Essential questions benefit leaders must ask about GLP-1 coverage

Obesity continues to be one of the most misunderstood and undertreated diseases in the United States. This, despite being the leading cause of serious comorbidities like type 2 diabetes, hypertension, some cancers, and obstructive sleep apnea — all drivers of significant healthcare spending. 

We continue to see advances in medical research and obesity treatments, yet, far too often, coverage decisions are swayed by long-standing misconceptions about obesity. Many of us were raised in a culture that blamed people for their weight struggles. We all saw commercials for fad diets, magazines fat-shaming celebrities, endless point counting and silly diet products like fat-free cookies. Diet culture has undeniably influenced all of us.

This has perpetuated a narrow understanding of — and bias towards — obesity, which many of us, including benefit leaders, still embrace whether consciously or unconsciously. I hear these biases regularly in my conversations with benefits leaders. Comments like, "Why can't people just eat less and move more?" or "Of course we cover GLP-1s for diabetes, but not for obesity" reflect a deep misunderstanding of the biological complexity of obesity. 

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Understanding challenges of obesity

While lifestyle changes such as diet and exercise are critical in managing weight, they are often not enough on their own for individuals with obesity. Obesity is more than a lack of willpower or moral failure. It involves a complex interplay of genetics, environmental influences, and physiological factors that make it difficult, if not impossible, for many individuals with obesity to maintain a healthy weight. By continuing to apply outdated, biased thinking, benefits leaders — or their executive leadership — fail to recognize the medical realities of the disease and perpetuate harmful stigmas that can hinder proper care.

One particularly glaring example of this bias is "stepped therapy," which requires patients to try lower-tier, less expensive treatments before gaining access to more effective medications like GLP-1s. If someone with diabetes had to prove for a month that they wouldn't eat a donut before being allowed access to insulin, it would be a major medical scandal. Yet, this is exactly what happens with obesity care. In lieu of a personal evaluation of health, one-size-fits-all models prioritize "cost savings" over science-based, individualized clinical care. The result is often poor health outcomes for patients, and ultimately, higher healthcare costs in the long run due to the need for more extensive medical care to treat comorbidities later.

In addition, the growing use of compounded weight loss medications and the push for deprescribing represent business-driven "solutions" that are not supported by medical evidence. Compounded medications, which are not FDA-approved, carry significant risks. Many companies that prescribe these knock-off medications also profit from selling these drugs, which creates a clear conflict of interest. Deprescribing is another trend that benefit leaders must examine critically. The evidence is clear — deprescribing at the population level is not an effective strategy. Most patients will regain the weight, so you're funding the most expensive round trip ever. 

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As benefit leaders, you are in a unique position to challenge the status quo and prioritize evidence-based care. If we truly want to provide clinical care for individuals living with obesity, it is essential to ask tough questions about how programs are designed, and whether they are based on medical evidence or other motives. It's possible to leverage evidence while achieving budget goals. As you evaluate potential partners for obesity care, here are a few critical questions to ask:

• How are you making prescribing decisions? Are treatment decisions based on an individual's condition severity and health status, or are arbitrary cutoffs and obstacle-course-like steps required?
• Do you make money on the prescriptions you write? Understanding whether a potential partner's incentives align with providing high-quality care or simply collecting profit from writing prescriptions is crucial. 
• When you say you provide physician-led care, what does that really mean? Is it possible for a patient to receive a prescription without a doctor visit? If so, what role do physicians play in the prescribing process? Do patients meet with a doctor throughout their treatment? Digging deeper will help you understand if the care is truly physician-led or if it is merely a facade.
• If the program is focused on deprescribing, is it because there is mass prescribing upfront? An overemphasis on deprescribing is a red flag. It suggests that a partner may be overprescribing medications in the first place to maximize profits. 

Read more:  The major factors that go into the decision to cover GLP-1s

By asking these questions, benefit leaders can begin to separate evidence-based solutions from those driven by desire to make a quick profit on GLP-1s. This will not only improve health outcomes for individuals with obesity, but also create a more sustainable, effective healthcare system for everyone.