Let's start with the bad news and a little background. For better or worse, Oprah has been American’s biggest weight loss influencer since the liquid diet fad in the late 1980s.
And now she’s all in for Ozempic, and presumably other GLP-1 drugs. Of course, her regimen also includes significant exercise and, we would guess, the means and opportunity to eat healthy. Unfortunately, those nuances will likely be lost on your clients’ employees jumping on the GLP-1 bandwagon in hopes of a magic cure.
Magic bullet or not, never before in the history of healthcare has anything – any drug, procedure, test, anything – combined this much effectiveness, popularity…and cost. Indeed, this single class of drugs – in what is forecast to be a "bumper year" for them – will likely add 10 basis points to the overall U.S. inflation rate in 2024. (You heard it here first, folks.)
Tip 1: Run the Numbers
Your clients covering these drugs for weight loss will experience the largest-ever cost increase attributable to a single covered benefit, so large that it will squeeze their overall profit margin. Don’t believe that?
Ask us for our Weight Loss Drug Economics Calculator (WLDEC), enter your own assumptions and see for yourselves.
WLDEC models every significant input – from obesity rate to uptake to cheating (see Tip 3 below), to our default estimates of the benefits – to estimate your cost increase, with and without using Quizzify.
WLDEC is available gratis to most advisers by writing to Al@Quizzify.com. Or, you can visit https://wldec.quizzify.com/, where you can enter your own assumptions, your own data and your own credit card.
See also: How Wearables Can Improve Worker Safety
Tip 2: Cover Zepbound, not Wegovy
Most of your clients have never even heard of Zepbound (“Sounds like an off-brand bus line,” someone said). Yet it is both more effective and currently much less expensive than Wegovy.
Of course, you’ve heard of Mounjaro. You may not be aware that the exact same dosage of the exact same drug, Zepbound, is also called Mounjaro.
As of this writing, Wegovy is $16,200/year before rebates vs. Zepbound @ $12,720/year.
Tip 3: Don’t Rely on PBM Preauthorization to Limit Use
Preauthorization only works if the diagnosis, test, image, etc. supporting it is objective and somewhat definitive. In my particular case, to get authorized for continued physical therapy (PT), I needed an actual MRI. (Probably cost more than the 12 additional PT sessions, but that’s a tale for another time.)
For weight-loss drug preauthorization, all you need is a body mass index (BMI) of 30. Unlike blood tests or scans, this hurdle can be easily gamed.
How do we know this? To begin with, the average American adult BMI is 30. (The median is lower.) A few hearty meals prior to a weigh-in can clear that hurdle for a big chunk of the population.
But will people gain this weight? Yes. Those old outcomes-based wellness programs were a hotbed of cheating, as employees would gain weight in order to lose it again. (People also cheat in "steps" programs.) And that was for maybe $1,000 tops. This is for a drug worth more than ten times that amount.
Cheating has an outsized effect on cost. Each point of cheating moves a full percentage point in your gross healthcare spending increase. (WLDEC will show you that.)
See also: How To Self-Fund Employee Healthcare Effectively
Tip 4: Ignore all the vendors who want to sell “coaching” or “behavior change” or “support” for people on these drugs
When you “run your numbers” on WLDEC and include coaching, you’ll find that hand-holding simply doesn’t pay for itself. It costs a lot and doesn’t meaningfully reduce use of other drugs or adverse medical events. All it does is keep people on the drugs longer before they drop out.
Further, coaches aren’t trained to know, for example, the safest way to treat common complications like constipation or heartburn, or what is by far the most likely and most hazardous nutrient deficiency or why those authoritative-looking Nutrition Facts labels are mostly misleading for people trying to improve their eating habits.
Tip 5: Teach client employees the downsides of these drugs before authorizing them
The optimal strategy would cover the drugs only for folks who are committed to using them as intended, with the greatest chances of keeping the weight off afterward – and educate them to help them realize those chances.
Of course, you can’t do that. What you can do instead is teach clients’ employees the downsides of these drugs, so only those who are serious and committed will want to continue. Your wellness or diabetes vendor should have a set of Q&A designed to do exactly that and track the results. (Publicly, we call our 22-question quiz Before Your Journey, though we privately call it Curb Their Enthusiasm.)
Many employees either won’t complete the quiz or else decide these drugs aren’t for them once they do. So you avoid a lot of eventual dropouts without spending for many months first, and without denying anybody anything. We call it “self-preauthorization.”
If you try to do your own self-preauthorizations or have your third-party administrator (TPA) do them, the PBMs will push back, because they make a lot of money on the rebates and want to maximize usage. But stand your ground! You work for your clients, not the PBMs.
Summary
What you just read is the most elegant and cost-effective way to direct your weight-loss drug spending to those who would benefit most.
You can start by asking AL@Quizzify.com for the weight-loss drug calculator. And if you ask nicely, we might even provide the answers to those questions in Tip #4. Or you could ask the coaches themselves. [SPOILER ALERT: As suggested above, they won’t know.]
