If you are like most benefits leaders, you are wrestling with the question of whether to
cover the new generation of GLP-1 drugs for weight loss, or just for diabetes. By way of
background, Ozempic and Wegovy are the same drug (also known as semaglutides), but in different doses. Ozempic is FDA-approved for Type 2 diabetes but not treatment of obesity. Wegovy is the reverse. Mounjaro (tirzepatide) is only approved to treat diabetes now, but will likely be approved for weight loss soon. The "pitfalls" above apply to all three.
You may think you have only three options, each of which has a major pitfall:
Not covering them could literally encourage some employees to find a new job;
Covering them could open the door to maybe a 12% overall cost increase*...and resentment from employees not using these drugs but who have to bear a chunk of the cost of them;
Precertification could limit the number of eligibles, but is quite easy to game… which segues nicely into the next section, on cheating.
If you cover Ozempic or Mounjaro for diabetes, a few pre-diabetic employees might cheat, potentially harming themselves to get the diabetes diagnosis. It’s quite simple: you schedule a fasting glucose…and then instead of fasting, eat candy. If you “flunk” two such tests in a row, you have diabetes. Hey, it’s a tough job but somebody has to do it. Even so, it's not that easy. A doctor is likely to prescribe metformin first.
Much more likely than actively cheating will be people simply deciding that it's not worth hypervigilance to prevent diabetes if indeed a perceived "cure" will be available. We may be wrong about this. We won't know for a few years, but remember where you heard it first.
On the other hand...
If you cover Wegovy for obesity, you’ll find that some number of employees will gain weight in order to qualify for what they believe (with considerable justification, of course – though many side effects are underappreciated) to be a miracle drug.
It may take a year or two, but at some point, the scale of this cheating may surprise you, and not in a good way. How do we know this? Recall the old days of the outcomes-based wellness fad, where the “idea” was that if you paid people enough, they would lose weight.
The predictable thing happened: employees gained weight in order to get paid to lose it again. There was even a cottage industry of coaching employees on how to gain weight, with this satirical blog post being (presumably) accidentally clicked on more than 100,000 times by employees googling on "how to cheat in a corporate wellness program." The "recommendations" in that blog post could harm employees.
Employees cheated on those wellness programs just to make (or avoid losing) $500 or $1000 in extra taxable income.
Imagine how much cheating there will be to get access to Wegovy (or Ozempic), a roughly $10,000 value equivalent to maybe $14,000 in extra taxable income.
Further, it is much easier to cheat because you aren't being paid to reach a goal weight, as in wellness. . If your BMI is 28, you need only gain ten pounds and, well, the indication for Wegovy is a BMI of 30...and you would qualify.
Coverage vs. Cost: "Squaring the Circle"
No one can square this circle. Cost control and coverage expansion are simply opposites. However, there is a fourth option – "self-precertification" – which, while not turning the circle into a square, can at least make a hexagon or even an octagon out of it.
For the most part, this fourth option gets the right people on GLP-1s while (also for the most part) keeping the wrong people off…and may even enable the right people to get off after a year. There are two components of what we call “self-precertification”:
Quizzify is repurposing and reconfiguring our nutrition/lifestyle quizzes (and added a quiz about GLP-1 usage and its side effects) specifically to support employees considering one of these drugs. For example, you could require employees to complete a baseline quiz with up to 50 questions, depending on how high you want to make the hurdle...and pass it. Even if it takes multiple plays. Then there are follow-up quizzes that you can require every quarter (or month or year, as you prefer) to maintain coverage.
You can also provide coaching that is specific to these drugs. Excellent coaching services, specifically designed to support employees on these drugs, are provided by Virta, AIMM, Connect Healthcare Collaboration (CHC) and US Preventive Medicine (USPM). Recall – and people seem to overlook this – that the trials showing the best results included adjunct lifestyle support. Hence the importance of coaching!
While Quizzify's "Jeopardy-meets-diabetes education" approach is unique, so are each of these groups' approaches to coaching:
Virta notes that: "GLP-1s are clinically effective but they aren’t a magic bullet for obesity and weight loss. They’re expensive and studies show weight regain when a patient stops taking his/her GLP-1. Virta offers a proven alternative at a fraction of the cost for patients and employers - lengthening the onramp (or avoiding it entirely for those who decide not to take the drug), and offering a sustainable offramp for those who are on it and looking to graduate."
CHC nurses get employees to commit to a healthier diet, and teach that building lean muscle will yield a higher likelihood of increased caloric burn. The goal is to ultimately get employees off Wegovy, since eventually they won't be covered, but not have them be one of the vast majority that gains their weight back when they do.
USPM's Dr. Ron Loeppke says: “This new enhancement of USPM’s Health Coaching and Disease Management programs provide a personalized program for individuals qualifying for, considering and/or already taking GLP-1 medications under their medical provider’s supervision and care. USPM has also built Quizzify’s fun and informative health education quizzes into our App, as we assess and explain a person’s health risks and current medical conditions, as well as the potential side effects and contraindications of GLP-1 meds.”
AIMM's CEO, Deb Ault, writes here that "the combination of being an obese individual, CEO of a self-funded plan and a medical professional gives me a unique perspective," and goes on to discuss how that informs the way AIMM coaches and precertifies.
Self-precertification is a total complement to any of those approaches
No matter which of those groups or other coaches/medical managers you use, self-precertification provides the perfect complement.
The reasons self-precertification – particularly as a complement to coaching – is an optimization and tempers those three pitfalls above are as follows:
You can set the quiz-taking and scoring hurdle as low or as high as you like, as described below
Near-complete avoidance of the moral hazard created by employees trying to "qualify" for these drugs;
You can ensure that only motivated employees gain access to these drugs...
...while the most motivated might learn enough (along with coaching) to decide they don't need them, the least motivated won't qualify for them;
These employees will also learn – and prove that they know – a lot about managing their health, hidden sugars, nutrition generally, reading labels, exercise and much more...which will make the drugs more impactful, as lifestyle improvement is the left shoe to GLP-1s' right shoes;
You and they can avoid the easily gamed precertification process;
If you are only going to authorize coverage of these drugs for a limited period, this level of literacy will reduce the extremely high likelihood that employees gain the weight back after they get off them;
Employees can't legitimately complain because they can’t really say: "My employer is making me learn how to become healthier and I want none of it!" Further, you can point out that the hurdle for these drugs is vastly lower than the hurdle for bariatric surgery.
As noted above, Quizzify allows you to "dial up" or "dial down" the hurdle for getting these drugs, four different ways. You can:
Vary the number of questions
Set the passing score higher or lower
Extend or reduce the interval following a failed quiz
Randomize questions so that the subsequent quizzes are different.
The bottom line: coverage is going to cost you signficant money no matter how you do it. This approach just helps you spend it wisely.
*Assume 1000 covered people that you are paying $10,000/year for. Figure 30% are obese. (National average is 40%.) Assume half either aren't interested, can't afford the copay, are not old enough, are contraindicated, or can't tolerate the side effects. That leaves150 people for whom you are paying likely $10,000/year. That adds $1.5 million (15%!) to your $10 million budget. Allowing an offset for possible avoided medical events, maybe you end up spending 12% more overall.