by Samantha Pederson, PA-C
Obesity is evolving into one of the most prevalent public health concerns today, and even for clinicians who do not directly treat obesity, their ability to provide optimal medical care is often affected by this disease. As our understanding and capabilities of treating obesity evolves, it is important to consider how we want policy and insurance coverage to evolve with it. As with all medical conditions, it is important to understand their economic impact in order to make policy changes and guidelines for medical practice.
Obesity is defined as any individual with a body mass index (BMI) of ≥30. As of 2020, 41.9% of the United States population was considered obese[1] with projections of increasing to 48.9% by 2030[2]. The economic impact of obesity can be estimated by combining direct and indirect costs, the latter being much more difficult to quantify. Direct medical costs refer to services including inpatient care, office visits, medication expense, imaging and laboratory studies, and nursing services. By 2016, the direct medical cost of obesity was estimated to be $260.6 billion in the United States3, which is now likely an underestimate when considering time and inflation. The annual medical expenditures of adults with obesity were twice that of those with normal weight, and as BMI increased so did cost. Anti-obesity medication coverage is one of the main concerns of clinicians, patients, and policymakers alike. Interestingly, those with obesity had 186.8% increase in prescription drug expenditures, which excluded anti-obesity medication costs from analysis. In addition, this study demonstrated that in comparison to those with normal BMI, adults with obesity and public health insurance cost an additional $2,877 while those with private health insurance cost $2,058 annually[3]. This suggests there may be additional incentive to improve obesity treatment for those with public health insurance.
Indirect costs of obesity are more difficult to quantify and refer to expenditures that cannot be directly correlated to obesity but still play a role in the economic impact of the disease. This includes costs related to loss of productivity, workers’ compensation claims, short and long term disability insurance, and sick leave. According to research, employees with a BMI in the normal range cost, on average, $3,830 per year in medical, sick day, short term disability, and workers’ compensation claims while those with BMI ≥40 cost $8,067 per year[4]. This suggests that weight loss could be associated with improved productivity and thus economic benefit.
There is no dispute that obesity contributes to significant direct and indirect costs to patients, their insurers, the government and taxpayers. Therefore, it is imperative to consider how treating obesity can result in cost reductions. A study published in 2021 evaluated the savings that could be associated with weight loss in commercially insured adults with comorbidities[5]. They analyzed direct medical costs from 20,971 patients with overweight (BMI 25-29.9) and obesity (BMI ≥30) with one or more of the following conditions: diabetes, hyperlipidemia, hypertension, mental health disorders, pulmonary disease, arthritis, and back pain. They defined direct medical costs as office-based visits, emergency room visits, prescription drug use, home health services, or inpatient care. Their findings showed statistically significant savings from year 1 to year 2 for patients with comorbid diabetes, hypertension, mental health disorders, arthritis, and back pain. For each decrease in one BMI unit, they found the following savings: diabetes (-$752), hypertension (-$367), mental health disorders (-$306), arthritis (-$209) and back pain (-$289). They also found that as patients lost more weight, savings also improved. For example, a patient with diabetes and a baseline BMI of 40 had $2,665 of savings with 5% weight reduction and $8,443 with 20% reduction. This is noteworthy considering many front running obesity treatments have the potential to achieve 20% weight reduction.
An analysis conducted in 2023 predicted cost savings if Medicare were to cover anti-obesity medications for all patients with BMI ≥30 or BMI ≥ 27 with at least one weight-related comorbidity[6]. Research has shown that anti-obesity medication may need to be continued indefinitely to maintain weight loss, which was factored into their analysis. They found that in the first 10 years of coverage, cost savings would reach $176 billion and increase to $700 billion by 30 years. 60% of this reduction was related to medicare part A, which includes hospitalization and inpatient care. This is unsurprising given recent research from Novo Nordisk showing a statistically significant 20% reduction in major adverse cardiovascular events (MACE) defined as cardiovascular death, non-fatal myocardial infarction and non-fatal stroke with semaglutide 2.4mg in patients with obesity[7]. They also concluded that Medicare coverage for weight loss medications would result in $770 billion of savings in quality of life benefits over the course of 10 years unrelated to direct medical costs6. Together, both direct and indirect savings would result in approximately $100 billion per year with Medicare coverage, which exponentially increased when private insurance was also factored into the analysis. This is due to the assumption that privately insured patients with anti-obesity medication coverage will enter medicare in a healthier state than without coverage. When factoring in both private and public health insurance coverage, it is estimated that $245 billion of federal tax savings could be achieved in the next 10 years.
Although longitudinal studies proving cost savings in preventing or treating obesity are lacking, there is sufficient evidence to suggest it may be in the best interest of both private and public insurance to improve coverage, especially for our most effective obesity treatments. To date, our most efficacious treatments include medication management with semaglutide 2.4mg (-14.9%)[8] or tirzepatide 10-15mg (-20.9%)[9] and bariatric surgery (weight loss percent is dependent on the type of procedure performed). As clinicians, we see the benefits of weight loss in our patients on a daily basis. We watch as their blood pressure, sleep apnea, arthritis and mental health improves with time, and celebrate with them as we reduce polypharmacy and frequency of office visits. We are hopeful as anti-obesity treatments improve, but are consistently hindered in providing the best care due to the lack of coverage, affordability or accessibility to our patients. Therefore, it is our responsibility as clinicians to promote policy change to advocate for our patients, and we are fortunate that what’s in the best interest of our patients aligns with the best interest of the government, tax payers, and insurers alike.
Works Cited
1) CDC. “Adult Obesity Facts.” Centers for Disease Control and Prevention, CDC, 17 May 2022, www.cdc.gov/obesity/data/adult.html.
2) Ward, Zachary J., et al. “Projected U.S. State-Level Prevalence of Adult Obesity and Severe Obesity.” New England Journal of Medicine, vol. 381, no. 25, 19 Dec. 2019, pp. 2440–2450, www.nejm.org/doi/full/10.1056/NEJMsa1909301, https://doi.org/10.1056/nejmsa1909301.
3) Cawley, J., Biener, A., Meyerhoefer, C., Ding, Y., Zvenyach, T., Smolarz, G., & Ramasamy, A. (2021, March). Direct medical costs of obesity in the United States and the most populous states. Journal of Managed Care & Specialty Pharmacy. https://www.jmcp.org/doi/10.18553/jmcp.2021.20410
4) Van Nuys K, Globe D, Ng-Mak D, Cheung H, Sullivan J, Goldman D. The association between employee obesity and employer costs: evidence from a panel of U.S. employers. Am J Health Promot. 2014 May-Jun;28(5):277-85. doi: 10.4278/ajhp.120905-QUAN-428. PMID: 24779722.
5) Alison Sexton Ward, PhD, et al. “Benefits of Medicare Coverage for Weight Loss Drugs.” Healthpolicy.usc.edu, 18 Apr. 2023, healthpolicy.usc.edu/research/benefits-of-medicare-coverage-for-weight-loss-drugs/, https://doi.org/10.25549/4rf9-kh77.
6) Thorpe, Kenneth PhD, MA; Toles, Anastasia MD, MPH; Shah, Bimal MD, MBA; Schneider, Jennifer MD, MS; Bravata, Dena M. MD, MS. Weight Loss-Associated Decreases in Medical Care Expenditures for Commercially Insured Patients With Chronic Conditions. Journal of Occupational and Environmental Medicine 63(10):p 847-851, October 2021. | DOI: 10.1097/JOM.0000000000002296
7) A. Michael Lincoff, et al. “Semaglutide and Cardiovascular Outcomes in Obesity without Diabetes.” The New England Journal of Medicine, 11 Nov. 2023, https://doi.org/10.1056/nejmoa2307563.
8) Wilding, John P. H., et al. “Once-Weekly Semaglutide in Adults with Overweight or Obesity.” The New England Journal of Medicine, vol. 384, no. 11, 10 Feb. 2021, pp. 989–1002, www.nejm.org/doi/full/10.1056/NEJMoa2032183, https://doi.org/10.1056/NEJMoa2032183.
9) Jastreboff, Ania M., et al. “Tirzepatide Once Weekly for the Treatment of Obesity.” New England Journal of Medicine, vol. 387, no. 3, 4 June 2022, www.nejm.org/doi/full/10.1056/NEJMoa2206038, https://doi.org/10.1056/nejmoa2206038.