Frank Diamond

Let’s go out on a limb and say that it’s tough to lose weight. Let’s go even further out and explain that a great deal of people who do lose weight regain it. The 95% figure is often bandied about, but that might not be accurate for a lot of reasons (http://www.nytimes.com/1999/05/25/health/95-regain-lost-weight-or-do-they.html), including the fact that people who tend to participate in weight loss clinical trials probably have tried everything else.

The harsh truth is that the one method of weight reduction that’s been proven effective is bariatric surgery. Surgery, though, is painful, costly, and can be problematic. “Like any surgery, there can be complications,” says Ed Pezalla, MD, MPH, the national medical director in charge of Aetna’s pharmacy policy and strategy. “There are failures. There are patients who have to get the surgery reversed. Bariatric surgery certainly has less morbidity and mortality now than it did several years ago, but it still has more morbidity and mortality than many other common surgical procedures.”

Ed Pezalla, MD, MPH

“Very little middle ground has been available that would help people if they’re trying hard with diet and exercise, but they’re just not making it with those things alone,” says Ed Pezalla, MD, MPH, of Aetna.

Aetna, like practically every other insurer in the country, operates wellness programs that aim to change lifestyles. When you “go on a diet,” after all, the implication is that you’ll go off it. But are surgery and wellness the only options?

“Very little middle ground has been available that would help people if they’re trying hard with diet and exercise but are just not making it with those things alone,” says Pezalla.

Pezalla thinks there may now be that middle ground. Aetna is collaborating with the pharmaceutical companies Eisai and Vivus in a pilot program offering two recently approved weight-loss medications — Belviq and Qsymia. The drugs will be offered along with lifestyle support through Aetna’s healthy lifestyle programs and its CarePass Web site, https://www.carepass.com.

“The drugs provide a tool for people beyond diet and exercise — which is not easy — and surgery,” says Pezalla.

The medications are part of a three-prong approach. “The first is to tell employers and their employees about what’s already available,” says Pezalla. “Many of our larger clients are already purchasing wellness programs, metabolic screening programs, and health advisory programs from us. And all these things can help patients be healthier even if they don’t lose a lot of weight. If they eat healthier and exercise, this improves their outcomes as well.”

Members who qualify and begin treatment with Belviq or Qsymia receive free premium membership to the mobile app “Lose It!” by signing up through Aetna Navigator and CarePass.

And for employers that offer coverage for prescription weight-loss drugs, those medications are covered through the pharmacy benefit on the preferred tier 2, less expensive than the nonpreferred medications but more expensive than generics.

“Members must meet the criteria for the medication, which is consistent with the National Heart, Lung and Blood Institute guidelines, and also the package labeling from the FDA,” says Pezalla.

The move comes in the wake of the American Medical Association last June declaring obesity a disease, a step the AMA took against the recommendation of its Committee on Science and Health. The committee worries that the metric used to gauge obesity — the Body Mass Index — is imperfect and that unnecessary prescribing may follow. But a growing number of physicians say they wanted to improve coverage so that treatment could be extended to more patients.

Where it makes the most sense

Aetna’s program is geared toward self-insured companies.

“It’s easier to introduce something mid-year or mid-stream like this to a self-insured client than it is to try and put it into an already formulated, fully insured benefit package that also would require a benefit change to be filed,” says Pezalla. “We placed the program where it makes the most sense. Also, we’re not charging for this pilot. The cost is entirely just in the drugs and in the physician’s office visits to monitor the members. We think this is a great opportunity for us to supplement and augment the wellness programs that we already offer to those clients.”

Pezalla says enrollees are expected by this month. “We intend to evaluate as many members as we can in the program for at least a year so that we can get a good read on what’s happening. By the end of the year, we might have some preliminary data.”

He hopes to have the pilot available to approximately 200,000 members. “That will give us a large enough number to understand the percentage of utilization,” says Pezalla. “We will also understand the impact on medical costs. We want to be able to get that kind of data so that we can guide our clients in the future because more of these medications are expected to be approved over the next couple of years. Some of them are going before the FDA fairly soon. There are going to be questions for us and we want to have valid answers for our clients.”

No specific launch date

Pazalla expects to have four or five companies enrolled by the end of the summer, though there is no cap on number of participants. “Companies are going to come in as they’re willing to. There’s no specific launch date, and there’s also no specific end date.”

The program does not target individuals. “This is a population-level approach,” says Pezalla. “We make the drugs and all the other tools available and accessible as covered benefits for people. The members have the choice and are encouraged to talk to their doctors. We’re not telling people they should be using the medicines.”

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