Easing Access to Bariatric Surgery Over Weight Loss Drugs by Some Insurers

Amid growing concerns regarding the expense associated with using glucagon-like peptide 1 agonists for obesity treatment, certain insurers are imposing additional restrictions or discontinuing coverage for these drugs altogether. Concurrently, there is a trend among healthcare plans to either maintain a certain level of accessibility to bariatric surgery or streamline the process for patients to undergo such procedures.

While GLP-1 agonists for obesity treatment offer promising benefits by effectively reducing weight and potentially lowering the risk of major cardiovascular events for some individuals, current data indicates that their cost-effectiveness is questionable given their current pricing.

Conversely, bariatric surgery is recognized as a cost-effective intervention, particularly for individuals with severe obesity and type 2 diabetes. Evidence suggests that bariatric surgery can significantly reduce weight, metabolic comorbidities, and mortality rates compared to lifestyle interventions alone. Procedures such as sleeve gastrectomy for moderate to severe obesity and less invasive options like endoscopic sleeve gastroplasty for mild obesity are considered to be economically viable strategies.

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The cost of bariatric surgery typically ranges from approximately $17,000 to $26,000. Insurers may recoup these expenses relatively quickly, within two to four years, through reduced spending on obesity-related conditions.

Weight Loss Drug vs. Bariatric Surgery

In response to these dynamics, some insurers are now simplifying access to bariatric surgery. For instance, Blue Cross Blue Shield of Michigan eliminated prior authorization requirements in September of the previous year, while BCBS carriers in Massachusetts and Vermont have also revised their protocols accordingly. Similarly, Geisinger Health Plan has expanded its coverage options for bariatric surgery.

According to the New York Times, starting April 1st, the North Carolina State Health Plan has ceased coverage for GLP-1 medications used for weight loss, such as Wegovy and Zepbound (tirzepatide, a GLP-1/GIP compound). These drugs can incur costs of approximately $1,000 per patient per month indefinitely. However, the plan will still provide coverage for bariatric surgery for individuals classified as morbidly obese and deemed suitable candidates for the procedure.

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