Europe’s lessons for the U.S. on how to cover weight loss drugs

It’s no secret that the obesity epidemic in the United States has reached alarming levels, with rates surpassing 40% of the population.

Despite a robust focus on wellness and exercise in the media, post-pandemic America continues to rank among the global leaders in obesity rates. Estimates indicate that treating obesity will be expensive, but those sums pale in comparison to the estimated direct and indirect costs of $1.7 trillion that obesity places on the U.S. health care system today. In 2018, research found that obesity is the No. 2 cause of preventable death in the United States.

As the CEO of a company based in the U.S. that also has an obesity drug on the market across Europe, called Contrave, I’m very familiar with the vast differences in the policy landscape between the two regions.

One driver of this disparity is our differing attitudes toward obesity. Historically, obesity has been seen as a lifestyle choice, physicians received little training on treating it, and there was, and still is, little to no treatment coverage by government and commercial insurers. Combine these elements with the social stigma of being overweight, and both the physician and patient shy away from difficult conversations about treatment options.

As we seek new approaches to what is one of our most urgent public health challenges, we can look to countries that are years ahead of us in treating obesity. Countries in Europe — including Norway, the Netherlands, Poland, and Italy — have instituted a range of reimbursement policies that demonstrate a possible pathway to affordable coverage for the U.S.

Pioneers like Andres J. Acosta of the Mayo Clinic have advanced our understanding of obesity with groundbreaking research. Obesity, we now know, is not a lifestyle choice, it’s a disease — one with multiple causes that accordingly demands a variety of treatments options. As the Mayo Clinic has highlighted in research, those grappling with obesity tend to fall into four distinctive categories:

• Hungry brain: mainly controlled by the brain-gut axis
• Emotional hunger: characterized by a desire to eat to cope with emotions and cravings
• Hungry gut: an abnormal duration of fullness (shortened)
• Slow burn: decreased metabolic rate

According to the study, the recently approved GLP-1 weight loss drugs like Wegovy are associated with the treatment of the hungry gut, and existing medications like Contrave and Qysmia are associated with emotional hunger and hungry brain, respectively. Patients need access to all medications empowering physicians to treat the different disease phenotypes most effectively.

Unfortunately the meaningful progress in classifying obesity as a disease is offset when it comes to patient access to medications and treatments; patients are left to fend for themselves. The lack of reimbursement for obesity treatments under government health care programs like Medicare and commercial payers make these medications unaffordable. Lack of access has, in turn, led to the escalation of comorbidities, worsening patient outcomes, and unnecessary preventable deaths.

Still, there are reasons to be optimistic. Perhaps most notably, the Treat and Reduce Obesity Act (TROA) was reintroduced. If Congress passes it, the bill would provide patients with obesity with Medicare coverage for all drug classes, which would be a meaningful step forward in ensuring access to treatment. The number of sponsors and co-sponsors of this bill is increasing, which makes me optimistic. Organizations like mine involved in treating obesity benefit from the passing of TROA, but the greatest benefit is for patients gaining affordable access to treatment for their disease.

Passing of TROA would be the first step toward the kind of obesity coverage already established by many European countries. They are leading the way when it comes to affordably treating obesity while slowing the progression of the disease.

The multisystem U.S. payer model stands in contrast to the European public payer model both in reimbursement guidelines and in treatment guidelines. The European treatment guidelines are established by the public payer system and then published and available to the patient population. In the U.S., we do not have that visibility. As the U.S. enters obesity coverage both our public and private payers could learn from the European published guidelines to affordably treat obesity while slowing the progression of the disease.

Many of them have experimented and adjusted their approach over multiple years. Initially, for example, individual reimbursement was established, allowing access to anti-obesity medications on a per-person basis. However, as costs escalated, access and coverage were adjusted in smart ways that would also benefit Medicare.

These adjustments diversified treatment options depending on the severity of the obesity, reducing the financial burden but still ensuring access to medications and slowing the progression of the disease. The CDC defines overweight as BMI between 25 and 30; Class 1 obesity as BMI 30 to 35; Class 2 obesity as BMI of 35 to 40; and Class 3 as BMI of 40 and higher. Some European coverage models deploy effective but lower-cost medications for patients with lower BMI — like my company’s Contrave, sold in Europe under the name Mysimba — while reserving GLP-1 treatments for patients battling more advanced cases of obesity.

Norway’s and the Netherlands’ treatment guidelines both deploy the approach of covering and reimbursing treatment types based on the patient’s obesity class, recommending treatment for overweight and lower classes of obesity with non-GLPs, like Mysimba, and recommending treatment with GLP-1s, like Wegovy, for the higher classes of obesity.

This approach ensures patient access and treatment, slowing the progression of the disease, in a cost-effective manner. U.S. payers could decide to approach treatment guidelines, both public and private, for obesity coverage in the same manner. Both the public and private insurers are striving to find ways to ensure access and treatment to obesity therapies affordably.

Italy’s guidance, for example, specifically states that Mysimba “could be a good choice in patients who struggle with emotional eating.”

The Polish policy also recommends Mysimba for emotional eating, binge-eating disorder, night-eating syndrome, or food addiction while offering a recommended use case for the GLP-1s: “This drug (liraglutide) should be the first choice in the treatment of obesity in patients with prediabetes or type 2 diabetes, as well as clinical features of insulin resistance. …” (Liraglutide is sold in the U.S. as Saxenda.)

U.S. payers could take the same approach as Italy and Poland and deploy the scientific foundations found in the Mayo Clinic study to establish the assessment of phenotypes, selecting the most effective medication for each patient type. Italy and Poland have established their treatment guidelines based in science.

Of course, medications alone won’t fully address this complex chronic disease, and investments in behavioral change are an important component to any health transformation.

Or look to the Netherlands, which requires individuals seeking pharmacotherapy for obesity treatment to participate in a behavior-modification program for one year prior to accessing anti-obesity medications with zero out-of-pocket cost. Since 2019, insurance companies across the Netherlands have reimbursed for interventions that help overweight citizens live healthier lifestyles.

These countries show that it’s possible to provide affordable and effective obesity coverage backed by science. It is past time that patients suffering from obesity receive access to medications and reimbursement for those prescriptions — just like patients suffering from any other chronic disease.

George Hampton is the president and CEO of Currax Pharmaceuticals.