A Tale of Two New Drugs and Health Insurance

This is seriously messed up. Let’s consider the case of two innovative new drugs and how health insurance will cover them. Each of them treats a chronic disease that can devastate a person’s health and quality of life. But these are different diseases and very different drugs.

One offers a breakthrough in effectiveness. In fact, doctors are calling it a “game-changer.” It will cost about $1,300 per month.

The other has effectiveness that is debatable. Does it work? The ongoing debate is fierce. But it is the first new drug in decades for treating the disease it targets, so FDA approved it despite “residual uncertainties regarding clinical benefit.” The price for this one is $4,700 per month.

Which one is health insurance more likely to cover? You guessed it – the higher priced drug with an uncertain clinical benefit.

Uncertain Coverage for Wegovy (Semaglutide)

The game-changer is Wegvoy – a form of semaglutide developed for treating obesity. The effectiveness is dramatically better than we have seen for other anti-obesity drugs. In fact, it works roughly twice as well as the most successful drug for obesity that came before it – Saxenda (liraglutide). That means that about a third of people who take Wegovy will get results of 20 percent weight loss or more. That’s an effect that comes closer to the effect that one might see with bariatric surgery.

To be clear, bariatric surgery remains the most effective treatment for most people with significant obesity. But Wegovy takes us closer to having drugs that will work as well.

However, insurance coverage for Wegovy remains quite uncertain. Yuki Noguchi describes the situation for NPR:

“Insurance coverage, it turns out, is a giant question — not just with Wegovy but with obesity drugs in general. Some private insurers do include some prescription obesity drugs in the list of medicines they’ll cover; it’s too early to tell whether Wegovy will make those lists. Many doctors and patients are optimistic, because it is a higher dose of an existing diabetes medication called Ozempic, which insurers often cover.”

Better Coverage for an Alzheimer’s Drug with Uncertain Benefit

The drug with debatable effectiveness is Aduhelm (aducanumab), for Alzheimer’s disease. FDA approved it because they listened to people living with Alzheimer’s, their families, and their caregivers. Those people told FDA they wanted access to an option that might help – and they were willing to accept a degree of uncertainty.

But because it’s Alzheimer’s and not obesity, healthcare experts expect “broad coverage” for this drug by health insurers. Medicare will likely cover it, too. Yes, they will hem and haw. They will try to negotiate discounts. But in the end, most of them will cover it for most patients who need it.

Seriously Messed Up

There’s no two ways about it. This is wrong. Both of these diseases are serious and both require better treatment. Health insurance is dodging responsibility for covering obesity care because they can.

Both Alzheimer’s and obesity come with a burden of stigma. But the stigma attached to obesity is different because it involves blaming the person who is suffering. And it’s that false assignment of blame that gives insurers a lame excuse for not living up to their responsibility for the health of the people they insure.

This is wrong.

Click here for more on coverage for Wegovy and here for more on Aduhelm coverage.

Village Street and Steps in Auvers with Two Figures, painting by Vincent van Gogh / WikiArt

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July 8, 2021