Capitol Fax.com - Your Illinois News Radar » Behind the CMS cost projections

Monday, May 6, 2024 - Posted by Rich Miller

* From a recent Sun-Times editorial…

The country’s obesity rates have been scaling up over the past two decades. Nearly 42% percent of adults in the U.S. qualified as obese in 2023, data collected by nonprofit Trust for America’s Health show.

Children haven’t been faring much better. Roughly 20% of boys and girls ages 2 to 19 were obese between 2017 and 2020, according to the U.S. Centers for Disease Control and Prevention.

The numbers for Black and Hispanic populations are even worse, due to a lack of nutritious food options, poor access to health care and other structural barriers. […]

The initiative is estimated to cost taxpayers $210 million the first year, although Pritzker spokesperson Jordan Abudayyeh said the price tag could end up being less. […]

The Pritzker administration needs to lay out the exact math for how much taxpayers will have to shell out for the weight-loss drugs as soon as it can. Or explain further why its estimate is more accurate than the other. Taxpayers deserve to know the final price of what they’re paying for.

Let’s take a look.

* Seven out of nine state health insurance policies were already covering these drugs. This was an expansion, mainly to Downstate areas that aren’t covered by Health Alliance and Aetna HMO. Those two state plans cover about 72,000 employees and dependents out of a total of 350,000 or so, about 21 percent.

Of those seven which already did cover the weight-loss drugs, Blue Cross’ HMO IL and its Blue Advantage plans don’t break out individual costs. Those two plans cover about 41,000 employees and dependents out of about 350,000 employees and dependents, or about 12 percent of all covered people.

* Five of those seven plans which were already covering the drugs, Aetna OAP, Aetna PPO, Aetna High Deductible Health Plan, HealthLink OAP, Blue Cross Blue Shield OAP, do have trackable expenditures because their prescriptions are administered by the state’s Pharmacy Benefit Manager, CVS Caremark. Those five plans cover almost 154,000 employees and dependents, about 44 percent of the total in all nine plans.

From the state…

According to CVS Caremark, in Fiscal Year 23 the following coverage was provided member and dependents covered under the State Employees Group Insurance Program for weight loss medication:

• Injectable weight loss prescriptions

o Total Rx claims: 7,580
o Total Users: 2,325 (up from FY22 total users of 993)
o Total Cost to the State: $10,620,147.72

• Oral weight loss prescriptions

o Total RX claims: 427
o Total Users: 233 (down from FY22 total users of 236)
o Total Cost to the State: $28,725.35

So, that’s a total of about $10.649 million last fiscal year for about 44 percent of all covered employees and their dependents. That would be around $23 million for everybody in the system if you extrapolated it out and everything else is even.

We don’t know yet what the FY2024 numbers are.

* However, CMS is projecting usage will rise to about ~~20,000~~ 16,000 people in FY25, from about 2,300 in FY23 - a 770 percent increase.

Plausible? I guess we’ll see. But the thing to remember is that the recent expansion will only account for a fraction of the total new cost increase.

26 Comments

- Three Dimensional Checkers - Monday, May 6, 24 @ 1:13 pm:
What’s the cost of not providing the weight-loss drug to people who need it? That needs to be taken into account too.

- Google Is Your Friend - Monday, May 6, 24 @ 1:15 pm:
==Plausible? I guess we’ll see.==

Who is to say there is even supply enough to cover such a projection? Ozempic has already had dosage cuts for starting the medication (which is also used for diabetes treatment) and Wegovy can’t meet demand currently.

- Tony DeKalb - Monday, May 6, 24 @ 1:19 pm:
I’m biased since I’m on one of the injectables and have seen results, but isn’t it better to pay now to have people lose weight and improve blood sugar numbers than pay even more in the future for surgeries and other more expensive treatments due to advanced diabetes, heart disease etc because of obesity?

- Dakno Thing - Monday, May 6, 24 @ 1:19 pm:
I was puzzled by this editorial and by the original article by it linked to which I found condescending at best and scornful of people who struggle with their weight at worst. Also- to quibble with a point in this article - diet and exercise don’t actually work for everyone, especially with people who have a genetic predisposition to obesity. And it’s attitudes like the ones espoused by the Sun Times that have gotten in the way of getting people help for real medical conditions. I have a few close relatives who have gone on these medications - including one who staved off a diabetes diagnosis and another who was dealing with hypertension and high blood pressure who has seen both of those problems resolve due to the medication. Both were folks who exercised regularly and ate well - but nothing they did seemed to work.

First has anyone done a study on how much the state will save in the long run providing these drugs and not having to cover things like insulin and heart operations?

Second, even if it does cost money aren’t the health benefits that these drugs convey worth the cost?

I’m baffled that there is any controversy here. Frankly if I were the legislature and the administration I’d be telling everyone they worked to cover these drugs as I’m going to guess it’s wildly popular. Seems very out of touch to think otherwise.

- AD - Monday, May 6, 24 @ 1:28 pm:
Don’t they have to be on a weight loss program for six months prior to getting the drugs or is that changing in July?

- Demoralized - Monday, May 6, 24 @ 1:54 pm:
==Don’t they have to be on a weight loss program for six months==

My spouse didn’t. Asked for the drug, met the medical criteria, and got it.

- Excuse me - Monday, May 6, 24 @ 1:56 pm:
I am not sure how this is even a story. Seems like fat shaming to me on McKinney’s part. This proposal is lifesaving and ground breaking. State employees should be thanking the Governor and legislators.

- TinyDancer(FKASue) - Monday, May 6, 24 @ 1:58 pm:
Why are obesity rates rising?
Same reason blood glucose and cholesterol rates are rising:
They keep lowering the thresholds.
There are definitely people who are obese and cannot get their weight down, but not in the numbers we are seeing.

- Bluey - Monday, May 6, 24 @ 2:06 pm:
Used to think Dave was a stand up reporter but this fell incredibly short. Downstate workers should have access to the same drugs that Chicago and Cook County workers have. State workers do tough jobs and giving them healthcare is a thing we do for them as one of the largest employers in the state. I’m not mad about that as a taxpayer. Dcfs workers probably deserve it

- Rich Miller - Monday, May 6, 24 @ 2:35 pm:
===They keep lowering the thresholds===

Define “they” and tell me why you think the thresholds should not have been lowered when more science came in.

- Friday Addams - Monday, May 6, 24 @ 2:43 pm:
Wouldn’t this money be better spent bailing out the state’s media outlets? /s

- AD - Monday, May 6, 24 @ 2:45 pm:
== My spouse didn’t. Asked for the drug, met the medical criteria, and got it.==

Not the experience I had and I met criteria as well. Did your spouse have to appeal? Anyone from CMS have any info on what qualifies for Prior Authorization criteria to skip the program?

- Demoralized - Monday, May 6, 24 @ 2:51 pm:
==They keep lowering the thresholds.==

BMI tables haven’t changed for the past 25 years.

- Demoralized - Monday, May 6, 24 @ 2:52 pm:
==Did your spouse have to appeal?==

No. We have HealthLink.

- benniefly2 - Monday, May 6, 24 @ 2:52 pm:
These medications seem to work great, but the problem is that you pretty much have to take them permanently or else the benefits go away pretty fast. I wonder, based on the cost of the injectables and the perpetual requirement to keep using them, if the insurance companies will start to rethink their very tight qualifications and restrictions on getting bariatric surgery at some point in the near future.

- Rich Miller - Monday, May 6, 24 @ 2:58 pm:
===have to take them permanently or else the benefits go away pretty fast===

Yeah, and they have side effects, which is probably gonna drive down usage eventually.

- AD - Monday, May 6, 24 @ 3:01 pm:
== No. We have HealthLink.==

Weird, that’s what we have and was rejected for both Ozempic and WeGovy. I don’t have Diabetes, but do have hypertension, cholesterol and obesity. Anyone have any suggestions.

- AD - Monday, May 6, 24 @ 3:04 pm:
== Yeah, and they have side effects, which is probably gonna drive down usage eventually. ==

Yeah, it’ll be interesting to see what the side effects end up being long term. I asked my cardiologist if they were snake oil and he said no, they’re more like another tool in the toolbox like statins. He was encouraged by them, but I’m still skeptical. That being said, I put so much other junk in my body that I’d hope I wouldn’t be that the pros would outweigh the cons.

- Frustrated with inequitable treatment - Monday, May 6, 24 @ 3:37 pm:
I have HealthLink and did the 6 months. Am on two medications that the number one side effect is weight gain, am genetically predisposed to obesity, my numbers are good, but my A1C started to climb but not into the diabetic levels — just low pre-diabetic and I had two surgeries on my legs last year for — of all things — muscular birth defects that they found at 48 years old. None of this helped me lose weight with diet and exercise and up until 2023 I had tried everything. I’d always been active and fit — not skinny, but fit. And with these medications and other life issues, I had gained enough weight and had so much trouble losing it that I met the base qualifications. I just got approved for a GLP1 after 6 months of weight loss management through a comprehensive program with a dr., mental health professionals (which after 1 visit was determined unnecessary in my case) and a nutritionist. CVS denied my Dr.’s first request stating “they cannot approve because I wasn’t seeing results on the medication” — I hadn’t even started it yet!!!! As someone who has worked with utilization review and external review — this sounds like a blanket denial to cut costs and see who will appeal and those who don’t — don’t get the medication. Very frustrated with the entire process and CVS — and yes I know people who just get it prescribed without the 6 month program. Now I just have to be able to get the medication as it is backordered in order to be able to see if it works for me. My goal is to be healthy — this is not about being skinny or looking good — this is about being here for my kids and grandkids and not being a burden to my family in the future. And overall it’s a lot cheaper than open heart surgery and the maintenance drugs that go along with it or a lifetime of diabetes medications and medical complications related to either diagnosis.

- TinyDancer(FKASue) - Monday, May 6, 24 @ 4:17 pm:
=BMI tables haven’t changed for the past 25 years.=

Correct. They were lowered in ‘98.
But, other thresholds have been lowered more recently.

- TinyDancer(FKASue) - Monday, May 6, 24 @ 4:29 pm:
=Define “they” and tell me why you think the thresholds should not have been lowered when more science came in.=

“They” are those who profit from sickness - mainly the Pharmaceutical companies.

Read “Over-diagnosed: Making People Sick in the Pursuit of Health” by Gilbert Welch, Lisa Schwartz and Steven Woloshin.
and
“Selling Sickness: How the World’s Biggest Pharmaceutical Companies are Turning Us All Into Patients” by Roy Moynihan and Alan Cassel’s

- TinyDancer(FKASue) - Monday, May 6, 24 @ 4:31 pm:
Here’s more:

https://www.chicagotribune.com/2016/07/29/prediabetes-the-epidemic-that-never-was-and-shouldnt-be/

- Rich Miller - Monday, May 6, 24 @ 4:38 pm:
===Here’s more===

lol

That’s some source you got there https://en.wikipedia.org/wiki/American_Council_on_Science_and_Health

- Also Frustrated - Monday, May 6, 24 @ 4:47 pm:
I am diabetic. Metformin is not lowering my blood glucose levels, yet Health Alliance denies my doctor’s request to prescribe Ozempic (twice). Maybe treating heart disease, stroke, renal failure, blindness, neuropahty, amputation, etc is cheaper than Ozempic.

- TinyDancer(FKASue) - Monday, May 6, 24 @ 4:49 pm:
And this:

https://www.reuters.com/investigates/special-report/usa-diabetes-overtreatment/

- formerGOPer - Monday, May 6, 24 @ 4:56 pm:
North Caroline recently dropped coverage of these drugs for their employees based on the damage it was doing to their budget. They had 20,000 taking the drugs.

https://www.wsoctv.com/news/local/drugs-weight-loss-no-longer-covered-by-state-workers-health-insurance/J6GWMA5PYZHSZMKGVZQNDGXMWY/

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