While obesity is considered one of the top comorbidities among injured workers that can impede their recovery, and insurers and employers have funded weight loss surgeries, the workers compensation industry is unlikely to cover increasingly popular and less-invasive weight loss pills, experts say.
Semaglutide, which goes by brand names Ozempic and WeGovy, is a diabetes drug that has been making headlines as it also causes patients to lose weight by slowing down the digestive system and quelling the appetite. A “Hollywood effect” is also driving its popularity, as film stars have been knowingly taking the drug to lose weight.
Unless a patient is diabetic the drug is typically not covered by insurance, and studies show that when a patient stops taking the drug the weight creeps back on. It also comes with a list of side effects including the more common nausea and constipation to, possibly, thyroid cancer and gallbladder disease.
It’s the side effects and that the drug must be taken long term that will keep comp from covering it, experts say.
“It is a drug; it does have side effects. It does have consequences and, if it is not monitored properly, people could harm 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 covered under comp, 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 it’s the payer that’s charged with continuous monitoring, Ms. Reema said, adding, “We have to be careful about that.”
The industry, also, rarely voluntarily covers costs related to weight loss despite the correlation between recovery and obesity, said Stuart Colburn, a shareholder of Downs & Stanford P.C., headquartered in Dallas.
The Boca Raton, Florida-based National Council on Compensation Insurance Inc. in 2012, found that claims with an obesity comorbidity have 81% higher lost-time costs compared with claims involving non-obese injured workers. That was among the last larger studies that examined the obesity connection in comp although smaller studies have reinforced the idea that some injured workers won’t recover if their weight is not addressed.
“We do have case law from various states,” Mr. Colburn said. “They say reasonable and necessary medical treatment would include something so invasive as bariatric surgery. No payer that I know of is going to just voluntarily as a matter of rule go ahead and volunteer to do that.”
Mr. Colburn and others say semaglutide’s popularity could push it into the comp system.
“We haven’t seen evidence of that approach surface within our pharmacy data as of yet, but this is not beyond 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.