Study: Bariatric surgery beats GLP-1s on long-term costs, outcomes

Adults with obesity and diabetes may benefit more in the long term from undergoing bariatric metabolic surgery than from taking widely popular glucagon-like peptide-1 receptor agonists, according to a new study published in JAMA Network Open.

The research out of Israel found that healthcare utilization costs were higher among adults with obesity and diabetes with GLP-1RA treatment than with BMS, suggesting surgery may carry clinical and economic advantages in the long run.

The study analyzed EHR records for over 5,400 adults with a mean body mass index of 40.5 and longstanding type 2 diabetes over 12 years. At first, the monthly costs to the healthcare system were similar to those for patients seeking BMS or GLP-1RAs, at $253.90 and $260.60 per month, respectively.

After treatment began, as measured by six months after the intervention, costs changed significantly for both groups. The mean monthly costs reached $304.90 among patients who underwent BMS -- mostly gastric bypass surgery -- and $415.30 for those treated with GLP-1RAs.

GLP-1RA patients cost the healthcare system over $100 more per month than BMS patients, the study found. And those costs increased steadily throughout the entire follow-up period, whereas costs stayed stable after the first four years following surgery.

The study found that the extra money for GLP-1RA patients was mostly spent on other diabetes medications and on more hospitalizations, while BMS patients' hospital costs remained stable after three years.

Researchers specifically examined the first four years after the intervention, which accounted for 76% of the total cost difference over the study period. They found that BMS patients cost $81.10 less per month on average, indicating that the greatest financial advantage of BMS occurred during these early years.

The cost differences also matched the health improvements, the study indicated. BMS patients lost more weight quickly in the first two years and had better blood sugar control early on. Meanwhile, GLP-1RA patients had slower, more gradual improvements that were sustained over time.

But dramatic early weight loss from surgery likely reduced the need for other medical care and medications during those crucial first years, according to the study.

Researchers suggested that a healthcare system that incentivizes efficiency and long-term health outcomes should prioritize BMS over first-generation GLP-1RAs among adults who qualify for both.

These findings come on the heels of Medicare's launch of the GLP-1 Bridge program on July 1st.

The Bridge program is a temporary Medicare demonstration that'll run through 2027 to expand affordable access to FDA-approved weight-loss medications, such as Wegovy, Zepbound and Foundayo. Under the program, qualifying beneficiaries can get a prescription based on BMI alone (35 or over) or BMI and a qualifying weight-related condition, such as heart failure or uncontrolled hypertension, or a history of pre-diabetes, heart attack, stroke or peripheral artery disease.

CMS recently expanded the Bridge model after canceling a broader demonstration that would provide longer-term coverage of GLP-1s for these populations. However, the demonstration did not garner sufficient participation from Part D plan sponsors to move forward in Medicare.

Private payers and Part D plan sponsors expressed concerns about how expanding coverage of GLP-1s will affect long-term healthcare costs and utilization. To manage costs, plans also said they would have to implement complex utilization management tools.

CMS said, though, that continuing the Bridge program through 2027 will enable data collection to help payers prepare for future GLP-1 coverage changes.

Jacqueline LaPointe is a graduate of Brandeis University and King's College London. She has been writing about healthcare finance and revenue cycle management since 2016.