March 29, 2024 – It could be a case of: if you can’t beat 'em, join 'em. Commercial weight loss companies like WeightWatchers and Noom, which were around before the explosion in popularity of some weight loss medications, now offer them to their members.
Providing glucagon-like peptide 1 (GLP-1) receptor agonists like semaglutide (Wegovy) or tirzepatide (Mounjaro) to the right candidates gives their subscribers as many options for weight management as possible, company representatives said. They emphasized that their firms carefully screen and refer people to medical professionals who work with their organizations.
While applauding the role that these behavior-based weight management programs play in a comprehensive approach, an academic weight loss doctor thinks the order is backward. Instead, people with obesity should see a primary care or obesity expert doctor first, then get referred to these commercial programs, said Caroline M. Apovian, MD, co-director of the Center for Weight Management and Wellness at Brigham and Women’s Hospital in Boston.
“These kinds of partnerships are important,” she said. “It should be with a medical treatment program first, as the main event, and the behavioral program as [a supplement] – not the other way around.”
Brigham and Women’s Hospital, for example, refers patients to a behavioral weight management company, Restore Health, to provide the medications.
“I am in no way saying that the behavioral treatment that WeightWatchers and Noom offer is not important. It's extremely important,” said Apovian, who is also a spokesperson for the Obesity Society, a professional organization dedicated to obesity treatment and prevention.
Primary Care Bottleneck?
“In an ideal world, that would be wonderful. However, the truth is that now less than 1% of providers are actually trained to provide obesity care,” said Amy Meister, DO, chief medical officer at WeightWatchers.
According to the American Board of Obesity Medicine, there are 8,263 doctors certified in obesity medicine in the U.S. and Canada. There are more than 1.1 million active physicians in the U.S. alone.
“A lot of people come to us and our competitors quite frankly because they can't get into traditional brick-and-mortar settings. Access is probably the number one thing that we bring to the table – and not just access to care, but access to providers which are specifically trained with that expertise,” Meister said.
The chief medical officer at Noom mirrored this take on the situation. “Primary care physicians are terribly strapped in terms of their bandwidth,” said Linda Anegawa, MD. Treating obesity takes time, sensitivity, and experience. She estimated that most doctors only receive about 10 hours of obesity-specific instruction during medical school and training.
“As a primary care doctor myself by background and training, I cannot overemphasize the importance of having a primary care doctor. I do know that many primary care doctors feel ill-equipped to deal with the needs of the medical patient who is undergoing obesity treatment. They don't feel that they have the specialized knowledge or training to fully support these patients.”
At the same time, the most recent CDC estimates reveal that 42% of Americans are obese, including 9% who are severely obese.
“Finally, we have effective treatments. But this is in the context of tremendous need, tremendous demand, and a tremendous cost,” Anegawa said.
The Reaction So Far
In May 2023, WeightWatchers purchased the telehealth company Sequence, a medical group that can prescribe drugs in 50 states and Washington, DC. They launched WeightWatchers Clinic in December the same year. Last year, Noom also launched a medical weight management program, Noom Med. The telehealth weight loss company Calibrate, established before these medications became so popular, now offers them as well.
“We've actually had a better response than we predicted,” Meister said. By the end of 2023, 67,000 people had subscribed to the WeightWatchers Clinic program. An estimated 70% of them came from the 3.8 million active WW members, or from lapsed members who returned because of the new offerings. “Unfortunately, the diet lifestyle solution just wasn't cutting it for them. Now they meet with our doctors and nurse practitioners to try a medical solution.”
Due to what Kristin Baier, MD, Calibrate vice president of clinical development, calls their extensive screening process before sign-up at Calibrate, an estimated 90% of prospective candidates who attend their doctor appointments are considered eligible for GLP-1 medication.
Obesity the Disease
For many years, obesity was viewed as a lifestyle problem. More recently, it is considered a complex and chronic disease, one that calls for a comprehensive medical approach and personalized treatment. “There's a dysfunction in the energy regulation pathway that goes from the gut to the brain,” Apovian explained. The medications are analogs of gut hormones that our body normally releases when we are eating. The hormones “let the brain know that you've eaten enough, that you're full. So, these medications are correcting a dysfunction for a serious disease.”
The anti-obesity medications, therefore, play an important role, agreed Katherine H. Saunders, MD, an obesity expert at Weill Cornell Medicine in New York and co-founder of Intellihealth, a firm that delivers virtual medical obesity treatment. “Most people with obesity are unable to lose a significant amount of weight and maintain their weight loss long-term with lifestyle interventions alone.”
Even though the GLP-1s are in the spotlight, they’re not the whole story, said Saunders, who also serves as a spokesperson for the Obesity Society. “It’s important to note again that obesity treatment isn’t about just one class of medications. There is so much we can do to treat obesity without [GLP-1s].”
“Because obesity is a complex, chronic disease, obesity treatment requires more than just medication for long-term sustainable results,” Baier said.
That could be good news for people who cannot access or afford these medications.
What About the Cost?
GLP-1 medications are expensive, and only a minority of insurance companies cover them for weight management. We asked these companies how they address the estimated $1,000 to $1,500 per month with their members.
“Medication cost is a huge problem, but it’s just one barrier preventing individuals with obesity from accessing life-saving medical treatment,” Saunders said. Other problems include a need to train more clinicians in comprehensive and long-term obesity care, a need for more payers and employers to cover care, and an increase in medication supply to meet demand, she said.
Apovian agreed the cost can be prohibitive.
“Nobody wants to pay out of pocket for these drugs, not even people with a lot of money. They're $1,500 a month, and you have to be on them forever,” she said.
She predicted people who want to lose 10 pounds before an event will pay for a few months, and they expect to regain the weight after they stop. But, she said, “That's not what these medications are for.”
Noom also offers medications “that are less costly for that patient but that can also be effective,” Anegawa said. “This can help maximize the effectiveness of GLP-1s while helping to contain cost.”
Pursuing Insurance Coverage
WeightWatchers, Noom, and Calibrate each highlighted that they have staff dedicated to pursuing insurance coverage for anti-obesity medications for their members. The companies handle the paperwork for prior authorizations and resubmitting denied claims, for example. “That’s part of our secret sauce,” Meister said.
Even so, only about 20% to 30% of the private insurers cover anti-obesity medications, Apovian said.
“Doctors do not have the time to deal with prior authorizations,” Anegawa said. Most doctors do not have the staff trained and equipped “to really pump out these appeals and denials and handle the mountains of paperwork. This gives us a unique advantage in prescribing.”
“Paying out-of-pocket for GLP-1s isn’t feasible for most people,” Baier said. “Navigating the red tape insurance has placed around access to these life-changing medications is daunting.”
She said that Calibrate helps members access medication by navigating their formularies to figure out which GLP-1 medications are covered based on their specific health history and insurance coverage.
“We have to demand better access for our lifesaving medications,” Apovian said. For example, in a clinical trial, semaglutide lowered major problems in the heart and blood vessels by 20%. “So now … 70% of insurance companies are not covering these agents – denying life-saving drugs to patients with significant obesity. That's a problem, right?”
Meister said that WeightWatchers also helps patients find medication during shortages by calling up to nine pharmacies within driving distance or contacting mail-order pharmacies if that is an option. “If you miss dosages because you can't get the drug, sometimes you have to start over,” she said. “That can be really frustrating to both the doctor as well as the patient, because it's going to impact their care and their outcome.”
“Obesity is a complex chronic disease. It's a treatable disease, but a holistic approach is needed.” Anegawa said. “While the GLP-1s have absolutely been therapeutic game-changers for those of us in obesity medicine, they're not a cure. So you really do need that anchor in behavioral change to help along with the medication, rewire the brain's craving pathways, improve insulin resistance, and drive those long-term improvements and the health outcomes that we are all looking for.”
