While obesity is considered one of the top comorbidities among injured workers that can hinder their recovery, and insurers and employers have funded weight-loss surgeries, the compensation industry is unlikely to cover increasingly popular and less invasive weight-loss pills, experts say.
Semaglutide, which goes by the brand names Ozempic and WeGovy, is a diabetes drug that has made headlines because it also makes patients lose weight by slowing the digestive system and suppressing appetite. A “Hollywood effect” is also driving its popularity, as movie stars have deliberately taken the drug to lose weight.
Unless a patient is diabetic, the drug is usually not covered by insurance, and studies show that when a patient stops taking the drug, the weight comes back. It also comes with a list of side effects including the more common nausea and constipation to, possibly, thyroid and gallbladder cancer.
It̵7;s the side effects and that the drug must be taken long term that will keep comps from covering it, experts say.
“It’s a drug; it has side effects. It has consequences, and if it’s not properly monitored, people can hurt themselves, said Reema Hammoud, Southfield, Michigan-based assistant vice president of clinical pharmacy for Sedgwick Claims Management Services Inc.
Hypothetically, if the drug is prescribed to an injured worker and is covered by compensation, the payer also inherits side effects as part of the claim, and if the claimant is kept on the drug indefinitely—as most semaglutide patients are—then the payer is responsible for continuous monitoring, Reema said, adding, “We have to be careful about that.”
The industry also rarely voluntarily covers costs related to weight loss despite the link between recovery and obesity, said Stuart Colburn, a shareholder at Downs & Stanford PC, headquartered in Dallas.
Boca Raton, Fla.-based National Council on Compensation Insurance Inc. in 2012 found that claims with an obesity comorbidity have 81% higher lost time costs compared to claims involving injured workers who are not obese. It was among the last major studies to examine the obesity link by comparison, although smaller studies have reinforced the idea that some injured workers will not recover if their weight is not addressed.
“We have case law from different states,” said Mr. Colburn. “They say that reasonable and necessary medical treatment would include something as invasive as bariatric surgery. No payer that I know of will just voluntarily as a rule go ahead and voluntarily do that.”
Mr. Colburn and others say semaglutide’s popularity could push it into the comp system.
“We have yet to see evidence of the approach in our pharmacy data, but this is not out of the realm of possibility given the attention these drugs are receiving for weight loss effects,” Nikki Wilson, senior director of clinical pharmacy services at Enlyte LLC, wrote in an email .