By: Ron E. Peck, Esq.

Insurance is supposed to be something you purchase to protect yourself against unforeseen – but costly – losses.  You don’t “expect” to be involved in a motor-vehicle accident, but you purchase automobile insurance to protect yourself against the costs incurred in an accident.  You don’t expect your home to flood or burn down, but you purchase homeowner’s insurance to protect yourself against the costs incurred in such incidents.  Automobile insurance does not pay to fill your car’s gas tank or change the oil.  These are foreseen, planned costs of automobile ownership and maintenance.  Homeowner’s insurance does not pay to replace the filters in your HVAC or power wash mold from the siding.  These are foreseen, planned costs of home ownership and maintenance.  Why, then, does health insurance pay for foreseen, planned costs of your body’s maintenance?  More importantly, how have recent trends taken advantage of our addiction to health insurance, and the expectation that it will pay for everything?

There is a direct correlation between maintaining your health and avoiding costly conditions.  Most health plans would rather pay for an annual checkup or routine exam, than be stuck paying for undiagnosed cancer or complications arising from untreated diabetes.  By paying for your body’s maintenance, your health plan hopes to minimize or avoid larger, catastrophic claims.  If there was a less costly “exam” your car could undergo once or twice a year, and it substantially reduced the likelihood that it would suffer a costly accident, would an auto-insurance carrier that is obligated to cover the costs of such an accident instead prefer to pay for that less costly exam?  Very likely.

Hence we find ourselves in a world where health insurance more or less pays for all of our healthcare – unforeseen and foreseen, planned and catastrophic.  So too do we find ourselves in a world where the consumer (that’s you and me – the patients) are not the payer (that would be our health plan).  When a consumer is the payer, they have an incentive to spend their money only on what is needed, and they are incentivized to seek out the best deals.  When a consumer is not the payer, they are less incentivized to care about the price.  While those who understand how insurance is funded recognize that high costs eventually trickle down to policyholders in the form of higher premiums, at the point of sale it’s hard not to overspend when you have “mom and dad’s credit card.”

Introduce into this world a wonder drug.  Introduce into this world a drug that can help you lose weight.  Sure, treating disease and staying well is great – but looking good on the beach?  Now that is something worth paying for… especially with someone else’s money.

One need only watch television, listen to the radio, or scroll through social media, and they will see non-stop chatter about Semaglutide and similar drugs, (sold under brand names such as Ozempic and Wegovy).  These medications are being prescribed at such a startling rate, pharmacists can’t keep them stocked.  Meanwhile, many of these medications – which are being used strictly for their weight loss properties – are actually primarily meant to help Type 2 diabetics control their blood glucose.  Thus, as a result of the weight loss demand, some diabetics can’t secure the medicine they need to maintain their health.

On top of that issue, health plans are being asked to pay for these drugs.  Certainly, in the case of a diabetic (who uses the medication as it was intended), this should be a covered expense.  For those that are not diabetic, however, and instead seek to use this solely for its off-label properties, should this be a plan expense?  Is it medically necessary?  Patients and providers argue that – for those enduring morbid obesity – failure to lose weight will likely result in greater costs for the plan, including Type 2 Diabetes.  Yet, many patients and providers are making such arguments in instances where the patient is hardly obese – or obese at all – and the specter of other weight-based ailments is nothing more than a phantom fear, used to grease the skids of payment by the plan.  

Health plans have a fiduciary duty to limit what they spend, and upon what they expend plan assets.  During this weight-loss-drug free-for-all, every health plan administrator should be auditing their claims to flag all such drugs, determine whether the applicable patient is a diagnosed diabetic, and if they are not – do a deep dive into whether they meet the definition of medical necessity; (in other words – is weight loss truly necessary to maintain their health, and if so, is there an equally effective but less costly option available to the patient).  If not, a hardline stance must be taken to avoid paying for what amounts to cosmetic claims.

Note – If and when the deep pockets of insurance are sewn shut, and would-be users of such drugs must pay for them out-of-pocket, we can expect to see the cost of such drugs drop drastically, just like the pounds we all hope to shed.