West Virginia’s Public Employees Insurance Agency for a short time ran a pilot program to support more than a thousand members with the costs of drugs to fight obesity, where the state’s statistics rank worst in the nation.
But, like other states, West Virginia was challenged by the expense of the drugs. PEIA paused the pilot program this past March 15, honoring existing pre-authorizations through June 30, the end of the fiscal year, or the term of the authorization, whichever was longer.
“The reasons for pausing the program were multifaceted and included cost, supply shortages, potential side effects, and inconclusive results. Many state programs, including PEIA, are facing similar adversities,” state officials said in response to MetroNews questions.
A medical weight management expert at West Virginia University has continued vocal support for the benefits these drugs could achieve if they were in reach for state residents. Meanwhile, a medical researcher at WVU penned a recent opinion piece in the Charleston Gazette-Mail headlined PEIA faces weighty decision.
The drugs like Wegovy and Zepbound may be used to treat obesity or diabetes — or both — but some insurers including most Medicaid programs only cover them when they are used to manage diabetes. The question for states as they try to consider public interest is how much to expand access for weight loss.
The balance of the potential benefits of weight loss drugs versus the cost has been a challenge across the country. A New York Times article highlighted the difficulty, spotlighting West Virginia among states struggling to meet the challenge.
The national article noted that at the time PEIA canceled its pilot program to cover weight-loss drugs the cost was mounting even though the program was limited to about 1,000 people — adding up to about $1.3 million a month. Brian Cunningham, PEIA’s director, told the Times that if the program were expanded to include up to 10,000 people as intended, the program could end up costing $150 million a year.
MetroNews has tried to ask the state’s chief executive, Gov. Jim Justice, about his view of what priorities should be considered on the matter — but has been shut out of recent administration briefings. Questions could have been: Do you have a position on the program? Would it be worthwhile to start it back up? Is cost a concern? Do we need to know more?
PEIA, through the communications staff of the state Department of Administration, provided written responses to questions posed for this article.
The drugs at the center of this issue are called GLP-1s, which stands for glucagon-like peptide receptor agents — a class of medications that treat Type 2 diabetes and obesity. The well-known Ozempic drug is GLP-1. So is Wegovy.
State representatives said PEIA has roughly 7,000 diabetic users of GLP-1s. At its height, the weight management program had nearly 1,100 members. The gross spend on all GLP-1s for the most recent fiscal year was more than $93 million, an increase of roughly $30 million from the prior fiscal year, state officials said.
“Simply put,” state officials said, “if a majority of individuals that meet criteria for either diabetes or weight management were prescribed a GLP-1, PEIA could easily experience a gross spend on GLP-1s of $500 million or more annually. While there are rebates that bring down the net cost of the drugs, those rebates are becoming less reliable.”
The cost of these drugs was a recurring theme of the most recent meeting of the PEIA Finance Board. “How do we come up with a more permanent or long-term strategy around weight loss?” asked Doug Coffman, a PEIA board member from Harrison County who represents hospitals.
In response to questions for this story, state officials said that matter will continue to be explored.
“PEIA continues to seek opportunities for making GLP-1s available to our critical need customers. While we understand the public interest in GLP-1s, finding a solution that meets the needs of all parties, and that is financially sound and sustainable, will take time.”
West Virginia’s Legislature has had some discussions of the cost of weight loss drugs — an issue that clearly affects both citizen health and government budgets.
“We talked to PEIA on this because our constituents were in this study,” said Delegate Amy Summers, R-Taylor, chairwoman of the House Committee on Health and Human Resources.
Summers said she understands the cost to the state is considerable and noted “We’re trying to keep insurance rates reasonable.” Her hope is that the cost could change based on the number of people in the market for the medicine: “As supply goes up and cost goes down, maybe they will reconsider — but not currently,” she said.
Dr. Laura Davisson, the chief of obesity medicine and director of the medical weight management program at WVU, noted that the pilot program for PEIA had limited numbers of participants and concluded it’s a shame that it was cut short.
“PEIA’s pilot program limited coverage to only a very small number of prescribers, so the magnitude of the financial impact was much less here than in other states,” Davisson said.
“For example, when North Carolina started covering anti-obesity GLP1s, coverage was wide open to all prescribers, so they quickly ended up with 25,000 patients on the medications for obesity. They saw that number increasing and got worried about sustainability and stopped coverage. 25,000 patients with wide-open prescribing is very different than 1,100 patients with extremely limited prescribing in a pilot program.”
She continued by noting the cost reporting is complicated because the same medicines used to treat obesity may also be used to treat diabetes. Although the two conditions may be intertwined, the two potential uses for treatment may complicate an assessment of the numbers of participants and costs.
“The actual cost for covering these 1,100 patients is unclear because we keep hearing the costs for the GLP1 spend, which includes the GLP1s used for diabetes, not just the spend for these 1,100 additional patients. We also keep hearing PEIA cite costs based on list prices which does not reflect what they actually pay after they get their rebates,” Davisson said.
She continued by observing that PEIA cited “inconclusive results” as one of the reasons for halting the pilot program, “but I have never heard them say what result they were using to determine success.”
WVU Medicine’s Medical Weight Management program was one of the authorized prescribers for the pilot program. Davisson said she cannot attest to the results of the broader pilot program, but, based on the results collected at WVU, “I think the results were incredible.”
Davisson presented the results to PEIA: The average weight loss of PEIA patients in the program at WVU was more than 14%.
“We typically look at weight loss in percentages, so to put that in context for readers who may think in pounds, a 14% weight loss for someone weighing 300 pounds would mean losing 42 pounds. A typical weight loss program that relies on lifestyle changes alone achieves a 5-7% weight loss which means that by adding the additional medical tools that our program can add, we can at least double the results of those other programs,” she said.
Should the pilot program get another go?
“My answer to that is a resounding yes. Everyone seems to be in agreement that in theory they would want to see it started back up if cost were not an issue. I think we should let the people in the pilot program continue therapy while working out a long-term plan to develop a program for the rest of the state. I have some ideas for how to offer obesity treatment in an appropriate cost-effective way and am happy to help with that,” Davisson said.
“The pilot is a small number of people we are talking about. They have gotten tremendous benefits from treatment and they are devastated by losing it.”
