How Medicare Could Help Manage Obesity - Western Asset Protection
How Medicare Could Help Manage Obesity

How Medicare Could Help Manage Obesity

Obesity rates have risen dramatically in the U.S. among all demographics, including older adults. Now, 41.5% of adults aged 60 and above are considered obese. Obesity in seniors can have serious implications, including increasing the risk of chronic disease, disability, and early death.

As obesity increases, attitudes are changing. What was once considered a personal failure due to lack of willpower is now understood to be a complex medical issue. Factors contributing to weight issues are not just environmental but also involve genetics, metabolism, and the microbiome of the gut.

New drugs on the market offer hope to many who have struggled unsuccessfully with weight loss. You may be fielding questions from your clients about these drugs. Currently, Medicare does not cover them, but you should still be fully informed and able to speak knowledgeably with your clients about the current situation and what the future may hold.

Obesity and Chronic Health Conditions

Obesity causes or contributes to many chronic health conditions, including diabetes, high blood pressure, high cholesterol, many cancers, heart disease and strokes, autoimmune diseases (such as lupus and rheumatoid arthritis), fatty liver disease, and sleep apnea, which is linked to higher rates of dementia.

Obesity can also impact mental health. Some people who are overweight struggle with poor self-image and depression, which can lead to reduced social interactions and isolation.

New Weight Loss Drugs

Ozempic and Wegovy are brand names for the same drug: Semaglutide, a glucagon-like peptide-1 (GLP-1) receptor agonist. Ozempic was approved in 2017 to treat diabetes, and Wegovy was approved in 2021 to treat obesity.

The drugs work by decreasing appetite and slowing digestion, helping people to feel full longer, which results in them eating less.

The drugs are authorized by the FDA for people with a BMI of 30 or greater or with a BMI of 27 or greater who have other chronic health issues that would improve with weight loss. The drugs are administered once a week by subcutaneous (under the skin) injection.

People who lose weight with these new drugs might need to keep taking them indefinitely since early studies show that individuals who stop taking the drugs gain weight back quickly.

Potential Side Effects and Risks in Seniors

Most clinical trials of these drugs were conducted with adults in their 40s and 50s. More studies are needed to fully understand the impact of the drugs on people over age 65.

Known side effects and risks include:

  • Gastrointestinal – People over 65 are more likely to experience gastrointestinal side effects like nausea and vomiting.
  • Bone loss and brittle bones – Rapid weight loss can make bones less dense and increase frailty, which can be a serious concern for seniors. The drugs may impair calcium intake and absorption.
  • Loss of muscle mass – Muscle mass naturally decreases with age, but these medications can lead to a greater loss, putting seniors at higher risk for falls and fractures. For seniors, maintaining muscle mass is key to staying mobile and independent.
  • Insufficient nutritional intake – The decrease in appetite can result in insufficient intake of proteins, nutrients, and fluids.
  • Fatigue – Seniors taking the medications reported an increase in fatigue.
  • Sharp drops in blood pressure – Fast weight loss can cause sharp drops in blood pressure, which can lead to dizziness and falls.

Medicare Coverage and Potential Cost Implications

A 2003 provision in a Medicare Part D law means Medicare may not cover any drugs prescribed for weight loss or weight gain. The cost of the drugs without insurance coverage is prohibitive – averaging approximately $1,300 per month – which means most seniors will find them unaffordable.

Congress is under pressure from Medicare beneficiaries, patient advocates, and drug manufacturers to change this law. In July 2023, the Treat and Reduce Obesity Act of 2023, which would allow Medicare to pay for weight loss drugs, was introduced to Congress. The bill was referred to the Subcommittee on Health, where it now resides. Congress must conduct a cost-benefit analysis to better understand how much federal spending will increase to cover the cost of the drugs. The increase could impact Medicare premiums for all beneficiaries. Some experts believe that instead of across-the-board approval, it is more likely there will be partial approval of the drugs for Medicare beneficiaries who qualify due to their BMI and another chronic health condition, such as heart disease.

What Medicare Currently Covers

Clients who ask about weight loss drugs may be disappointed to find out that Medicare does not cover them. However, you can let them know what Medicare does cover to support their efforts to lose weight and stay healthy.

  • Behavioral Therapy for Obesity – Covered in full for individuals with a BMI of 30 or higher, this benefit provides obesity screenings and behavioral counseling with a primary care doctor.
  • Bariatric Surgery – Medicare only covers two types of bariatric surgery: gastric bypass and laparoscopic banding. This is available for individuals with a BMI of 35 or higher who have an underlying health condition, such as diabetes or heart disease. A doctor must have determined that the surgery is medically necessary and candidates must prove they have been unsuccessful with weight loss through dieting and exercise. Deductibles and copays may apply, depending on the individual’s Medicare plan. Rapid weight loss from surgery can result in bone and muscle loss, resulting in some of the same health risks as with weight loss medications.
  • Dietitian – For those with qualifying health conditions (such as kidney disease or diabetes), Medicare will cover a nutrition and lifestyle assessment and working with a registered dietitian to create a plan for healthy eating.
  • Gym Benefits – Many Medicare Advantage plans offer gym benefits, such as through SilverSneakers.

Your Role as a Medicare Agent

It may seem uncomfortable or even inappropriate to mention weight loss to your clients unless they bring it up first. However, there are steps you can take to make sure clients know about their benefits and are receiving the right care. For instance, you should remind all your clients to make an appointment for their Annual Wellness Visit with their primary care doctor. During these visits, their doctors will discuss any chronic health issues (including weight) along with an appropriate treatment plan. Educate your clients on any wellness benefits their plan covers that can support weight loss, such as gym memberships.

Do you have questions? The experienced team at Western Asset Protection is here to support you as you grow your business. Contact us today.