Insurance Math and the GLP-1 Lottery
Insurance math means spending $500/month on health insurance premiums and then paying for all of your healthcare out of pocket anyway because your deductible is over $7,000. This is the situation for the majority of Americans with health insurance. Imagine if they all decided to boycott the health insurance industry, save $6,000 per year, and demand transparent and affordable cash prices for healthcare. Insurance math also means that the more you use your insurance, the higher the premiums, and anything covered by insurance increases in price. This is why cosmetic and other elective surgeries and procedures are much more affordable than covered surgeries and procedures, and it’s why Direct Primary Care is the most affordable way to pay for primary care.
46 million Americans have used a GLP-1 agonist for weight loss. That’s 18% of the US population. 74% of Americans are overweight or obese and could medically benefit from using a GLP-1 agonist for weight loss; however, most of them cannot afford this treatment. The market rate for these medications is $200-300/month. This is the average cost through compounding pharmacies, and over the course of the past year, cash prices for GLP-1 agonists from pharmaceutical companies has dropped from $500-1000/month to $200-300/month as insurance coverage for GLP-1 medications continues to decline, and the majority of users pays cash.
Insurance companies will reimburse pharmaceutical companies up to $1000/month for GLP-1 agonists. If insurance companies covered these medications for weight loss for all Americans who are overweight or obese, the cost would be over $3 trillion annually, and the cost of insurance premiums would need to double, such that individual health insurance premiums would cost over $1000/month for weight loss alone!
Last year, less than 1% of those with an ACA plan received coverage for a GLP-1 agonist for weight loss after their doctor completed a prior authorization. The prior authorization process is essentially a random lottery created by the insurance companies to ensure that patients continue to feel dependent upon health insurance and then blame their doctors when the prior authorizations are denied. I have completed numerous prior authorizations for GLP-1 agonists for my patients, but unfortunately, only a handful have been approved for weight loss, and most of these have been temporary, covered for the first year and then later denied.
Many of my patients have found that by switching from health insurance to a health share or an indemnity plan, they get the same or better financial protection against unexpected healthcare costs with hundreds of dollars saved each month, which they can then use to pay cash for GLP-1 agonists and still save money, which is a much better option than playing the GLP-1 lottery.
