By Dr. Arnold Saperstein, CMO
Editor’s Note: This post was originally published on February 2, 2023, and has been updated to reflect market changes in the last year.
An alarming forty percent of Americans are living with obesity. It is the second leading cause of preventable death, leads to many other chronic illnesses and cancers, and is a common comorbidity that adds to the complexity of health management. However, many still consider obesity a behavioral issue and not a disease. According to a segment featured in 60 Minutes, and surprisingly, many providers aren’t taught that obesity is a disease in medical school. This leaves them to recommend diet, exercise, and willpower as the solution. But science tells us that it is, in fact, the brain telling you to maintain a certain “set point.”
The set point theory, developed in 1982, proposes that our bodies will adjust metabolism and hunger levels to keep us within a predetermined weight range. However, it’s becoming clearer that weight regulation is far more complex and multifaceted with the interplay between genetics, environment, and behavior (such as diet and physical activity) representing challenges to weight loss and sustained maintenance of a healthy weight.
GLP-1: Breakthrough of 2023
The pharmaceutical industry continues to make progress in developing therapeutics, including GLP-1s (named by Science as the Breakthrough of 2023), to help the brain “reset” the set point. For example, Lilly’s Zepbound was FDA approved for chronic weight management in November 2023. Proof of clinical efficacy grows (1) (2) (3) with treatments that sustain double-digit, long term weight loss—continuing to spur consumer interest and demand. Patients on these medications themselves have taken to social media to report on the benefits they have experienced, including the quieting of “food noise” (with 1.8B views and counting on TikTok alone). While not a clinical definition, the concept of food noise further highlights the connection between the brain and the number on the scale.
The coverage conundrum
While health insurers have long provided weight management programs focused on lifestyle change, they have been slow to cover medications as they waited for clinical evidence. Since treating obesity lowers the risk of other diseases including diabetes, heart disease, multiple forms of cancer, and many more contributing to the high cost of care, it has been in their best interest to do so. But now the results are coming in, and not only do these therapies impact upwards of 5% total weight loss, but they are also effective in reducing cardiovascular complications including myocardial infarction, stroke, and death (4).
Health plans are now faced with tough coverage decisions—what drugs to include on formularies, eligibility criteria, and so on—while navigating the impact of new direct-to-consumer options such as LillyDirect, which launched at the beginning of 2024. The Centers for Medicare & Medicaid Services (CMS) is also feeling the pressure to rethink its position, as drugs prescribed for weight loss are excluded from coverage. Without insurance, these drugs cost upwards of $1,500 a month. Thus, creating health disparity in access and affordability of these medications and a significant barrier for widespread adoption.
Change on the horizon
The perfect storm between clinical evidence, insurance coverage, supply in the form of new pharmaceutical entrants, and public demand are creating an environment ripe for meaningful change. Looking ahead, we can expect to see progress on oral versions of semaglutide for obesity which will add more complexity to the access and affordability conversation. Additionally, there is a robust pipeline of new anti-obesity medications, some of which are already in phase 3 clinical trials.
As a virtual specialty care organization with solutions across a range of chronic diseases, we predicted an uptick in weight management programs with these therapeutics through 2023 as insurers started to include them in formulary. It’s not surprising that many new solutions were brought to market, but it will be interesting to see how these programs evolve and scale to the sizeable population impacted by obesity. From our experience supporting patient populations with virtual chronic weight management, we see that a combination of care—digital, behavioral, and therapeutic with clinical support and oversight—is the only way to drive enduring, widespread results in helping patients sustain long-term weight loss.
- Wilding, JPH et al. (2021) Once-Weekly Semaglutide in Adults with Overweight or Obesity. Available at: https://www.nejm.org/doi/full/10.1056/NEJMoa2032183. Accessed 1 February 2023.
- Ghusn W et al. (2022) Weight Loss Outcomes Associated With Semaglutide Treatment for Patients With Overweight or Obesity. Available at: https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2796491. Accessed 1 February 2023.
- Aronne L et al. (2023) Continued Treatment with Tirzepatide for Maintenance of Weight Reduction in Adults with Obesity. Available at: https://jamanetwork.com/journals/jama/fullarticle/2812936. Accessed 10 January 2023.
- Lincoff, AM et al. Semaglutide and Cardiovascular Outcomes in Obesity without Diabetes. Available at: https://www.nejm.org/doi/full/10.1056/NEJMoa2307563. Accessed 10 January 2023.
About the Author
Dr. Saperstein began his managed care career in 1992 and continues to dedicate his expertise to developing programs that ensure the highest quality of care. He joined Cecelia Health in 2019 as Chief Medical Officer, where he built the first national virtual Endocrinology telemedicine practice. Dr. Saperstein has expanded the company’s chronic disease management approach beyond Diabetes to include Cardiovascular risk reduction, Congestive Heart Failure, Obesity, Chronic Kidney Disease, Asthma, and COPD programs.
Dr. Saperstein leads Cecelia Health’s national network of expert clinicians and specialty providers, achieving excellent clinical results for patient populations across the country. Prior, Dr. Saperstein held leadership positions at MetroPlus Health Plan, joining in 1995 as Chief Medical Officer, next serving as President and CEO from 2006 until 2019. Under his leadership, MetroPlus ranked as one of the highest scoring plans for quality of care (measured by the New York State Department of Health Medicaid Incentive Program and by the Medicaid Consumer Guide for New York City) and rose to the forefront of Value Based Purchasing. During his tenure, Dr. Saperstein developed a groundbreaking quality incentive pay for performance program across the entire network of an estimated 32,000 providers and grew the member population 1100% to serve more than 500,000 people.