Botox, Knee Replacements, and Obesity Meds

Health insurers, including Medicare, are regarding obesity meds like Botox Cosmetic, when they should be thinking of them more like a knee replacement. This observation, from a report by Jamy Lee in MarketWatch, sums up the challenge for people seeking obesity care in a health system that pays for the complications of untreated obesity, but not for treating obesity itself.

But the situation is changing, albeit gradually. ConscienHealth’s Ted Kyle told Lee:

“This momentum comes from people having a better understanding of what we’re dealing with. Ten years ago, policymakers would come out and say, ‘Fat people need to eat less and move more.’”

Today, medical experts know that obesity is a complex, chronic disease that doesn’t just disappear when someone changes their diet or joins a gym. Diet and exercise can help a person cope, but to really bring the condition under control, surgery and meds are often necessary.

Health systems are slow to catch up with this new reality.

Rethinking Already in Progress

Financial Analyst  David Risinger sees a rethinking of coverage for obesity care coming. He told Lee:

“Historically, payers viewed obesity drugs like they did Botox for wrinkles. They viewed it as something that was a cosmetic drug that should not be covered by insurance. There needs to be a rethinking of coverage when there are drugs that offer transformational health benefits for a disease, even if it’s common.”

This is what Federal Employee Health Benefit plans are doing. A spokesman for the Office of Personnel Management told Lee that the office is pressing for better coverage of obesity care because:

“The bottom line is that we follow the science and, in this instance, the science is telling us that we should recommend uptake of anti-obesity drugs more strongly than we did previously.”

Magnifying Disparities

Right now, the uneven coverage for obesity meds is serving to magnify health disparities. High economic status buys a person access to effective obesity care and obesity meds. Low status leaves people with little or no access. Without insurance, it’s unaffordable. So the disease progresses and bills for the complications mount – diabetes, heart disease, liver disease, some cancers, and joint disease, to name a few.

This is why the House Appropriations Committee told CMS this year:

“It is a matter of health equity and key to reducing modifiable risk factors for cancer and Alzheimer’s disease, to ensure that seniors have access to obesity treatments under Medicare Part D to complement coverage of intensive behavioral therapy and bariatric surgery under Medicare Part B.”

So yes, health plans need to regard obesity meds less like Botox and more like a knee replacement. In fact, there’s a chance that treating obesity can delay or prevent the need for replacing a knee. That’s what we would call a two-for-one deal.

Click here for Lee’s report in MarketWatch.

Kneeling, from a painting by Henri Matisse / WikiArt

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October 3, 2022