The Challenges and Opportunities Associated with Reimbursement for Obesity Pharmacotherapy in the USA

Abstract

Obesity has become a serious public health problem that has stimulated primordial and primary prevention efforts, and a triad of management options (lifestyle, pharmacotherapy, and surgical interventions). A growing body of evidence supports the need for a multi-pronged, clinic-based approach that leverages the synergy between pharmaceutical and lifestyle modification. Recent US policy changes—namely, the passage of the Patient Protection and Affordable Care Act coupled with recognition of obesity as a disease by the American Medical Association—suggest that financial incentives and attitudes towards obesity management are changing. This paradigm shift has implications for current and future obesity pharmacotherapy. However, barriers to pharmacotherapy utilization include patient and physician perceptions of modest efficacy, historical safety issues, regulatory obstacles, and lack of reimbursement. The shifting attitudes and challenges associated not only with a multi-payer system, but also the lack of clearly defined cross-payer reimbursement strategies, prompted a survey to determine coverage for obesity treatment. Participants indicated that federal/state mandates and growth of quality-driven healthcare initiatives will eventually drive wider pharmacotherapy reimbursement within 1–5 years. There are signs that federal/state programs are already moving towards reimbursement by improving quality measures to track obesity outcomes and reduce costs. Future research on clinical and economic outcomes of combination weight-management programs coupled with innovative approaches (e.g., eHealth) in the real-world setting that demonstrate value to patients, healthcare providers, payers, and employers will help reshape obesity management by reducing barriers and broadening reimbursement coverage for anti-obesity pharmacotherapy.

Characteristics of patients potentially eligible for pharmacotherapy for weight loss in primary care practice in the United States

“…Also, no weight‐loss drug has been demonstrated to decrease cardiovascular morbidity or mortality 6. Additionally, patients often prefer self‐management or over‐the‐counter options for weight control such as dietary changes, exercise, diet, or exercise weight‐loss programmes and dietary and herbal weight‐loss supplements 11. As mentioned previously, more patients who were eligible for pharmacotherapy reported the use of non‐prescription weight‐loss drugs (3.7%) than prescription weight‐loss drugs (2.2%) in the past year in the USA 9.…”

For a Step Change to Curb the Obesity Epidemic

“…In addition, a few treatment options have been introduced, including both pharmacological and surgical approaches. Yet, as evidenced by Cecchini and Sassi [18], Baum et al [20], Chawla et al [19], and Chawla et al [21] in this issue, and others [17] elsewhere, interventions have faced and continue to face significant challenges and, to date, have failed to curb obesity. While many interventions appear to have provided some benefits, the gains have often been marginal [18,22].…”

“…As reported by Baum et al [20], Finkelstein et al [26], and Chawla et al [19], many patients face inadequate access to treatment-pharmacological and surgical-with poor health insurance coverage/ reimbursement, even in rich nations such as the USA and European countries, particularly when patients do not yet experience comorbidities. As noted by Baum et al [20] and Chawla et al [21], pharmaceutical innovation in the obesity field has been limited. A poor safety track record of initial pharmaceutical interventions has resulted in cautiousness on the part of regulators in reviewing/granting new drug applications [20].…”

“…[23]. Misperception of obesity as a cosmetic or lifestyle issue, rather than a serious health problem, has been a significant hurdle to mobilizing patients, communities, and payers to embrace prevention and treatment initiatives [19,20]. Many researchers, including those in this issue, note the need for (1) more comprehensive, multi-factorial interventions [17,22,24], and (2) treatment as opposed to purely preventive approaches (to both address the needs of the already obese and the limited effectiveness of prevention) [25], as key learnings from past failed experience in obesity prevention/management.…”

“…As noted by Baum et al [20] and Chawla et al [21], pharmaceutical innovation in the obesity field has been limited. A poor safety track record of initial pharmaceutical interventions has resulted in cautiousness on the part of regulators in reviewing/granting new drug applications [20]. Current studies assessing the economic benefits/cost effectiveness of obesity treatments [18,26] suffer from limited available data.…”