Relaxation of restrictions on bariatric surgery based on GLP-1 costs

Amid growing concerns about the potential long-term costs of using glucagon-like peptide 1 (GLP-1) agonists to treat obesity, some insurance companies are facilitating access to bariatric surgery.

Although there may not be a complete causal relationship, data suggests At least for now, newer obesity drugs like semaglutide (Wegovy) and tirzepatide (Zepbound) are not cost-effective, but surgery is.

According to GoodRx, the list price for Wegovy (semaglutide) is approximately $1,350 for a 28-day supply. Additionally, the American Society of Metabolic and Bariatric Surgery (ASMBS) stated that the average cost of bariatric surgery ranges from $17,000 to $26,000. However, ASMBS estimates that third-party payers will recoup these costs within two to four years by reducing or eliminating obesity-related conditions and associated treatment costs, reducing healthcare costs by approximately 29% over five years. he added.

For example, Geisinger Health in Pennsylvania and Blue Cross/Blue Shield of Massachusetts recently expanded body mass index (BMI) eligibility for bariatric surgery. Blue Cross Blue Shield of Michigan Eliminated prior authorization requirements for some services, including bariatric surgery.

In most cases, Major health insurance company Applying Wegovy to obesity treatment typically requires prior approval and testing of other treatments first. recently, some employers Denied insurance coverage for obesity treatment drugs. Medicare does not cover these drugs. Coverage varies by state Medicaid plan.

“For years, insurance companies… have been toying with surgeries and letting people jump through the hoops in hopes of giving up and walking away. And now health plans are starting to worry about that. [the cost of] Obesity drugs are getting a lot of attention, so people are thinking, oh, maybe we shouldn't be playing these games anymore,” said Obesity Policy Expert and Founder of Consien Health. said Ted Kyle, RPh. Medscape Medical News.

However, said Dr. Christopher Dube-Still, director of nutrition and weight management at Geisinger Medical Center in Danville, Pennsylvania: Medscape Medical News In May 2023, the Geisinger Health Plan will change and the eligibility criteria for BMI surgery will be lowered from 35 kg/m.² ～30kg/m² Costs for people with comorbidities were unrelated to costs for GLP-1 drugs.

“To this day, bariatric surgery remains the most effective and durable treatment for obesity and, most importantly, its coexisting medical problems. So that was the real reasoning. Weight loss It's secondary to the deep medical benefits of the surgery. I think that was the driving force behind that change, even though it didn't really have anything to do with GLP-1 at the time.” said Still.

The Geisinger Health Plan does not currently cover anti-obesity drugs, but the state's Medicaid plan, the Geisinger Health Plan Family, does, although Pennsylvania does not cover drugs through Medicaid. This is because it is one of the few states that does so.

the equation keeps changing

said Dr. James Chambers, a health economist at Tufts University in Boston, Massachusetts. Medscape Medical News“When we think about the value of a treatment, we don't look at it in isolation; we look at the difference between cost and benefit. So just because these expensive drugs are now available, we don't think surgery is cheaper. ' , but that would change the interpretation of cost. When diet, exercise and counseling were the only real options, surgery seemed like a much more expensive intervention. But With the advent of GLP-1, perhaps the plan is to consider the cost of the surgery a little differently. ”

And that equation is likely to change further, Still said.

“I think we're dealing with short-term financial issues because there are basically only two major treatments and prices are high. But as more treatments come to market, prices will come down. '' he said.

Christy Gallagher, MPAff, research project director for the STOP Obesity Alliance at the George Washington University Milken Institute School of Public Health in Washington, DC, agreed.

“We have a lot of data on obesity treatment applications from before 2023. [GLP-1] The explosion happened in 2023…Healthcare payers are exploring coverage and trying to understand what this will look like for them,” Gallagher said.

However, she says, “There is no one-size-fits-all treatment. GLP-1 does not work for everyone because of the different stages of obesity, side effects, and coverage. I think I guess,” he pointed out. We will never see a decline in bariatric surgery in the short term. ”

Gallagher also said that while current data suggests people will have to continue taking the drug for the rest of their lives, there may be other approaches in the future.

“Once a person reaches their target weight, perhaps they can move on to a different pill form that is cheaper. maintenance medicine. I think that's largely unknown at this point,” she said.

And Kyle says that while bariatric surgery does offer the most lasting benefits, “it's true that you do gain weight back after surgery. People are still healthy five years later, but they do gain some weight back.” And in such cases, it would be better to: Follow-up with medicine… Just like surgical treatment for cancer, it is not necessarily an either/or; surgical oncology is an either-or option to medical oncology. ”

A new way of looking at obesity

According to Kyle, this attention to new drugs is “prompting people to rethink and think about obesity differently, to think more carefully about it as a chronic medical condition rather than a physical or behavioral condition. , it's all good whether you're obese or not.'' Because when you think about it in terms of bariatric surgery or in terms of treating obesity, people start to consider their options more rationally. ”

This change in the way obesity is viewed means bariatric surgeons and bariatric medicine specialists are starting to collaborate more, he said.

“I feel like there is a trend toward a more integrative approach to obesity,” Kyle said.

He added: “We now have a lot more tools, and as a matter of fact, we're in the middle of the tricky part of figuring out how to use them.”

And when it comes to insurance coverage, “People make mistakes. They make mistakes. But I'm an eternal optimist and I believe people understand that too. From this It will be difficult to do anything bad.”

So far, efforts to increase bariatric surgery rates in the GLP-1 era have not yet had an impact, said Marina S. Kurian, MD, president of the American Society of Metabolic and Bariatric Surgery. Medscape Medical News In a statement.

“Although we have heard that some insurance companies may change bariatric surgery requirements, we are not seeing a significant increase in procedures related to changes in coverage for anti-obesity drugs or metabolic/bariatric surgery. ” said Kurian.

Kyle has received speaking fees or professional fees from Novo Nordisk, Behringer Ingelheim, Nutrisystem, Roman Health, and Emerald Lake Safety. Mr. Still was in the speaker's bureau and was responsible for clinical trials for Eli Lilly and Novo Nordisk. Chambers and Gallagher had nothing to disclose.

Miriam E. Tucker is a freelance journalist based in the Washington, DC area. She is a regular contributor to her Medscape Medical News, as well as to the Washington Post, NPR's Shots blog, and Diatribe. She belongs to her X: @MiriamETucker.