Obesity Medications: Who Needs Priority Access

When new medications are so effective that physicians refer to them as “gamechangers,” it tends to generate a lot of interest. In the case of glucagon-like peptide 1 receptor agonists (GLP-1 RAs) such as semaglutide and tirzepatide, the demand was so intense that shortages resulted. 

“They work really well, and the amount of weight loss that people are seeing is unprecedented,” said Supriya Rao, MD, a gastroenterologist and obesity medicine specialist, managing partner of Integrated Gastroenterology Consultants, Lowell, and director for medical weight loss at Lowell General Hospital in Lowell, Massachusetts. “These injectables have really changed the landscape.”

Many experts now suggest that the medications work so well that it’s time to expand access to these medications and allow more high-risk patients to benefit. 

In fact, according to the results of a recent Medscape survey, many doctors believe that some patients deserve priority access. The survey of physicians in September found that 73% of doctors believe high-risk patients should get better access to obesity medications. For the purposes of the survey, “high risk” was defined as having conditions such as heart disease and hypertension that are exacerbated by excess weight. 

Who Gets Access

Both Novo Nordisk’s Ozempic (semaglutide) and Eli Lilly’s Mounjaro (tirzepatide) received approval from the US Food and Drug Administration (FDA) for the treatment of type 2 diabetes. Demand surged when people realized the drugs also enabled people to lose significant amounts of weight.

Eventually, the FDA expanded access to these drugs by approving Wegovy (semaglutide) and Zepbound (tirzepatide) specifically for treating patients with obesity and weight-related health conditions. Wegovy was also granted approval to prevent cardiovascular events in adults with cardiovascular disease and obesity. The FDA also expanded its approval for Zepbound in December to include treatment for obstructive sleep apnea, a condition common in people with obesity. 

And many doctors would like to see even more conditions approved to give easier access to people who could benefit from these weight loss medications. 

“I think they should start allowing more of these metabolic comorbid conditions to qualify,” said Rao, suggesting fatty liver disease as one potential example. 

The potential for lifesaving benefits would justify expanding access, said Elizabeth Benge, MD, an instructor in the Division of Sleep Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston. “For example, reducing obesity in a patient with severe comorbidities not only alleviates their symptoms but also decreases the risk of long-term complications and healthcare costs,” she said. 

In fact, these medications could also benefit people who are obese and are at risk for weight-related comorbidities but haven’t developed them yet, according to Brian Wojeck, MD, MPH, an endocrinologist and assistant professor of medicine with the Yale School of Medicine, New Haven, Connecticut.

The benefit would be prevention of obesity-related comorbidities rather than addressing the damage that’s already occurred over time from conditions like type 2 diabetes, he said. “If you can prevent that from occurring, that’s huge,” Wojeck said. 

Already, research continues to delve into other potential benefits of GLP-1 RAs, including a new study in Nature Medicine that suggests that these drugs may reduce the risk for dementia and other neurocognitive disorders, among others. 

Two Major Barriers: Cost and Coverage

Although shortages have prevented some from getting access to semaglutide and tirzepatide, the shortages of both are over for the time being.

Currently, cost is perhaps the biggest barrier to access for most people. GLP-1 RAs are known to be expensive. Insurance coverage and manufacturer coupons can make GLP-1 RAs much more affordable with significant discounts to the list price. However, there’s a wide variation when it comes to insurance coverage of GLP-1 RAs for obesity treatment or weight loss. 

Medicare doesn’t cover the cost of these medications solely for weight loss, although Medicare Part D will cover the cost of Wegovy for patients if the patients have an additional medically accepted indication, such as a history of cardiovascular disease. Many state Medicaid programs don’t cover the cost for weight loss purposes either. Some private insurance companies cover part of the cost for this purpose, but many don’t. A May 2024 Kaiser Family Foundation Health Tracking Poll found that even among the majority of patients with insurance, the cost of GLP-1 RAs was “ difficult to afford.” 

According to Ethan Lazarus, MD, obesity medicine physician, former president of the Obesity Medicine Association and owner of Clinical Nutrition Center in Greenwood Village,
Colorado, cost is the main barrier for many of his patients, even high-risk patients who’ve undergone bypass surgery. 

“Obesity is generally a carve-out, and in my practice, 80% of people do not have coverage, no matter how high-risk they may be,” he said. “Yes, this is unethical and needs to change.”

The majority of doctors surveyed by Medscape in September agreed that private insurance companies should start covering the cost of obesity medications and remove any existing coverage restrictions.

Physicians hope the costs will eventually drop. “In time there will be enough competition out there that these drugs will have to get cheaper,” said Wojeck. 

One recent development could pave the way for lower costs. Semaglutide was named as one of 15 drugs up for Medicare price negotiations, as set up by the Inflation Reduction Act. (This will include Ozempic, Wegovy, and Rybelsus, an oral form of semaglutide.) The move could eventually lower the prices of Ozempic and Wegovy enough to make them accessible to many more older adults.

But in the meantime, that leaves physicians trying to determine how to help patients who need these medications gain access to them.

“I write a lot of appeal letters,” said Wojeck. 

Also, physicians should make the effort to collect data to help them better understand their patient populations and learn what other barriers to access may exist, noted Faith Fletcher, PhD, associate professor at the Center for Medical Ethics and Health Policy at Baylor College of Medicine in Houston. For example, in some cultures, stigma may exist around weight loss, so not everyone who could benefit from GLP-1 RAs may be asking for them. 

Shortages Are Over…for Now

Shortages could happen again in the future, and that could restrict access to these medications again. Physicians need to be ready, if that happens.

“If some of your patients that need GLP-1 drugs cannot get them, you should work collaboratively and creatively with others to reduce barriers to accessibility and identify viable alternatives,” said Gerard Wong, PhD, associate professor and director of the master of arts in bioethics program with Emory University’s Center for Ethics in Atlanta. “When doing so, you should consider all of the factors that affect the patient’s health, including socioeconomic status and challenges to access healthcare.”