Someone I work with has had difficulty losing weight. Thus, about a year ago, she was grateful and delighted to find herself losing weight easily on a drug usually prescribed for Type II diabetes. “I lost 30 pounds in about three months,” she told me, “and if this continues, I should be able to get down to a normal weight. It is the only thing that has worked for me for years.”
The drug semaglutide was approved for weight management by the FDA in June 2021 when obese patients on the drug to control their diabetes found themselves losing weight. It is unclear exactly how this drug works to control appetite, but apparently, it slows the emptying stomach, thus leaving the dieter feeling full for longer periods of time.
Weight loss among those treated with this drug was considerably greater than found with earlier anti-obesity drugs. Patients lost, on average, about 15 percent of their initial weight; some as much as 20 percent. Previous drugs were unable to produce a weight loss, on average, of 5-10 percent initial body weight.
And my associate’s weight loss was yet another example of the success of this medication. She hoped to continue on the drug until she reached her goal, but a few months ago this possibility was snatched away from her. Her doctor told her that her insurance would no longer cover the cost of the drug despite that continued weight loss would have decreased the risk of her developing a myriad of obesity-linked disorders.
Hers was not a unique situation. According to a recent New York Times article, it is very difficult for obese patients to have the cost of a weight reduction drug covered by their insurance. Moreover, Medicare will not cover the cost of weight-loss drugs despite years of lobbying by patient advocacy groups. Contrast this absence of coverage with the willingness of insurers to pay for Bariatric surgery to reduce the size of the stomach.
But is the reluctance to pay for this medication based perhaps on its excessive monthly cost when prescribed for weight loss when the same drug, prescribed for type 2 diabetes costs much less? According to the article in the New York Times, the drug company, Novo Nordisk, sells the same drug for obesity and diabetes. But if the drug is prescribed for obesity, as it was for my associate, it costs 51 percent more than if it were prescribed for diabetes.
Indeed what could be a reason for altering the price of the same drug even if it is used for two different objectives? But there apparently is a work-around to this disparity in price, and the refusal of insurers to pay for the drug. When my associate was found, after a routine blood test, to have elevated blood glucose, her physician was now able to prescribe the drug for type 2 diabetes and her health insurance would pay for it.
“It’s crazy,” she said to me. “Should I hope my blood sugar stays high so I can continue to get the medication? If it returns to normal, which of course is better for my health, I will no longer be able to get the drug prescribed for diabetes. And I cannot afford to pay for the drug if it is prescribed for obesity. The insurance company would prefer me to be diabetic than thin.”
One ongoing problem with supporting weight loss interventions through health insurance and Medicare is the sense of utility on the part of health providers. The probability of regaining weight after the cessation of a weight loss regimen is very high and used as an excuse or justification for not paying for yet another weight loss intervention. This attitude is based on the assumption that once ‘cured’, weight gain should and must, never happen again. If the patient reaches a weight loss goal on a liquid diet, commercially available packaged meals, a strenuous boot camp exercise program, or surgery, the weight loss should be permanent.
But of course, obesity, like many other metabolic and behavioral diseases, is probably a chronic disorder for many people. Imagine telling someone with depression who goes out of remission that anti-depressants will no longer be covered by insurance or Medicare because the patient should not have become depressed again. We don’t withhold treatment for alcoholism or smoking withdrawal because the individual started drinking or smoking again after a period of abstinence. No health club would deny membership to someone who stopped exercising after reaching a level of fitness.
Moreover, what is the justification for increasing the cost of a drug for obesity when the same drug costs much less when used to treat diabetes? It is as if some antidepressants used to help treat pain conditions cost less than when prescribed for depression because the patient should not have allowed himself to become depressed again.
No drug for obesity can treat the complexity of this disorder with its behavioral and metabolic components. Emotional triggers for overeating, cravings caused by antidepressants, the absence of physical activity, disturbed sleep, and lack of time to plan and consume healthy meals cannot be resolved by a daily pill or injection. But weight loss itself will help the patient ease into exercise, sleep more soundly, and thus reduce exhaustion, motivate planning meals that nourish, and seek help to understand what causes emotional overeating.
The weight loss may and indeed probably will not be permanent. But if and or when it recurs, one hopes that help in losing weight once again will not be withheld.