Why half of all staff could have trouble getting medical health insurance for weight reduction drugs

Companies are increasing their employees' access to latest blockbuster weight-loss drugs, but employer size could make an enormous difference in early access. Small businesses and their employees are sometimes caught in a bind relating to this burgeoning medical health insurance market.

Small businesses employ about half of all staff within the U.S. labor market and have been adding jobs faster than large employers. Since the primary quarter of 2021, based on the U.S. Bureau of Labor Statistics, 53% of the 12.2 million net jobs created across all employers got here from hiring at small businesses, consistent with the longer-term trend.

The blockbuster obesity drugs, called GLP-1 agonists, cost around $1,000 a month on average — and are typically taken over an extended time period. Access to those weight-loss drugs is coming from more sources in the marketplace, drugmakers are ramping up production, and use cases are continuing to expand. Clinical trials are showing advantages for conditions starting from sleep apnea to heart disease risk. But most of the 100 million American adults who’re obese can't afford to pay out of pocket for drugs like Novo Nordisk's Wegovy and Eli Lilly's Zepbound, so that they're turning to their employers for help.

A survey of 205 corporations by the International Foundation of Employee Benefit Plans last October found that 76% of respondents covered GLP-1 drugs for diabetes, while only 27% covered weight reduction. However, 13% of plan sponsors said they’re considering covering weight reduction. Covering these drugs is harder for smaller employers, nonetheless, as lots of them depend on prepackaged plans from their insurance carriers. While there are plans that cover GLP-1 drugs, the associated fee might be prohibitive for a lot of small businesses.

There is robust demand from employees for medical health insurance, and smaller employers would really like to achieve this, but there are trade-offs, says Shawn Gremminger, president and CEO of the National Alliance of Healthcare Purchaser Coalitions, a nonprofit, purchaser-led organization. Companies must consider the impact on wages or other advantages they wish to offer. “Corporate money has to come from somewhere,” he says.

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In some cases, even when small employers wish to cover the associated fee of weight reduction medications, they’re simply priced out of the market and must accept that they can’t provide the coverage they would really like.

“Given the prices of these drugs, you have to do a cost-benefit analysis, and many small companies – even some larger ones – just can't do that,” Gremminger said. “No matter how much they want to.”

Here are some points that small business employers and employees should consider when considering receiving expensive weight reduction drugs as a part of their advantages.

Agreements on additional annual advantages are currently being negotiated. The open enrollment period for medical health insurance doesn't begin until the autumn, but employers should start talking to their insurance broker or agent now about renewing their insurance, and that conversation should include mentioning weight-loss drugs. Small employers should tell their broker they would really like to supply weight-loss drugs to their employees and ask for help finding the suitable provider or plan, said Gary Kushner, chairman and president of Kushner & Company, an insurance advantages design and administration firm.

The market is changing quickly. Last yr, an insurer asked if it covered weight-loss drugs may need said no, but it surely's price asking again since it could have been forced to vary its offering resulting from competitive pressures, says Kate Moher, president of national worker health and advantages on the Marsh McLennan Agency, which advises employers on plan and profit program design. “You should be asking this question every year,” she said.

Insurance premiums could rise. To get access to weight-loss drugs, many small businesses could have to change medical health insurance providers and certain pay more. “It's most likely going to be more expensive if one insurance company doesn't cover the drugs and another does,” Kushner said.

Employers even have to make a decision how much of that may reasonably be passed on to employees without unduly burdening staff who may never need those drugs. “If 20% of your population takes them, the premium for everyone goes up by the percentage that's supposed to cover the cost,” Gremminger said.

Smaller corporations should consider establishing their very own company medical health insurance. In general, any company with at the least 50 employees could consider working with a captive health plan resembling Roundstone, ParetoHealth, Stealth and Amwins, Moher said. These corporations allow groups of corporations that might not self-insure – the approach most large corporations take – to pool their resources and work together to create a bunch health plan.

That approach may give a small business and its employees more flexibility, Moher said, but owners still need to weigh the prices and there are requirements to qualify. It's also not something corporations can change yearly, like they’ll when working with a standard insurer. “It's a long-term game; you can't just get in and out,” Moher said.

These plans are designed for the long run because participants conform to spread risk as members and owners. This approach can keep costs low over time and reduce volatility. However, if business owners are in search of a fast fix or would relatively wait and see how the market performs over the subsequent yr, this might be not the suitable model.

For some small businesses, a standalone insurance option for GLP-1 drugs may additionally work. Companies like Vida Health, Calibrate, Found Health and Vitality Group offer these plans independently of the employer's primary insurer, Gremminger said. Employers must weigh whether this is likely to be more cost effective and whether the choice really meets the needs of their employees based on the plans.

Use an FSA to cover the associated fee of weight reduction medications. If insurance options aren't an efficient solution today, small employers could have another options to assist their employees cover the associated fee of weight reduction medications. For example, they might contribute to employees' flexible spending accounts or health savings accounts. They could also consider a health reimbursement arrangement (HRA), an employer-sponsored plan that reimburses employees for qualified medical expenses.

But each of those options comes with strict rules and requirements. With an FSA, for instance, the IRS caps an employer's contribution based on the worker's contributions, and that also is probably not enough to cover the associated fee of those drugs in the long run. “Does it help? Sure. Does it solve the problem? No,” Kushner said.

It's also not a step you need to take without prior approval from legal counsel. “You need the advice of your ERISA attorneys to make sure you meet all the criteria,” Moher said. “It's a creative way to go, but you need to make sure you meet all of your compliance requirements.”

Right now, the underside line might be very daunting for small corporations and their employees, given the associated fee and limited options, but it surely's also essential to know that there are about 20 drugs within the approval phase. Once they're approved, costs will likely come down, Moher said. “That may be a short-term thing until we get more GLP-1 drugs approved.”

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