Policy Changes for Supporting Obesity Management

As we begin the transition between administrations, we find ourselves in a sort of limbo, not unlike the shoulder season in a mountain town.  It’s time to brace ourselves for the uncertainty ahead. A prime example of this uncertainty emerged last week when the Biden administration proposed extending Medicare and Medicaid coverage to weight loss medications like Wegovy and Zepbound. If finalized, this decision would significantly expand access to GLP-1s for millions of Americans and clearly, effectively recognize obesity as a condition requiring medical treatment.  This move could have far-reaching implications for commercial health insurance plans. The proposal’s impact Under the new policy, an estimated 3.4 million Medicare beneficiaries and 4 million Medicaid enrollees would become eligible for obesity medications, at an estimated federal cost of $36 billion over 10 years. With bipartisan support and public interest growing—61% of Americans support Medicare coverage for obesity drugs—this policy could mark a turning point in how obesity is treated in the U.S. The evidence is clear that GLP-1s improve overall health, not just by aiding weight loss but by reducing the severity of obesity-related conditions, but critics are right to be concerned about high costs. A new reality for commercial plans If Medicare and Medicaid expand their coverage, commercial health plans will face heightened pressure to follow suit. It’s soon becoming table stakes to stay competitive in attracting and retaining members. Commercial plans still on the fence about covering obesity care may want to consider the following: Comprehensive Care Models: Just as CMS highlights the importance of using GLP-1s alongside broader obesity management strategies, commercial plans can partner with a solution like Vida that integrates nutrition counseling, mental health, and preventive care to maximize outcomes and mitigate costs. Workforce Implications: Employers are increasingly focused on workforce safety, retention, and productivity. Providing coverage for obesity care could be a way to meet those goals. Expanding Indications: These medications aren’t going away. In fact, the FDA may soon approve them for sleep apnea, kidney disease, fatty liver, and more. It’s better to get a strategy in place now for effective wraparound care and cost management. A catalyst for change For commercial health plans, the expansion of government coverage could be a catalyst for change. As one CMS leader noted, “The more friction there is in the system…the harder it is for people to get the care they need.” Removing those barriers may be the key to ensuring equitable care across all populations. I’m curious: how is your organization responding to the rising demand for GLP-1s?

The USPSTF could force private insurers (including MAPDs) to cover GLP-1s for prevention of disease. --- CMS decided not to move forward with a Biden administration proposed rule to cover #obesity drugs like #GLP1s. However, the United States Preventive Services Task Force (USPSTF) is developing a draft recommendation statement (story in the comments) on whether #WeightLoss interventions like Wegovy (semaglutide) and Zepbound (tirzepatide) affect health outcomes such as cardiovascular disease. --- The USPSTF uses a systematic and evidence-based process to assign ratings to preventive healthcare services like screenings and chronic disease management medications. These ratings have significant clinical and policy implications. The Affordable Care Act requires most health plans to cover preventive services that receive an “A” or “B” grade from USPSTF without cost-sharing or deductibles. If the task force gives the GLP-1s a grade “A” or “B”, it could mean the drugs must be covered for the approved indication by private insurers, including #MedicareAdvantage plans (but not standalone #PartD plans). Yes--they must cover them for $0 to the member. And with limited ability for utilization management with prior authorizations or step therapy. --- The results of this kind of coverage are pretty easy for most of us to imagine. -Dramatic increase in utilization/demand -Payers redesign formularies and budgets -Major shifting from PDPs to MAPDs for members that qualify -Lobbying from payers -More GLP-1s pursuing similar preventive outcomes This would be a major shift in access compared to current coverage. Are you in favor of a change like this?