‘Human dramas’ due to end of Ozempic coverage

2023-06-14 08:08:02

“Human tragedies, I see them every day in my office! ” The D^re Marie-Philippe Morin, specialist in bariatric medicine, is discouraged. Angry too. Private insurers have recently decided to stop reimbursing the drug Ozempic to treat obesity. Some of his patients will not be able to benefit from an organ transplant because they will not be able to reach the weight required to be eligible for the intervention.

“What do I do with these patients? asks the D^re Morin, who practices at the University Institute of Cardiology and Pulmonology of Quebec (IUCPQ). “Is there going to be a grandfather clause [clause de protection des droits acquis] or exceptional patients for these dramatic cases? »

The D^re Morin estimates that around 100 patients at the IUCPQ bariatric medicine clinic will not be able to lose the pounds needed to qualify for the long-awaited organ transplant or operation. They risk gaining all of the lost weight back if they stop Ozempic injections.

“For me, it’s a case of life or death. Sabrina Vallerand has been using Ozempic for two years. His weight went from 260 to 183 pounds (from 118 to 83 kilos). “I have three or four pounds left to lose to have my kidney transplant,” says the 37-year-old woman on dialysis.

She says she has a healthy lifestyle. “It’s not because I’m not moving or that I eat badly,” she said. With dialysis, you can’t eat just anything. The room attendant in a hotel can’t afford Ozempic without insurance. “It’s very expensive,” she says.

Vincent Doyon will also have to stop Ozempic because of the end of reimbursement by his insurer. Before he started taking the drug at the end of January, he weighed 305 pounds (138 kilos). “I had high blood pressure that was uncontrolled, shortness of breath and tachycardia on exertion,” said the 39-year-old. My sleep apnea was getting worse and I was starting fatty liver disease. »

Thanks to Ozempic, he lost 70 pounds (32 kilos). “My blood pressure and liver enzymes are normal,” says the nurse. My sleep apnea has improved tremendously. I started to resume physical activity, which I was no longer able to do. »

The D^re Morin believes that insurers will “gain nothing” by no longer covering Ozempic for obese patients who “really need” it. Yes, they will no longer have to pay the Ozempic. But they will have to reimburse blood pressure and cholesterol medications as well as sleep apnea devices for patients who no longer needed them, she argues.

“Grandfather” clauses?

Ozempic has been on the rise in North America since weight-loss users raved regarding its benefits on social media. Faced with the flood of prescriptions, Canadian insurers have recently chosen to end the reimbursement of the drug when it is used for obesity. They continue to cover it in the case of type 2 diabetes, the “indication approved by Health Canada”, they point out (see the box “Off indication or not?”). The Régie de l’assurance maladie du Québec (RAMQ) does not reimburse drugs related to weight loss, such as Ozempic.

The duty contacted private insurers to find out if grandfather clauses (grandfather clauses) will be put in place for obese patients on Ozempic. Only Médavie says “provide” one “for insured persons for whom the drug is already reimbursed”. Desjardins indicates that it will contact the insured concerned. “For the vast majority of cases, reimbursement will continue,” one email wrote. Manulife and Beneva (La Capitale and SSQ Insurance) did not mention any such clause in their responses.

The D^r Yves Robitaille, who practices at the Metabolic Medicine Center in Lanaudière, is not surprised by the insurers’ decision regarding Ozempic. According to him, “some prescribers” have shown “abuse”, as have patients who “shop around” for prescriptions. “I see people [dans mon bureau] who sit and cross their arms and say to me: “I came to get a prescription, then I will not see a nutritionist, no kinesiologist and no psychologist.” »

The D^r Robitaille is of the opinion, however, that Ozempic should be reimbursed for the treatment of obesity by the RAMQ and private insurers. “Not necessarily a broad and unconditional reimbursement”, he nuances. To prevent abuse, the D^re Morin believes that insurers might create a system of “authorized prescribers”, made up, for example, of doctors working in tertiary centers and specializing in bariatric medicine.

At the Ministry of Health and Social Services (MSSS), it is indicated that “work is in progress” to determine “the relevance of access to Ozempic for the treatment of obesity and if so, according to which terms”.

Medications aimed at weight loss have been excluded from the General Prescription Drug Insurance Plan (RGAM) since it came into force in 1997. The National Institute of Excellence in Health and Social Services (INESSS) cannot therefore evaluate these treatments. for the purpose of registering with the RGAM. However, last October it published a state of knowledge on this subject.

“This situation is not unique to Quebec,” writes the MSSS in an email. No Canadian province covers these molecules for the treatment of obesity, and elsewhere in the world, very few countries provide public coverage of these drugs. »

The D^re Marie-France Langlois, endocrinologist at the CIUSSS de l’Estrie-CHUS, believes that it is high time that governments recognize obesity as a “chronic disease”, in the same way as diabetes and hypertension, and not only as a risk factor for other health problems. The World Health Organization did so in 1997. “When obesity is recognized as a chronic disease, it becomes more normal to reimburse treatments,” observes the professor at the University of Sherbrooke.

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