Ozempic? Mounjaro? Are they worth it in the overall costs of healthcare?

Doctors, clinically obese patients and insurance companies are not all on the same page on the issue.

A new report comments on how some health insurers are refusing to pay, and there is an ongoing evaluation of the balance between pharmacy costs and the long-term value of GLP-1 therapies.

The commentary from AM Best said that as pharmacy cost trends continue to rise and clinical evidence evolves, health insurers face a fundamental question on whether improvements in long-term morbidity and the potential for improved mortality outcomes ultimately justify significant investments in GLP-1 therapies.

“GLP-1 Therapies: Evaluating the Balance Between Pharmacy Costs and Long-Term Value,” states that GLP-1 therapies have become one of the most significant drivers of pharmacy spending across the healthcare industry.

Growing evidence, Best says, supports improved morbidity outcomes and more-effective chronic disease management, which may reduce future medical costs.

However, affordability pressures continue to shape health insurance coverage decisions, as GLP-1s remain a significant driver of pharmacy spending and long-term cost offsets remain uncertain.

AM Best director Joseph Zazzera noted: “The conversation now centres on whether the long-term health benefits justify the significant near-term pharmacy costs.

“Because GLP-1 therapies may require long-term treatment, they could continue to place upward pressure on pharmacy expenditures.”

The report says the most immediate impact of GLP-1 therapies from a population health perspective is likely to be on morbidity rather than mortality.

Morbidity typically refers to having a specific illness or health condition, while mortality refers to the number of deaths that a specific illness or health condition causes.

Obesity is one of the leading drivers of global chronic morbidity, serving as a primary risk factor for dozens of other debilitating medical conditions.

When an individual has obesity, it drastically increases their likelihood of developing co-morbidities — multiple overlapping chronic illnesses that diminish quality of life and place a heavy burden on healthcare systems.

The Best report notes: “If positive outcomes seen from GLP-1 therapies can be sustained, the potential to reduce healthcare utilisation, improve quality of life and lessen the long-term burden of chronic disease increases, which may reduce future medical costs.”

Whether improvements in morbidity ultimately translate into measurable reductions in mortality remains an important question.

The commentary also notes that most employer-sponsored health insurance does not cover GLP-1s for weight loss, so it is likely that many individuals are self-paying.

Even with lower prices for some of the GLP-1 therapies, the magnitude of individuals who could be eligible for weight loss drugs has insurers and employers continuing to grapple with the affordability implications.

In addition, because members frequently change employers and health plans, the payer funding today’s treatment may not be the organisation that ultimately realises tomorrow’s medical savings benefit.

Mr Zazzera added: “Pharmacy costs are immediate and measurable, while many of the anticipated benefits — including fewer diabetes complications, reduced hospital admission and improved management of obesity-related chronic diseases — may not be realised for years.

“GLP-1 therapies are likely to remain one of the industry’s most closely watched developments, influencing pharmacy trends, employer and health plan benefit designs and long-term healthcare economics.”