According to recent statistics from the Centers for Disease Control and Prevention (CDC), obesity rates in the United States have reached alarming levels, affecting over 42% of the adult population. This epidemic not only contributes to a myriad of chronic health conditions, including diabetes, cardiovascular disease, and certain cancers but also exerts a substantial economic burden on the health care system. In fact, the CDC estimates that the annual medical costs of obesity-related conditions in the United States exceed $147 billion.
In recent years, there has been a seismic shift in how employers approach health care benefits, particularly concerning obesity care. The surge in demand for more comprehensive coverage, including medications like GLP-1 agonists, marks a turning point in addressing the challenges of obesity. This increased breadth in coverage is not without its challenges, as evidenced by the mounting costs faced by employers. In 2023 alone, employer pharmacy benefit costs saw an 8.4% increase in cost year over year, compared to 6.4% in 2022.
In light of these staggering figures, the emergence of GLP-1 weight loss drugs offers a glimmer of hope, presenting a potential avenue for addressing obesity and its associated health risks. However, the question remains: how can health care stakeholders design coverage for these medications in a manner that is financially sustainable yet ensures equitable access for those in need?
Employers such as the State of North Carolina, are grappling with a significant uptick in the utilization of GLP-1s, a trend mirrored across the country. Since mid-2023, usage within State of North Carolina workers has skyrocketed by a staggering 731%, escalating from 2,800 to 24,000 members reliant on GLP-1s. Such exponential growth forecasts are joined by financial implications, with pre-rebate costs soaring from $3 million to a staggering $14 million per month and projected net costs to the Plan expected to balloon to $170 million in 2024, and $600 million by 2028. These figures not only pose an existential threat to health care budgets but also necessitate unwelcome premium hikes of nearly $50 per member per month, a sharp departure from six years of stagnation.
Faced with this financial strain, employers are compelled to make tough decisions to rein in costs. The State of North Carolina Health Plan’s decision to enact a benefit exclusion for GLP-1s for weight loss, albeit a hard pill to swallow, underscores the urgency to address the burgeoning financial burden. However, this exclusion could potentially affect 24,000 members, necessitating a nuanced and proactive approach to ensure continuity of care.
Employers are at a crossroads in balancing the imperative for comprehensive obesity care with the realities of escalating health care costs. The growing demand for GLP-1s necessitates a reevaluation of benefit design strategies to ensure both fiscal sustainability and optimal health outcomes.
Leveraging the clinical expertise of apree health’s advanced primary care model, we are introducing a specialized medication management and weight loss program focusing on GLP-1 therapy. This comprehensive program is tailored to meet the diverse needs of members, whether they are utilizing GLP-1s for weight management, managing Type 2 diabetes, or seeking alternatives after prescription denials. This isn’t another point solution, our integrated technology allows all members of the care team to see the members personalized health profile to allow for continuity of care across provider and care settings.
Within the program, apree prioritizes an whole person approach to well-being, recognizing the profound impact of Social Determinants of Health (SDOH) on individual outcomes. Going beyond traditional weight management, our initiatives address diverse factors, including food choices, insecurities, and considerations related to social vulnerability. Acknowledging the significance and sensitivity of combatting weight-related stigma, we are committed to creating a supportive and inclusive environment throughout our programs.
By using our extensive member profile including clinical data, gaps in care, health risk assessments and more, apree is able to do targeted outreach campaigns and identify eligible members best served by these new offerings. Employees and members who are routed to us following a GLP-1 denial will receive outreach from an apree health Care Guide, informing them about the denial and presenting a weight management offering to conduct a more thorough evaluation of their medical needs. A care guide will review the member’s health, chronic conditions, self-identified goals, and assign the member a path.
The path for members within a certain BMI range and with a chronic condition may be placed on a medical management plan, where other members may be placed on a lifestyle management path. All paths will consist of a multidisciplinary team including a Certified Nutritionist, and a Board Certified Health Coach to reach program goals. Members of the medical management plan who meet criteria will also be assigned a registered nurse as the champion of their care journey.
apree isn’t just another company promising to solve health care cost trends – the pricing model of these programs reflects our commitment to value-based care. We believe health care programs need to include shared incentives with financial risk and show a reduction in total cost of care. Our model includes a range of options from performance guarantees for engagement targets and clinical outcome measures to downside risk in a total cost of care agreement. By aligning incentives with outcomes, apree’s program is aimed at achieving mutual success with our employers and addressing utilization challenges inherent with fee for service models.
The evolving landscape of obesity care demands proactive, integrated solutions that prioritize both clinical efficacy and financial sustainability. apree health stands poised to empower employers in navigating this complex terrain to chart a path to a healthier future while solving the affordability crisis in health care.
Sources:
Designing fiscally viable coverage for GLP-1 weight-loss drugs
Payer strategies for GLP-1 medications for weight loss – Milliman
GLP-1 Medications for Weight Loss
North Carolina state health plan drops weight loss drug coverage; to incur $54M rebate loss
Buried in Wegovy Costs, North Carolina Will Stop Paying for Obesity Drugs – The New York Times
STATE HEALTH PLAN – GLP-1 Weight Loss Drugs, Revenues and Expenditures Fact Sheet
