From Bloomberg News and iHeartRadio. It's the big take. I'm Wescasova. Today. New drugs to treat obesity really work. The question is who will get them and who won't. There's been a lot of news coverage lately about ozepic and other drugs like it that are shown to be effective at helping people living with obesity to lose weight. The downside, you often have to stay on them, and they are expensive thousands of dollars a year. Some insurance companies are reluctant
to cover them, even with a doctor's prescription. And this is stirring up all kinds of questions about taking obesity seriously as a disease and about how healthcare is often very different from people who can afford to pay for costly treatments and those who can't.
And now you know, we're at a point where people are more accepting of it is more about people's chemistry than about their character, right, This is not a character of law. This is a biochemical process that creates the disease of obesity, just like you know, similar to what was a struggle for mental health for very many years until there was an increased awareness and increased focus.
That's doctor Angela Fitch. She specializes in treating obesity, and we're going to hear more from her later in the show. First, Bloomberg reporters am A Court and Robert Langreth. They've been covering the upsides and downsides of these medications and the back and forth over who should foot the bill. Emma, can you start by telling us how do these drugs work?
The drugs have a bunch of different names. I think people are maybe most familiar with ozembic, which is actually not specifically a.
Drug for weight loss.
It's a drug for diabetes that happens to produce some weight loss. Basically, there's a group of these drugs ozempic. The one that's been specifically approved for obesity right now is called Wagovi. There's an earlier one called Sexenda. There's one that's sort of going through the regulatory process soon for obesity called Munjaro. These drugs are all part of a class called GLP one receptor agonists, and basically the way they work is they help people feel full, they
eat less, and people lose weight. The catches that people may need to take them long term to keep the weight loss off they've done some studies where people quit taking the drugs and they regained a lot of weight. But the main factor here to think about is these are drugs that replicate a hormone that exists naturally, but at pretty high pharmaceutical levels of sort of mimicking this hormone in the body, and it comes with some side effects.
A lot of people have nausea, diarrhea, constipation, but they're considered relatively safe because they have been studied in diabetes for many years.
The interesting thing to me watching the pharmaceutical industry for so many years, there's been a long history of attempts to develop weight loss drugs that have run into lots of problems or have been many examples of previous weight loss pills that had to have recalls for safety reasons. This class, which is showing, you know, more efficacy than previous weight loss drugs before, in some sense, kind of came out of left field. It really came out of
diabetes research. These GLP and hormones that they're essentially mimicking in these drugs. It turns out that in addition to helping regulate blood sugar, which is the reason they were originally discovered these hormones also have important roles in sending
fullness signals to the brain. And when they did some of the early trials or the early versions of these drugs and diabetes, you know, they discover that people with diabetes they lost weight, but for a long time that wasn't the main focus the research and drug companies didn't until recently really pursue the weight loss angle of them
as an O B city standalone agent. So that's only started accelerating recently as they've developed much more potent, longer acting versions of these drugs and lo and behold, when they did that, the amount of weight loss that was produced in some of these trials, you know, went up dramatically, and that's kind of the big surprise. It has tons of drug company executive just like you know, almost like salivating over the potential enormous market size.
How much weight can you lose on them? Like? How much more effective are they than previous efforts to make a weight loss drug.
Well, there are some of the most significantly effective drugs of single agents that have ever been developed from what we see so far, especially the newer ones and some of those with GOVI, which is Nova Noordius drug, which is a higher dose version of a zempeic that produces
around thirty pounds of weight loss. And Eli Lilly has a diabetes drug called Munjaro that's also testing for obesity, and in their early big trial, in their first big trial of that drug, that produced at high doses around fifty pounds of weight loss, which is kind of like almost an unprecedented thing, you know, for a single drug and a big trial. The sense is like almost all sorts of drug companies just kind of racing to get in the field.
They clearly work, but there's kind of a big downside. They are not cheap, is that right, Emma?
Yeah, So these drugs, you know, depending on which specific drugs you're talking about, like the class generally costs more than ten thousand dollars a year, with GOV specifically is more like seventeen thousand dollars a year. And you know, typically insurance pays for medication, right, I mean, they don't pay for everything, and they might give you a hard time, but if you have a disease, typically you know, you can get insurance coverage for treatments, you know, more or less.
In this case, though, obesity is treated pretty differently from other conditions, and that there isn't like sort of routine,
regular coverage for weight loss drugs. And so, you know, we found in like our reporting that you know, whether you're looking at private insurers, like if you work at a big company and you have private insurance, whether you're getting insurance through Medicare, which is for elderly people in the US, to get health insurance coverage Medicaid, which is for low income people, generally, coverage is really really spotty. You know, a minority of insurers are covering drugs like
these for weight loss. Medicare isn't covering it at all, and there's been a big push from pharma to try to change that.
We surveyed all fifty states Medicaid plans and only roughly eleven states provided you know, broad coverage for BC drugs, and many many states excluded it entirely. Private insurance coverage was maybe a little bit better, but it varies all over the map. Roughly from the surveys, we see maybe a quarter of private plans we'll cover BCD drugs. It's one of those rare categories in the US. Insurance feel they can just like blanket not cover and not get too much pushback.
So what that means is if you're a person and you have a body mass index of over a certain threshold for OBCD it's thirty plus. So you go to the doctor, your doctor weighs you, they say, you have obesity. We're going to prescribe you this new, cutting edge medication that works really well to help people lose weight. You try to get that prescription covered by insurance, and it is going to be a big battle, and chances are you're going to lose that battle.
Bob. What is the insurance industry's reason for not covering these drugs.
One of the reasons is simply cost. There's roughly half the adult population would qualify under the label, under the official FDA label you know, for these drugs, So if everyone used it that could potentially qualify, the costs would
just be enormous. Some industry financial analyst estimates are estimating that this class of drugs could eventually have sales of one hundred and fifty billion dollars a year between obesity and diabetes, like basically making one of the best selling you know, classes of drugs ever.
You know. I think another piece of it is they don't have to cover it. There is a precedent for not covering it. Medicare doesn't cover it. Medicare is sort of the gold standard for coverage, right. If Medicares cover something, private insurers typically follow. But it's interesting because there is pressure already to cover the stuff, and it's going to only increase as you know, Novo Nordisk, the maker of
ozembic and magov puts more money into this fight. You know, if Eli Lilly gets approved for obesity, you're going to have more and more companies coming into this space, lobbying in Washington to change coverage, pushing private plans. You already have patients going to their HR office and saying, you know, why don't you cover with goov? You know, my companies to have this great health insurance. You know, I'm paying top dollar for why aren't you paying for this drug?
You know.
One of the points that insurers make is that, yes, these drugs do cause a lot of weight loss. Are not disputing that, but they say that the drugs, you know, haven't been proven to reduce you know, kind of hard clinical health outcomes, like they haven't been proven to reduce heart attacks and strokes, So they haven't been proven to reduce sleep apnea or other complications of obesity, and the
insurers are right about that. And what the drug companies are doing in response is they're actually doing so called outcomes trials trying to prove that if you give their drugs to someone who's a bee that though, you'll reduce the rate of heart attacks and strokes, or you'll prevent complications of sleep apnea, or in someone who is abese
with heart failure, to prevent heart failure related events. So they're trying to do that and those trials, which should start reading out as soon as this summer, those are going to be very, very important to determine what kind of coverage that these drugs get over the long term.
And this kind of speaks to the bigger question of like what is obesity? Is obesity inherently a disease? And about a decade ago, the American Medical Association said, yeah, obesity is a disease. And part of the reason they did that is they wanted doctors to start diagnosing it, they wanted health insurance to start paying for it. What's interesting about that is if obesity is a disease, then weight loss alone might be enough to make a difference
with this disease. You don't normally see a company having to run more trials than just this sort of initial trial to get coverage like this, Like this shows that the bar for proving these drugs work.
Is higher, and question about why is it higher?
You know, I think some people would say this is stigma, this is discrimination, But I think there is a really interesting question at the heart of this of you know, many many people in America are considered to have quote unquote excess weight. But are all those people sick? Well, we know a lot of them aren't, right. We know many people with these higher BMIs don't necessarily have all these other diseases, right, They don't necessarily have diabetes or
heart disease. And it gets into all these thorny, complicated, difficult questions.
After the break, with so much demand for these drugs, will the price start to come down? Emma, you report that obesity can sometimes get in the way of doctor's ability to treat people for serious illnesses. What did you find?
Something that is not super well known is that there are body mass index limits, often for medical equipment. So if you're trying to get certain kinds of scans you might not be able to if you you know way too much. There are also body mass index limits for procedures, often and you know, ostensibly to make them less risky.
Carolina Povian, who's a obesity doctor at Brigham and Women's Hospital in Boston, told us she has patients who because of their body mass index, can't qualify for literally organ transplants. We're talking heart transplants. People can't qualify for because of their body mass index. And yet they they also can't get access to a drug that would help them unless they're quite wealthy or they work at a company with exceptional insurance benefits.
There have been some big wins for the Coalition to Doctors and advocates and companies are pushing for better coverage. And one of the most concrete examples of improving coverage is the Federal Employee Benefits Plan, and that's a big cluster of plans that covers federal employees. We're talking eight million people are in this. The federal government this year put out a rule that is requiring insurers in that plan to cover at least one of these GLP one
drugs for BC. That's a big change that adds a lot of people onto the coverage roles.
We also found in our analysis of state medicaid plans, So this is Medicaid is the program that ensures low income individuals in the US, and it varies a lot by state to state.
And what we found as part of this is policies are changing.
So a couple of states have actually started covering obcit drugs in recent years. A bunch of states, about eight told us that they're actually looking at maybe covering So it does seem like things are changing incrementally.
What did the drug companies say about why these drugs are so expensive.
I've done a lot of reporting on drug pricing over the years, and I found when you ask a company you know about the price, it's very hard to get a clear answer why they price it the way they do. But you know what Eli Lilly and Novadora say is, you know, the price of the drugs reflects the value and clinical benefits that they provide. Now, I will note that the Munjaro that's Eli Lilly's drug, is only approved right now for a diabetes, So they're talking about diabetes.
And there's another strange aspect of the pricing that's going on in that Novo Nordisk when it came out with a higher dose version of a zempic called the GOVI that's only approved for obesity, it decided to price it about forty percent higher than ozempic, even though it's just a modestly higher dose of exactly the same drug.
And why do they say they did that?
We asked Novo Nordisk about this.
Basically what they say is that with gov is more effective than their previous weight loss drug called Sexenda.
You know, that's why they priced it that way.
One common answer as well, it's a higher dose than nozepic.
But it's not that much of a higher dose.
As you continue to cover this, what are you looking for? What do you think comes next?
Well, I want to see will any of these other attempts, you know, develop other follow on drugs, Will any of them come to fruition, Like one of the things that could help will be something that's not an injection that could be taken as a pill on. You know, some other drug companies like fives are working on but it's not clear whether those are going to have as much efficacy. So we'll get to know that in a few years.
I do think there's going to be a lot of pressure to expand insurance coverage. I also think there's gonna be a lot of resistance to paying for it. It feels like things are going to come to a boil pretty soon.
Emma, Bob, thanks so much for coming on the show.
Thank you, thank you.
When we come back, I talked to a physician about these weight loss drugs and the challenges of treating obesity. Let's hear now from someone who confronts these questions every day. Doctor Angela Fitch specializes in the treatment of obesity. She's president of the Obesity Medical Association, and I caught up with her at the group's spring conference in New York City. Angela, the American Medical Association ten years ago classified obesity as
a disease. What is the importance of this distinction?
So obesity really is a disease like other chronic diseases, and the path of physiology behind it is much more complicated than just the idea of eating less and moving more. Right, there's a lot of diseases hypertension, high cholesterol, heart disease that have lifestyle factors involved with them. But for many years it was felt even by personally, by patients, by society, that obesity was just people's fault, that it was just their own responsibility, and that they were just eating too
much and not moving enough. And so this importance of classifying it as a disease was that it really is a disease because it's more complicated than just eating less and moving more and the AMA you know, declaring it a disease in twenty thirteen, you know, that's a long time ago, but over the course of this time, I really feel like we're finally at an awareness currently that it is a disease. You know, I liken it to
mental health issues as well. For longest time, people didn't think depression or anxiety or other types of mental health issues was a disease state. It was more of just a you know, the person's own issue that they're dealing with. It was very stigmatizing, and now you know, we're at a point where people are more accepting of it is more about people's chemistry than about their character, right, This
is not a character law. This is a biochemical process that creates the disease of obesity, just like you know, similar to what was a struggle for mental health for very many years until there was an increased awareness and an increased focus on treating the disease in a comprehensive chronic disease management fashion.
You mentioned treating the disease. How does classifying obesity as a disease change the treatment? What are the practical effects of that?
Yeah, because what we're leveraging for is better insurance coverage. We're leveraging for coverage of the whole spectrum of the disease process, from lifestyle management to medications, pharmacotherapy to bartic surgery, which is a very comprehensive approach to the treatment of a disease state. You know, much like cancer. You have a surgery for cancer, you have chemotherapy, you have radiation treatment, you have mental health treatment, you have lifestyle treatment that
affects cancer. You know, a lot of cancer centers offer yoga and other types of mindfulness based treatment to help their patients live a longer, healthier life. And a lot of those times, those types of services can be covered under certain plans or by employers because of the fact that they are part of the overall comprehensive disease treatment.
So it's about gaining access for patients, you know, access to coverage for these services by their insurance versus having to pay for so long, obesity was something patients were expected to pay out of pocket for in order to get access to that care.
The treatment that we're talking about today are obesity drugs, this new class of drug that seems to be very effective. Are you using these drugs in your own practice?
Yes, I've been practicing obest medicine. Now. I was a primary care physician double bordered in inter medicine and pediatric, so I see the full spectrum of the disease from young childhood, you know, through even older adulthood, so that full spectrum of treatment. You know, we offer pharmacotherapy as part of that treatment in the appropriate patient that it's indicated for, because it is much more effective than lifestyle alone.
You know, a person with a blood pressure of one hundred and eighty over one hundred in my office, you know, I'm not going to just recommend lifestyle therey to start with, because that person has a disease burden of hypertension that is so strong for them, whether that's genetic or environmental, or maybe they have one kidney because they lost one
in surgery. You know, the point is that they have a disease state that's bothering them, and if we don't treat it with a medication, they might have a stroke or a heart attack or some other thing happen.
And the same is.
True as obesti as a disease. You know, this has a lessyle component to it that is effective, but also it's much more effective. We're talking ten times more effective to reach your goals by adding pharmaco therapy, which is very similar to other chronic diseases that we manage diabetes, hypertension, cardiovath but disease, etc. Biologically, as humans, we are not designed to lose weight. It goes against everything in mother nature for us to lose weight. It's not the normal
process for us. So trying to alter mother nature takes more than usually what we can sort of will away, if you will.
What's been your exp eperiencing trying to get coverage for patients you prescribe these drugs, so it is very variable.
I'm very fortunate that in New England where I'm practicing right now, we have excellent coverage by our commercial payers. So one of the things that we're trying to fix here at the OBC Medicine Association for which I'm president right now, is advocate that obese treatment would be a standard benefit on the insurance plan right now, the problem across the country and all commercial payers is that it's not a standard benefit, so employers have to choose to
add it for an extra cost onto their coverage. Employers sometimes don't do that, they don't know they have to do it. Maybe there's a lot of reasons, you know, for that.
In recent years, we've seen the rise of a body positivity movement, which says that just because you have a large body doesn't mean that you're sick. That there are people who are obese under the clinical definition but lead healthy lives, and there's people who are not clinically obese who have diseases. What is your view on that.
I would say that one thing we're trying to work on too is to get rid of the word obese from our vocabulary, because what we talk about is obese sort of defines a person by their disease, and we don't like to use that terminology. And so when you have the disease of obesity, it's a disease that you have and you live with It's not something that sort of defines you, like I am an obese person, right, that sort of defines who I am versus I have obesity.
The disease, as you pointed out, not everybody has the
same severity of the disease is the issue. So what we're really looking at is identifying what each individual person's risk factor is related to that disease, like we do with any disease state, and then deciding in an individual shared decision making fashion between the patient and the clinician if treatment is warranted for them at this time, because even if they might be very healthy without other comorbidities, their obesity may be preventing them from running around as
much at the playground with their grandchildren or fitting into the airline seat when they're traveling a lot because that's what they do for work. There's other reasons besides just general health or metabolic health that people choose to make changes to their weight, and they certainly should be accepted no matter what size they are, so reducing the bias and stigma around size is very important. At the same time, if they want to change their size, they should have the access to do that.
Is there a concern that if these drugs are so widely available and are so effective that people will depend on them instead of living a healthy lifestyle where they eat well and they exercise, that this will become something that actually exacerbates a problem instead of addressing the core cause.
We really are addressing the core cause with pharmacotherapy. Again, to assume that the core cause is poor eating or lack of physical activity is a biased assumption. Many people living in larger bodies with obesity are very active. So just assuming that someone has OBCs not active. I mean, I have patients who the Boston Marathon recently, and I didn't run the Boston Marathon. I can't do that, but they can because that's what they do and they practice
for it. Right, And there's many people who eat a very healthy lifestyle, and that's why it's a disease state. You know, just like if you get cancer, right, it's not your fault. It's not maybe something that you did, maybe you didn't smoke, but at the same time you ended up with lung cancer. Now that being said, we all in the United States of America have to choose to live differently than our current environment because our current
environment is very obesogenic. We have very large portion sizes, we have more ultraprocessed food around us, we have less physical activity. It's good for us to eat healthier, it's good for us to eat more vegetables, to eat more fiber and not eat the ultra processed food, right, but it doesn't always treat the disease of obesity. So again we need that comprehensive approach, and all of us at the OBC Medicine Association that practice OBC medicine take a
comprehensive approach to treatment. You know, we're not just sort of dolling out drugs, so to speak, talking about some of these other lifestyle factors that are involved, because again it's optimizing that whole patient journey. That is really what all of us do as physicians and clinicians that practice medicine every day, you know, with any issue that our patients have, is to help them holistically, you know, to reach their health and wellness goal.
Doctor Angela Fitch, thanks for speaking with me today.
Thank you so much, Bess as a pleasure.
Thanks for listening to us here at the Big Takes, a daily podcast from Bloomberg and iHeartRadio for more shows from my Heart Radio, visit the iHeartRadio app, Apple Podcasts, or wherever you listen, and we'd love to hear from you. Email us questions or comments to Big Take at Bloomberg dot net. The supervising producer of The Big Take is Vicky Vergalina. Our senior producer is Catherine Fink. Rebecca Shasson is our producer. Our associate producer is Sam Gebauer. Raphael M.
Seely is our engineer. Our original music was composed by Leo Sidrin. I'm Wescaso. We'll be back on Monday with another Big Take. Have a great weekend.
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