When Is Obesity Care Worth It?

At what cost can we decide that obesity care is worth the money? Until now, the answer has largely been to refuse considering this question. But as the cost of untreated obesity adds up, it’s becoming impossible to dodge the question anymore and an increasing number of serious analyses are underway.

The Institute for Clinical and Economic Review (ICER) published a draft analysis for public comment last month. On top of that come two new analyses that begin the task of sorting out questions about value for money in obesity care – specifically, the worth of obesity medicines.

Cutting the Cost and Severity of Obesity

The first of these two new studies looks at the costs associated with obesity and asks if those costs go down when obesity medicines come into play. Tim Garvey at the University of Alabama at Birmingham worked with health economists from Novo Nordisk on this analysis.

They used data from a retrospective cohort of medical claims records for 219,971 patients with obesity. Of those patients, 1,405 patients received an anti-obesity medicine. A difference in differences method provided estimates of changes in total healthcare costs, including medicines for indications other than obesity, over two years of follow up.

They found that costs rose in the first year for both groups. But by the second year, costs for the patients receiving anti-obesity medicines stabilized and started going down. Costs for the other patients continued rising. Patients receiving those medicines were more likely to move into a class of less severe obesity.

Is It Worth It?

This broad question of value may well be impossible to answer in a unqualified way. The simple reason is that obesity is heterogeneous and the response to therapy is extremely variable. With earlier medicines (and really just about any treatment) the response can range from nil to life-changing. So the value is different for different people in different circumstances.

But health economists want a blanket assessment – and that’s what we have from ICER in its draft analysis. In this, its first public draft, the conclusion was that only phentermine/topiramate (Qsymia) is cost effective – not the much more effective (and expensive) semaglutide (Wegovy).

In the newest analysis of semaglutide, Sean Sullivan at the University of Washington worked with health economists from Novo Nordisk and reached a more favorable conclusion about Wegovy. They found that it cleared a threshold of $150,000 per QALY over a 30-year time horizon for cost effectiveness.

If you are scratching your head and asking what’s a QALY, you’re not alone. It’s a value that health economists use to compare very different treatment by a common measure. The acronym stands for quality adjusted life years and it’s intended to tell us how much does it cost for a treatment to provide one year of a good quality of life. Thresholds, such as $150,000, provide a very crude benchmark for cost effectiveness and thus, some people argue that they QALYs should not be used for this purpose.

More to Come

You can be sure that these arguments will heat up for obesity care – and it’s a good thing, too. It means that payers are on the cusp of moving away from the stupid proposition that they won’t pay for any obesity medicines. So now we can move on to dickering about the price.

Click here and here for the two new analyses in the Journal of Managed Care + Specialty Pharmacy.

Portrait of Luca Pacioli from Five Hundred Years of Bookkeeping, painting attributed to Jacopo de’ Barbari / Wikimedia Commons

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August 2, 2022