Obesity/Overweight | Access and Reimbursement | US | 2016

Type 2 diabetes and obesity are chronic diseases that affect millions of Americans and represent a costly expense for the nation’s healthcare payers. In the effort to manage quality and costs associated with treating these conditions, many health insurers have turned to accountable care organizations (ACOs) to better coordinate care for large patient populations. Given the large affected population and the availability of a range of effective drugs and measurable outcomes, type 2 diabetes represents the low-hanging fruit for the ACO. As a contributor to diabetes, obesity has also become a focus of ACO management, especially since the emergence of novel branded therapies—including the latest, Orexigen Therapeutics/Takeda Pharmaceutical’s Contrave (naltrexone SR/bupropion SR)—that illicit greater weight loss but are much more expensive than generic phentermine. As ACOs work to manage diabetes care, they are faced with a broad array of branded, non-insulin therapies whose distinct mechanisms of action improve upon the effectiveness of generic metformin. These classes have become familiar to payers over the past decade: oral DPP-IV inhibitors, such as Merck’s Januvia (sitagliptin); the oral SGLT-2 inhibitors, such as Johnson & Johnson’s Invokana (canagliflozin); and the injectable GLP-1 agonists, such as Novo Nordisk’s Victoza (liraglutide). ACOs are making PCPs and endocrinologists more conscious of the long-term consequences of each prescribing decision by linking their reimbursement to the achievement of goals such as reducing hospital readmissions and total medical costs, as well as saving on prescription drug costs.

Questions Answered:

  • The novel weight-loss drugs that have launched in the United States since 2012 have struggled to gain coverage through Medicare, but their potential to help curb the diabetic epidemic increases their chances for coverage in the commercial ACO setting. What percentage of managed care organization (MCO) directors say that their commercial ACOs are more likely to cover obesity drugs in the ACO setting because of the ACO’s focus on diabetes management? What is the difference in coverage and tiering among the branded weight-loss therapies, and how widespread are formulary exclusions? How has ACO involvement affected PCPs’ and endocrinologists’ prescribing patterns for weight-loss drugs?
  • Surveyed physicians’ prescribing is influenced by a variety of factors, including the preferred therapies established by their ACOs. How do PCPs and endocrinologists value the various attributes of diabetes (and obesity drugs) differently in the ACO setting versus their normal practice? How are physicians encouraged to meet the goals of the ACO? What are surveyed physicians reporting about their ACOs’ impact on the drug choices they make? What formulary do physicians use when prescribing drugs?
  • A primary feature of an ACO is the financial incentives that are built in to hold providers accountable for the care of ACO members, but the level of accountability varies by ACO. How do MCOs hold providers in the ACO responsible for keeping drug spending in check? Do MCOs expect ACOs to take full financial risk for pharmacy as well as medical services and in what time frame? On what quality measures are physicians tracked—both general ACO measures and those relating to diabetes and obesity drugs in particular?


Markets covered: United States.

Primary research: Online survey of 70 PCPs and 71 endocrinologists, 30 MCO medical directors, and 11 MCO pharmacy directors.

Commercial context: Drug profiles, epidemiology tables, drug-treatment algorithms, and ACO background information.

Therapies covered: Weight-loss therapies and three classes of antidiabetic drugs: DPP-IV inhibitors, GLP-1 receptor agonists, and SGLT-2 inhibitors.

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