Justin Bronder thought he knew exactly what he needed.
Bronder, 57, of San Jose, Calif., had struggled with his weight for most of his adult life. His work in artificial intelligence took him all over the world, but the long hours and constant travel led to constant weight gain. At his heaviest — 265 pounds — his BMI fell squarely into the obese Category. His blood work began to reflect this with higher blood pressure and blood sugar.
He had tried many diets, including keto and intermittent fasting, but even when he managed to lose weight, he took it all back.
Then, about 5 months ago, Bronder discovered research on a weight loss drug called semaglutide (Wegovy). The drug mimics a natural hormone called GLP-1 that reduces cravings, increases satiety, and slows digestion so you feel full longer.
Clinical tests on Wegovy, including a double-blind, placebo-controlled study (the scientific gold standard) shows an average weight loss of 15%. That’s quite an effect, considering scientists have long known that losing just 5-10% weight can stop or slow the onset of diabetes and help improve blood pressure, cholesterol, and blood sugar.
Bronder seemed like a perfect candidate for the drug. And his doctor agreed.
But there was a problem. Many insurance companies refused to cover the drug. Some insurers call it a “lifestyle” or “vanity” drug – a curious way of referring to a drug that treats a condition (obesity) that is a risk factor for diabetes, heart disease, obesity. hypertension, arthritis, dementia and depression. , among other conditions.
Bronder is a good example. It was prediabetic, according to his doctor, a problem almost certainly caused or made worse by his weight. In fact, it was this condition that qualified him for a drug (Ozempic) identical to Wegovy, but at a lower dose (1 milligram versus 2.4 milligrams for Wegovy).
Ironically, the very drug that might have helped prevent his prediabetes probably wouldn’t have been covered until he actually developed the disease.
Bronder knew he was one of the lucky ones. Message boards and social media chat groups were filled with stories of frustration, many of which ended in denial of coverage. And without insurance coverage, a cost of $1,000 to $1,600 per month puts these drugs out of reach for the vast majority of Americans.
“It seemed inconsistent. Some people were able to get it covered by their insurance, some weren’t. Or they covered it, then their insurance declined it later,” he says.
“I think that’s terribly unfair because your health shouldn’t depend on whether you’re rich or poor,” he says.
Efficiency seems irrelevant
“It was extremely frustrating because [Wegovy] is the most effective obesity drug we’ve ever seen and many insurers don’t cover it at all,” says Katherine H. Saunders, MD, assistant professor of clinical medicine at Weill Cornell Medicine in New York.
“We try to treat as many patients as possible, but we’ve been really limited by insurance coverage,” she says.
But Wegovy isn’t the first effective drug insurance companies have refused to cover, and it’s unlikely to be the last, says Geoffrey Joyce, PhD, director of health policy at the Schaeffer Center for Health Policy. and Economics from the University of Southern California.
“We could have eradicated hepatitis C with the drugs Sovaldi“says Joyce. “But who could afford the initial price of $84,000 for the treatment?”
The problem with Sovaldi wasn’t so much the cost of the drug as the size of the market, says Joyce. About 5 million people with hepatitis C could have benefited from Sovaldi. Insurers were hesitant to take it all on at once, Joyce says.
“We have a lot of expensive drugs for things like cancer and MS that are covered because the patient population is not that big, so insurers can absorb the cost of premiums, but when the market is that huge, it’s too much for everyone. insurer to swallow.
The possible market for Wegovy is closer to 100 million – maybe more.
However, why not cover it? Wouldn’t it be easier – and cheaper – to treat obesity? before does it lead to more serious diseases such as diabetes, heart disease and high blood pressure?
Maybe, Joyce said. But insurance companies are in a difficult position. In the short term, it may be impossible to suddenly cover a market of 100 million people or more without going bankrupt. So insurers kick in, even when long-term expenses may be higher, Joyce says.
signs of hope
Wegovy is a relatively new drug, approved by the FDA in June 2021. Good news about its effectiveness continues to filter down to healthcare providers and insurance companies. As it does, insurers might start to loosen the reins, Joyce says.
At first, insurers can restrict access only to patients who have a very high BMI or who have tried other medications without success. And some restrictions will likely continue — like with Sovaldi (the hepatitis C drug) — until competition drives prices down and generic drugs are allowed on the market, Joyce says. (Effective patent is about 8-12 years on most brand name drugs).
But if the drug really works, it will usually make its way to the mainstream, he says. If you can’t get coverage at first, keep asking questions. In many cases, there are non-profit organizations that will help people in need pay for their medications. Or there may be a similar drug that your insurer will cover instead.
As for Bronder, he lost 52 pounds on Ozempic and he can’t believe how good he feels eating simple, low carb meals with one protein and one vegetable. He likes to look slimmer, but his recent blood tests show that the drug is much more than just physical appearance. His cholesterol, blood pressure and blood sugar returned to normal.