Can Obesity Treatment Be Cost Effective?
by Rhonda Greenapple
Obesity management continues to be a major challenge to health plans as the prevalence continues to rise. The relationship of BMI and serious co-morbid conditions such as Type 2 diabetes, Hypertension, Hyperlipidemia and Obstructive Sleep Apnea, has been well documented. But although the cost of these patients is high, few payers are able to identify or track patients by BMI.
Current prescription options are seen as highly ineffective and had serious safety issues. There is still an unmet need for safe, effective treatment options for obese patients.
Reimbursement Intelligence conducted an Obesity Survey with both payers and physicians who treat over 400 obese/morbidly obese patients per month to get their feedback about treatment options including diet, prescription medication and bariatric surgery. In addition to current treatment options, we asked them to look at four new obesity products in the pipeline: Contrave, Locarserin, Qnexa and Empatic.
Payers do not perceive current therapy as effective. A history of safety and side effect issues results in less than 20 percent of employer plans covering these drugs; but even when covered, the patient faces high co-payments and utilization restrictions.
From a physician's perspective, reimbursement was rated as high as efficacy and safety as a factor in not prescribing. Physicians were willing to accept a threshold of 5 percent weight loss to accept a new therapy demonstrating the unmet need for an effective treatment option.
Payers stated a threshold of 18 percent of weight loss from placebo would influence formulary coverage and reimbursement. After reviewing the four products detailed above with weight loss averaging 8 percnet, 53 to 65 percent of plans were very unlikely to provide formulary coverage.
Twenty-three to 35 percentof surveyed physicians said they are very likely to prescribe Contrave, Empatic or Qnexa for obesity. Only 13 percent of physicians are very likely to prescribe lorcaserin.
Nearly 85 percent of payers believe Bariatric Surgery is a more effective treatment option than current prescriptions medication. Over 83 percent of plans are currently covering bariatric surgery and expect utilization to increase over the next few years. Although they have a lengthy pre-certification process, payers believe that bariatric surgery can reduce BMI and related health conditions. A recent study demonstrated that both gastric banding and gastric bypass surgery resulted not only in weight loss but reduction in lifetime medical costs.
It is unlikely that there will be a pill that "cures" obesity. There are lifestyle, medical and psychological factors that can contribute to obesity. As new therapies come onto the market, payers need to reconsider their current position as multiple treatment options are needed for members.