POV: Insurers Should Cover Antiobesity Drugs

Photo by Flickr contributor Tony Alter

Somehow, there must be a better way.

More and more of my patients with weight issues are gaining more weight on purpose in order to become eligible for bariatric surgery. The frustration comes from struggling with diets and exercise for years, gaining and losing the same 20, then 50, pounds, over and over again and not being able to keep it off.

We now have six drugs on the market that can help patients with obesity change their lifestyle and stay on a diet and exercise program. These drugs can alter appetite and increase the sense of fullness. So why are some of my patients gaining weight so they become eligible for surgery?

Because surgery is covered under most insurance plans and by Medicare (the federal health insurance program for the elderly) and Medicaid (the federal/state program for the poor). Obesity drugs are not. Medicaid and Medicare should cover obesity treatment of all kinds—medical visits, drugs, and surgery.

The drugs, to be sure, are expensive. So is surgery. Surgery requires anesthesia, and for some procedures, altering bowel anatomy, not to mention a rather big change in eating habits and choices.

Obesity was proclaimed a disease by the American Medical Association several years ago. This step was needed to keep moving forward for a solution to the obesity epidemic in the United States. Obesity is a disease where there is a dysfunction of energy regulation and balance; patients with obesity defend a higher body weight than they would if the energy regulation was normal. Drugs that increase the sense of satiety in the brain help regulate energy balance back to more normal levels and help patients defend a lower body weight for as long as they take the drug. You are eligible for a drug if you are moderately obese, with a body mass index (BMI) of 30 or higher (or higher than 27 for those with other medical conditions). You are eligible for bariatric surgery if you are severely obese (a BMI of 40 or higher) or if your BMI is 35 and you have at least one other medical condition.

Why should patients wait until they gain so much weight as to be eligible for an anatomy-altering procedure to get help for their obesity?

Insurers should not stop at covering just visits to see an MD, because the MD doesn’t have time to counsel on diet and exercise. Dietitians are trained to do this, but are not covered. In addition, the Centers for Medicare and Medicaid Services (CMS) should cover the treatments that can help patients stick with the diet and exercise program—obesity drugs. CMS is currently the brick wall preventing health care providers from treating obesity effectively and preventing patients suffering from obesity from getting the help they so desperately need.

Caroline Apovian is a School of Medicine professor of medicine and pediatrics and director of the Nutrition and Weight Management Center at Boston Medical Center. She can be reached at Caroline.Apovian@bmc.org. 

Dr. Apovian has participated on advisory boards for Amylin, Merck, Johnson and Johnson, Arena, Nutrisystem, Zafgen, Sanofi-Aventis, Orexigen, EnteroMedics, Scientific Intake and Novo Nordisk. She has received research funding from Lilly, Amylin, Aspire Bariatrics, GI Dynamics, Pfizer, Sanofi-Aventis, Orexigen, MetaProteomics, and the Dr. Robert C. and Veronica Atkins Foundation, MYOS Corporation. Dr. Apovian is currently on the Takeda Speakers Bureau for the medication Contrave.

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