Obesity Care and Health Payers: Getting Real

For decades, we’ve watched growth in the prevalence of obesity and the chronic diseases it causes. Health systems have profited from treating those downstream diseases. Without really thinking about it, public health policy and payers have conspired to deny care for the root cause of those diseases – obesity. Bias inspired some of this because many policymakers presumed that people with obesity were doing this to themselves. Treatment options were limited and it was easy for payers to act as though treatment was pointless.

But now, the landscape is changing fast. Advanced medicines for obesity make it obvious to anyone with an open mind that treatment is not pointless. So it is fascinating to watch health payers struggle to come to terms with this new reality for the landscape of obesity care.

Some health payers are leaning into a floodgates argument – if we pay for any of this care, the floodgates will open and all those people with obesity will bankrupt us. But in Health Affairs this week, it was good to see a more sensible perspective emerge.

The Imperative for Value-Based Care in Obesity

Tom Hubbard and colleagues wrote that nihilistic arguments about obesity care are obsolete. It’s time to think about realistic scenarios that can meet the medical needs of people with obesity and deliver good value for money:

“It is not too early to think ahead to a point when these medical interventions will not only be widely accessible but will be seen as essential interventions to halt the growing impact of obesity on public health, patient quality of life, and on the nation’s health care spending. Given the prevalence of obesity, and the aggregate cost of high-volume treatment and care, it is incumbent on us to think not only about how obesity treatment and support can be delivered safely and effectively at greater scale, but also about how it can be delivered in concert with our healthcare system’s continuing movement toward value-based care.”

The Floodgates Argument

The opposite argument still crops up, though. In NEJM recently, Khrysta Baig and colleagues presented a scenario where spending for semaglutide for obesity in Medicare “would exceed the entire Part D budget.” (Part D is shorthand for prescription drugs under Medicare.) Baig et al came up with those numbers by assuming 100% of people with obesity would get semaglutide and keep taking it continuously. They also assumed prices would stay high – unaffected by market pressures.

Arya Sharma described this scenario as “unbelievably naïve” and “disingenuous.” To compare that 100% scenario to reality, consider the situation with hypertension meds. After decades of concerted efforts to drive higher uptake of medicines to control blood pressure, only 30% of people who need these meds get them. Persistence on therapy is about 65% and adherence is in the range of 75%. The result is that patients only use 15% of the doses for hypertension presumed by a 100% utilization scenario. Furthermore, hypertension medicines are now “cheap as chips” because of market forces.

So proposing that utilization of advanced obesity meds would even reach 15% anytime soon, while prices remain high, is truly a flight of fancy. This is the shaky foundation of the floodgates argument.

Needless to say, we favor getting real about the need for obesity care and putting efforts into planning for value-based care as Hubbard et al suggest.

Click here the new article from Hubbard et al and here for further perspective.

Maria and Annunziata “from the Harbour,” magic realism by Christian Schad / WikiArt

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April 14, 2023