previous unsuccessful weight loss attempts. Bariatric surgery is best performed at a hospital with a multidisciplinary team, and many employers restrict this surgery to centers of excellence.

Until recently, medical therapy for obesity has been far less successful than surgery. Many of the available drugs have undesirable side effects and result in modest weight loss. Most diets do not lead to sustained weight loss of 10% or more of body weight. Although ketogenic (ultra-low carbohydrate) diets, such as the one recommended by the vendor Virta Health, have been successful for those able to maintain this type of restricted diet.

New anti-obesity drugs lead to weight loss similar to bariatric surgery

A relatively new class of drugs initially marketed for diabetes is associated with weight loss that rivals bariatric surgery, although this weight is regained if the drugs are stopped. The drugs can cause serious side effects, though these are rare. However, the drugs are very expensive. Their average wholesale price is about $15,000, and even after rebates they cost about $8,000 to $9,000.

Drugs approved to treat obesity include:

These drugs are once daily or weekly self-injections. Rybelsus is an oral version of semaglutide given once daily, but only approved at this time for diabetes. The FDA approved the weight loss drugs as an adjunct to diet and exercise. Each of these medications is a top-cost drug for employees.

Employers currently cover these medications for diabetes, and many employers also cover them for obesity. But there are press reports of widespread use of the diabetes drugs for weight loss among those who don’t have diabetes. Semaglutide is currently in short supply, which could be the result of the off-label use of Ozempic and Mounjaro. The shortage is expected to be resolved by the end of the year. If these drugs are used by a substantial portion of those with obesity, the increase in medical costs will be high.

The American Gastroenterology Association earlier this month recommended coverage of weight loss drugs for those with BMI over 30 or BMI over 27 with complications. This recommendation mirrors the FDA approved labeling of these drugs and will increase pressure on health plan sponsors to cover these medications.

In this context, the two societies for surgeons who perform bariatric surgery, the American Society for Metabolic and Bariatric Surgery, and the International Federation for the Surgery of Obesity and Metabolic Disorders, just released new guidelines for bariatric surgery. Guidelines from 1991 recommended bariatric surgery for those with BMI over 40, or BMI over 35 with comorbidities like diabetes. Based on more recent data on long-term safety and effectiveness of surgery, they now recommend coverage of bariatric surgery for those with BMI over 35, or over 30 with related problems like diabetes.

These societies also recommended coverage of bariatric surgery for children or adolescents who are more than 140% of the 95th percentile, or 120% of the 95th percentile if they have diabetes or other complications. Long-term follow-up of children or adolescents who have bariatric surgery demonstrates sustained weight loss without negative impact on bones or sexual development.

Implications for employers:

  • The tools to address severe obesity have significantly improved, but the cost of these new treatments are high.
  • These advances are coming at an excellent time for patients who need them but at a difficult time for employers already facing the highest medical inflation rate in decades.
  • Bariatric surgery comes with a track record of safety spanning decades but has a high initial cost.
  • The new class of medications cost less than bariatric surgery in the first year, but the cost over time would generally be higher than the cost of bariatric surgery. Also, long-term experience with these drugs is very limited.
  • A ketogenic diet might be a good alternative to bariatric surgery or medicine for those able to maintain the diet.
  • If adding drug coverage, consider sponsoring lifestyle modification (i.e., diet and exercise) benefits in line with the FDA-approved intended use of pharmacotherapy.
  • Consider making bariatric surgery available to children or adolescents, as appropriate.

More than half of adults say they have experienced a mental health crisis in their families

Recently, KFF (formerly the Kaiser Family Foundation) published results from the Mental Health in America survey it completed with CNN. Some key survey results:

  • 28% of respondents had a family member who received inpatient mental health treatment
  • 21% reported a family member had a drug overdose requiring medical attention
  • 16% said a family member had died by suicide
  • 21% of respondents reported that they had received mental healthcare in the last year
  • 27% said that they had not received mental healthcare or medications when they thought they might need it

The polling researchers did not define “family,” but this gives us a sense of the pervasiveness of the mental health crisis. One in six respondents reporting that someone in their family died by suicide might seem high, but suicide is in the top four causes of deaths for every age group from ages 10 to 44.

In related news, the U.S. Surgeon General just released a report on workplace mental health and wellbeing. The report, which includes five case studies of organizations that have succeeded in better addressing the mental health needs of their employees, focuses on protecting workers from harm, providing connection and community, work/life harmony, and giving workers a sense of purpose and opportunities for growth.

Implications for employers:

  • Mental health continues to pose a challenge, which has worsened since the beginning of the pandemic.
  • Employers should publicize the 988 crisis line for suicidal individuals.
  • My colleague Erin Young, LICSW, lists five approaches for employers to better address mental health issues:
    • Raise awareness
    • Focus on the workplace environment
    • Arrange a wellness event
    • Communicate
    • Address burnout

U.S. maternity care worsened in the pandemic, COVID-19 vaccination associated with better pregnancy outcomes

The Government Accountability Office (GAO) released two reports late last month about maternity care in the U.S. The first demonstrates worsening maternal mortality due to the pandemic. For the first time in recent years, more than 1,000 women died of pregnancy-related causes in 2021, and about a quarter of these were directly due to COVID-19. Black maternal mortality was the highest at 69 per 100,000 births in 2021, up from 44 per 100,000 births in 2019.

The second GAO report confirms that obstetric access in rural areas is getting worse. Half of rural counties don’t have a hospital with maternity services, and the problem is especially worse in rural areas with lower incomes and more minority residents. This confirms reporting from the March of Dimes earlier last month.

Meanwhile, JAMA Pediatrics published research last month that demonstrated that COVID-19 vaccination in pregnancy was associated with lower risk of neonatal intensive care unit admission and fetal death, and was not associated with any adverse pregnancy outcomes. About a third of pregnant women in the U.S. have not been fully vaccinated against COVID-19.

Implications for employers:

  • In the U.S., employers pay for just over half of all deliveries. They can encourage their health plans to provide adequate information on maternity services to their members and contractually require quality reporting by delivery services.
  • Employers can continue to encourage COVID-19 vaccination and boosting.

Population Health Leader, Health and Benefits, North America

Jeff is an internal medicine physician and has led WTW’s clinical response to COVID-19 and other health-related topics. He has served in leadership roles in provider organizations and a health plan and is an Assistant Professor at Harvard Chan School of Public Health.

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