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Monthly healthcare insights: bariatric surgery and glp-1 drugs, mammograms

By Jeff Levin-Scherz, MD, MBA | May 16, 2024

Our population health leader weighs in on bariatric surgery, GLP-1 drugs, mammograms, prostate cancer, and more.
Health and Benefits

Bariatric surgery is more cost-effective than GLP-1 drugs

GLP-1 drugs are highly effective, and on average people are able to lose about 15% of their body weight with weekly self-injections. The drugs, semaglutide (Ozempic and Wegovy) and tirzepatide (Mounjaro and Zepbound) are very expensive, with list prices of over $15,000 annually, and net employer prices of about $9,000 annually after rebates and discounts. Liraglutide, a daily anti-obesity drug, is somewhat less effective and just as expensive.

Bariatric surgery is also highly effective in lowering patients’ weight. The two surgeries now performed most often, gastric sleeve (sleeve gastroplasty) and bypass (Roux-en-Y) are well-tolerated and rarely require revisions. Patients commonly lose 15% or more of their body weight after these procedures. Laparoscopic band surgery is now rarely performed because of high failure rates.

In April, JAMA Network Open published a study that modeled the impact of endoscopic sleeve gastroplasty (bariatric surgery) and injected semaglutide (GLP-1) for a synthetic study group of those with a Body Mass Index (BMI) between 35 and 40. They evaluated the cost of each intervention, including cost of complications, and assessed how much cost was incurred to achieve each quality-adjusted life year (QALY) over a 5-year time horizon (with 3% discounting). They found that bariatric surgery was less costly and provided more QALYs than semaglutide. They calculated that semaglutide, which now costs about $9,000 a year after rebates and discounts, would have to be priced at $3,590 per year to achieve costs of $100,000 per QALY.

Implications for employers

  • Bariatric surgery, such as endoscopic sleeve gastroplasty is cost-effective, meaning that the plan spends under $100,000 per quality-adjusted life year saved.
  • GLP-1s are less cost-effective than bariatric surgery, and at current prices don’t meet most public policy cost-effectiveness thresholds.
  • Note that the substantial weight loss from either GLP-1s or bariatric surgery is likely to have higher amounts of cost savings and QALY generation beyond the five years modeled in this study, as many of the complications of obesity are expressed later.
  • These researchers didn't account for a decrease in other medications and office visits, so cost effectiveness might be somewhat higher than the authors have expressed.
  • Employers that don't provide coverage for GLP-1 medication for obesity can offer bariatric surgery as an option.

Review of GLP-1 side effects

GLP-1 drugs are very effective at treating obesity and are only approved for people with body mass index (BMIs) of over 30 (or 27 with metabolic diseases such as diabetes or hypertension) in conjunction with calorie restriction and increased exercise. The Food and Drug Administration (FDA) requires that GLP-1s prescribed for weight loss are used in conjunction with calorie restriction and increased exercise but doesn't require a prescription of a “behavioral modification program.”

This class of drugs has been used since 2005 for diabetes, so a large new category of adverse events is less likely to become evident. Here's a brief review of the side effects and concerns for this set of medications.

Well-established adverse effects

  • Gastrointestinal side effects. Most patients start at a low dose of semaglutide or tirzepatide, which is gradually increased over three to five months. They will often initially have nausea and constipation; these symptoms tend to get better over time.
  • Lean body mass weight (sarcopenia). Those who lose a substantial amount of weight generally lose a lot of lean muscle mass, too. This could be altered somewhat by regular weight-bearing exercise. People have also reported “Ozempic face” where wrinkles and lines appear with weight loss. Again, this is similar to what to expect with large amounts of weight loss.
  • Gallbladder attacks. Substantial weight loss is associated with gallbladder attacks, where the gallbladder goes into spasm or a gallstone gets stuck in the bile duct. Gallbladder attacks are often painful and can require surgical intervention. This is also a well-known complication of bariatric surgery.
  • Slow transit of food through the stomach. This is part of how these drugs work to decrease appetite; an empty stomach leads to the release of gut hormones that influence hunger in the brain. Sometimes this is severe enough that the stomach is paralyzed, and in rare cases people need to have a nasogastric tube to drain the stomach and must stop the GLP-1 medication.

Uncommon potential adverse effects

  • Thyroid cancer. Early mice studies suggested that thyroid cancers may be higher with the use of GLP-1s. As a result, the drugs have a boxed warning about the risk of these cancers. Since then, human studies have been mixed. A French study found a 1.8 times higher rate of medullary thyroid cancers and a 1.6 times higher rate of all thyroid cancers. A large Scandinavian cohort study didn’t find any increased risk of thyroid cancers in GLP-1 users. Medullary thyroid cancers are quite rare, so even a statistically significant increase in the rate of such cancers will mean relatively few such cancers.
  • Increased fertility. There are reports of unexpected pregnancies in those on GLP-1 drugs. These drugs delay absorption of oral contraceptives, and losing weight increases fertility. Some physicians are prescribing these drugs off-label to treat polycystic ovary syndrome (PCOS), which is often associated with obesity, high blood pressure and infertility. These drugs aren’t recommended during pregnancy, so women considering pregnancy should use effective contraception while taking them. GLP-1 drugs aren’t likely to impact the effectiveness of long-acting contraception such as intrauterine devices (IUDs) or progesterone implants.
Side effects that are reported but not likely to be related to GLP-1 medications
  • Suicidality. An FDA report in 2023 suggested there might be an association between GLP-1 medications and suicidality, and Iceland recently reported three cases of suicidal ideation to the European Medicines Agency. However, a huge observational study, with 53,000 patients on Wegovy and 53,000 patients on non-GLP-1 anti-obesity medications, showed only a quarter as much suicidal ideation in those on GLP-1 medications. There were 14 suicide attempts in the non-GLP-1 group, and none in the Wegovy group. In January, the FDA said that its preliminary evaluation didn’t suggest a causal link between these drugs and suicidality.

Implications for employers

  • GLP-1s have a host of known side effects (GI upset) and more serious gastrointestinal issues or concerns for cancer and altered fertility. Despite those risks, GLP-1s have a long safety record for the last 20+ years. Safety concerns, by themselves, should not stop an employer from covering these medications.
  • Adherence to this class of drugs is important to avoid weight regain; benefit designs and formular decisions should minimize member disruption that can adversely affect adherence.
  • There are some patients who cannot or don’t want to take GLP-1s. Employers should review their pharmacy benefits to be sure they are also covering alternatives to this class of drug.
  • Members should be fully aware of all the potential side effects of these medications, but these side effects aren’t likely to dissuade people who seek to lose weight and have unsuccessfully tried many other interventions.

Factors associated with women not getting mammography

Mammograms save lives, but about a quarter of women don’t get mammograms every other year as recommended by the U.S. preventive services task force. The Center for Disease Control and Prevention (CDC) reviewed results of the Behavioral Risk Factor Surveillance System survey, completed by about 117,000 women during 2022, and published information recently about the factors associated with getting mammography.

The researchers found that obtaining the recommended breast cancer screening is strongly associated with higher income, higher educational level, metropolitan area residence, having health insurance and having a physician. Those with more social risk factors were less likely to get mammograms. Black women have higher rates of mammography than women of other races.

Financial strain predicted lower mammography rates. High-risk women and individuals with dense breasts may require magnetic resonance imaging (MRIs) or ultrasounds that require patient cost-share.

Implications for employers

  • Employers can tailor their communication programs to those at highest risk of missing mammography.
  • Employers can remind all women that mammography screening generally doesn't incur out of pocket costs.
  • Employers can offer on-site screenings to decrease barriers to mammography.

Prostate cancer screening intervention decreased mortality by a tiny amount

Prostate cancer screening has been controversial for well over a decade; a new study published recently in JAMA adds to the controversy. Researchers in the United Kingdom report on a 15-year follow-up of over 200,000 patients who were randomized to receive a single written recommendation to get a prostate specific antigen (PSA) screening test, compared to over 200,000 patients who received no such note. Randomization was done by clusters of treating physicians.

Forty percent of those who got the letter received a PSA test, while an estimated 10-15% of those in the control group got this screening test. This intervention led to more diagnoses of prostate cancer.

Mortality declined, but not much. Prostate cancer mortality rate in the group which received a screening recommendation was 0.69% (69 in 1,000) in the intervention group, and 0.78 (78 in 1000) in the control group.

While deaths from prostate cancer were statistically significantly lower, all-cause deaths weren't statistically significant between those who got the screening letter and those who didn't.

The strength of this trial is its large size and randomized design. This lowers the risk of selection bias, where the screened group is systematically different from the unscreened group. This research was performed in the U.K. using medical records from the National Health Service, and there were few Black men in the study. So, the findings might not be applicable to a more diverse population. Since the study began in 2000, more diagnostic tests (including MRI scans) and better cancer therapy have become available. This study wasn't a test of PSA screening effectiveness, but of whether the screening performed after a reminder saved lives. It did save lives, though not many.

The U.S. Preventive Services Task Force (USPSTF) doesn't recommend routine PSA screening for prostate cancer in men 55 to 69 unless they specify a preference to have such screening. Black men and those with family history are at higher risk of aggressive prostate cancer and would benefit more from screening. It's possible that new approaches to prostate cancer screening, including MRI tests before prostate biopsies, will allow for early detection with fewer false positives. This could lead the USPSTF to start recommending screening in the future.

Implications for employers

  • This research demonstrates that there is a mortality benefit to encouraging prostate cancer screening, but this advantage is very small.
  • Employers can choose to cover PSA screening without cost sharing, although this isn't required by the Affordable Care Act since the USPSTF does not recommend such screening. Companies can check with their counsel, but in general such coverage wouldn't threaten the tax-advantaged status of Health Savings Accounts associated with high-deductible health plans.
  • This small decrease in death from prostate cancer isn't compelling enough to support employers offering incentives for men to have prostate cancer screening or running programs to encourage this screening. Some men will make an informed choice not to get screened after discussing with their provider.

Body scans not proven to increase longevity

There's a growing “longevity” movement, and many have proposed that increased screening can find disease early when we can better intervene. Some have suggested that full-body scans could both save lives and decrease health care costs. However, such screening can unearth abnormalities that don’t matter, and encourage a “cascade” of tests where those in good health take serious health risks to assess an issue unlikely to pose a threat.

Whole-body computed tomography scans (CT), which use a computer and radiation to construct a three-dimensional image of the body, have been used for such screening for a few decades, although they have fallen out of favor in recent years. One problem was that these tests had high false-positive rates, so that many people were asked to have follow-up ultrasounds, CT scans or other tests based on initial findings. Another problem is that CT scans use radiation, and each scan exposes a patient to about three times the annual amount of background radiation. Whole-body CT scans can be useful for patients with symptoms or known disease but aren't recommended for healthy people with no symptoms. They aren't considered “medically necessary” and are therefore not generally covered by employer-sponsored health insurance plans. Here's a link to the FDAs guidance on full-body CT scans.

Whole-body MRI scans have been used more recently to screen healthy people. These involve no radiation exposure, but about a third (32%) of these scans find some sort of abnormality. Positivity rates are higher if the heart or the colon are included. One study of volunteers in Germany showed that those who had screening MRIs had 18% higher total medical costs over two years of observation. Moreover, there's no solid evidence that these scans increase the chance of living longer. These aren't considered medically necessary and are also generally not covered by an employer-sponsored health plan.

The New York Times weighed in recently with a report by a business journalist who flew to Stockholm, Sweden to get a whole-body scan from a company founded by Daniel Ek, the founder of Spotify. These scans were neither a CT nor an MRI, but rather a combination of photographs and pressure scans of various parts of the body, for instance, checking blood pressure, blood vessel stiffness and even pressure inside the eye. The scans are targeted to be lower-cost than CT or MRI scanning and used in conjunction with screening blood tests. There's no published data to demonstrate that this type of scanning will find earlier, more treatable disease or save lives.

The founders asserted that their product could lower the cost of health care by emphasizing early diagnosis, but in fact, there's no evidence-based early cancer diagnosis available now that lowers medical costs even over a longtime horizon. Health care policy experts generally hope that “cost effective” intervention costs less than $100,000 for a “quality adjusted life year.” Advances in health care can bring us longer or better lives, but they generally don’t come with a rebate.

Implications for employers

  • Be aware that new screening tests are highly unlikely to lower health care costs because many individuals must be screened and undergo follow up tests for each person who's diagnosed with earlier disease.
  • Not every case of earlier diagnosis leads to longer or better lives. Finding cancer earlier can lead to an improved five-year survival rate even if earlier diagnosis doesn't delay a person’s death.
  • Most carriers have well-developed technology assessment programs, and employers can look to their carriers to help them to determine whether they should cover such procedures.
  • Executive physicals don't require medical necessity, and even those exams rarely include full-body scans.

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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