Read ASGE and ABE's response to the recent Wall Street Journal opinion commentary article, "The Economics of Obesity".
We read with great interest the opinion commentary article, “The Economics of Obesity” by Tomas J. Philipson. The article succinctly describes some of the factors contributing to obesity in America, namely inexpensive high calorie foods and decreased physical activity due to a trend towards sedentary jobs. While the complete picture is more complicated, these are clearly important factors contributing to the rising rates of obesity in the U.S and around the world, as Philipson points out.
The article also reviewed the costs of treating just one of the obesity-related diseases, diabetes, on a population level. However, to truly put this into perspective for patients and insurers it is useful to view costs from an individual patient perspective. Obesity is the leading risk factor for the development of type 2 diabetes when compared with genetic factors and lifestyle factors1 and affects 37 million adults in the US2. In 2017, insurers paid $9601 more in medical expenses for patients with diabetes3, which was directly related to their diabetes care. This pales in comparison to some other obesity related diseases. For example, body mass index (BMI) correlates with risk for cardiovascular disease4 and a study from the Kaiser Permanente Northwest cardiovascular disease registry found that the direct medical costs for patients with cardiovascular disease were an eye popping $18,953 per patient per year in 20055.
As presented by Philipson, weight loss through lifestyle modification alone is both difficult to achieve and, more importantly, difficult to maintain. Given the per patient costs of obesity and obesity related diseases and the limited success with sustained weight loss by lifestyle modification alone, the economic argument for treating obesity becomes clear. We wholeheartedly agree that new anti-obesity medications like semaglutide and tirzepatide (once approved by the FDA for weight loss) should be covered by CMS and private insurers. These medications will likely reduce overall medical costs; however, they are plagued by the same issues physicians face with all medications – poor patient compliance. In an analysis of 26, 522 patients for whom an anti-obesity medication was prescribed, only 7-28% of patients were still filling their anti-obesity prescriptions at 12 months6. Since weight gain recurs with cessation of an anti-obesity medication treatment, non-compliance can ultimately undo months of weight loss progress and reduce economic benefit.
Novel anti-obesity medications are not the only new treatments available for obesity. Multiple new minimally invasive endoscopic therapies have been developed to treat obesity and, in some cases, directly treat diabetes. They are part of a new category of treatments called Endoscopic Bariatric and Metabolic Therapies. In general, these procedures achieve less weight loss than bariatric surgery but are on par with the new weight loss medications. These interventions have significantly fewer complications and much faster recovery times compared to bariatric surgery because they are less invasive. Furthermore, the endoscopic bariatric therapies are commonly performed in the outpatient setting, do not require a hospital stay and eliminate the issue of patient compliance, which plagues medical therapy. Different categories of endoscopic bariatric and metabolic interventions are now commercially available and/or are part of clinical trials:
- Intragastric balloons (space occupying devices that are inflated in the stomach and removed after 6-8 months)
- Suturing and plication devices used in gastric remodeling procedures such as endoscopic sleeve gastroplasty, (these aim to reduce the caliber of the stomach lumen)
- Small bowel therapies which target the small intestine for diabetes treatment, and
- Non-balloon intragastric (stomach) devices.
The above therapies have not only demonstrated weight loss in multiple randomized controlled trials, but they have also been shown to positively impact obesity related metabolic diseases7.
While multiple devices have been approved by the FDA, only two are currently commercially available and include the Orbera Balloon and the Overstitch Suturing System used for endoscopic sleeve gastroplasty (Apollo Endosurgery, Austin TX). This limited commercial availability is not due to safety or lack of evidence for weight loss effectiveness – it is solely due to lack of insurance coverage and reimbursement for these procedures. For the most part, these procedures remain a “cash only” option for eligible patients in the United States.
Although costs vary from practice to practice, the vast majority of these procedures are performed at a cost that is substantially less than one year of treatment with the new obesity medications. Some also have weight loss benefits that can last up to 5 years or longer8, further supporting their economic benefit. So, while there is a strong case for coverage of anti-obesity medications, the case for covering endoscopic bariatric and metabolic therapies for both health and economic benefits is much stronger.
Endoscopic bariatric interventions have come of age with proven efficacy. It is time that insurance coverage and reimbursement models are also in place so more patients can benefit from these interventions and insurers can reap the economic benefits.
Bret T. Petersen, MD, MASGE
President, American Society for Gastrointestinal Endoscopy (ASGE)
Shelby Sullivan, MD, FASGE, FACG, ABOM
Immediate Past Chair, Association for Bariatric Endoscopy
University of Colorado Anschutz Medical Campus
1. Schnurr TM, Jakupović H, Carrasquilla GD, et al. Obesity, unfavourable lifestyle and genetic risk of type 2 diabetes: a case-cohort study. Diabetologia 2020;63(7):1324-1332. (In eng). DOI: 10.1007/s00125-020-05140-5.
2. CDC. National Diabetes Statistics Report website. In: CDC, ed.2022.
3. Association AD. Economic Costs of Diabetes in the U.S. in 2017. Diabetes care 2018;41(5):917-928. DOI: 10.2337/dci18-0007.
4. Metabolic mediators of the effects of body-mass index, overweight, and obesity on coronary heart disease and stroke: a pooled analysis of 97 prospective cohorts with 1·8 million participants. The Lancet 2014;383(9921):970-983. DOI: https://doi.org/10.1016/S0140-6736(13)61836-X.
5. Nichols GA, Bell TJ, Pedula KL, O'Keeffe-Rosetti M. Medical care costs among patients with established cardiovascular disease. Am J Manag Care 2010;16(3):e86-e93. (In eng).
6. Ganguly R, Tian Y, Kong SX, et al. Persistence of Newer Anti-Obesity Medications in a Real-World Setting. Diabetes Res Clin Pract 2018. DOI: 10.1016/j.diabres.2018.07.017.
7. Jirapinyo P, McCarty TR, Dolan RD, Shah R, Thompson CC. Effect of Endoscopic Bariatric and Metabolic Therapies on Nonalcoholic Fatty Liver Disease: A Systematic Review and Meta-analysis. Clin Gastroenterol Hepatol 2022;20(3):511-524.e1. (In eng). DOI: 10.1016/j.cgh.2021.03.017.
8. Sharaiha RZ, Hajifathalian K, Kumar R, et al. Five-Year Outcomes of Endoscopic Sleeve Gastroplasty for the Treatment of Obesity. Clin Gastroenterol Hepatol 2021;19(5):1051-1057.e2. (In eng). DOI: 10.1016/j.cgh.2020.09.055.