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Comp sector unlikely to buy into diet meds trend


While obesity is considered one of the most common comorbidities among injured workers that can impede their recovery, and insurers and employers have funded weight loss programs and expensive surgeries, the workers compensation industry is unlikely to cover increasingly popular and less-invasive weight loss medications, experts say.

Semaglutide, which goes by brand names Ozempic and WeGovy, is a diabetes drug that has been making headlines as it also causes patients to lose weight by slowing down the digestive system and quelling the appetite. A “Hollywood effect” is also driving its popularity, as film stars have  knowingly taken the drug to lose weight. 

Unless a patient is diabetic, the drug is typically not covered by insurance, and studies show that when a patient stops taking the drug the weight creeps back on. It also comes with a list of potential side effects ranging from the more common nausea and constipation to thyroid cancer and gallbladder disease.

It’s the side effects and the need to take the drug over the long term that will keep workers comp payers from covering it, experts say.

“It is a drug; it does have side effects. It does have consequences, and, if it is not monitored properly, people could harm themselves,” said Reema Hammoud, Southfield, Michigan-based assistant vice president of clinical pharmacy for Sedgwick Claims Management Services Inc. 

Hypothetically, if the drug is prescribed to an injured worker and covered under comp, the payer also inherits side effects as part of the claim, and if the claimant is kept on the drug indefinitely — as most semaglutide patients are — then it’s the payer that’s charged with continuous monitoring, Ms. Reema said, adding, “We have to be careful about that.” 

The industry rarely voluntarily covers costs related to weight loss despite the correlation between recovery and obesity, said Stuart Colburn, a shareholder of Downs & Stanford P.C., headquartered in Dallas. 

In a 2012 study, the Boca Raton, Florida-based National Council on Compensation Insurance found that claims with an obesity comorbidity have 81% higher lost-time costs compared with claims involving non-obese injured workers. Other, smaller studies have since reinforced the idea that some injured workers won’t recover or costs will be higher if their weight is not addressed.

A study published in 2016 in the Journal of Occupational Environmental Medicine looked at comp claims in Louisiana and found that overweight workers with major injuries were more than twice as likely to incur costs of $100,000 or higher.

And another study in 2016 found that an obesity diagnosis could prolong a workers comp claim by 55% compared with claims for injured workers who are not overweight. That analysis, by Harbor Health Systems, a division of One Call Care Management that manages a workers comp medical provider network, also found that surgery rates increased 140% when an injured worker was obese.

The courts have also embraced the connection, in some cases ordering bariatric surgery for injured workers, which can cost up to $30,000, and even exercise programs. (See related story below.)

“We do have case law from various states,” Mr. Colburn said. “They say reasonable and necessary medical treatment would include something so invasive as bariatric surgery. No payer that I know of is going to just voluntarily as a matter of rule go ahead and volunteer to do that.” 

Mr. Colburn and others say semaglutide’s popularity could push it into the comp system, and that state courts could have set a precedent. 

Even those currently managing claims say weight loss drugs could creep into comp, as some claimants could see them as less invasive than surgery. 

“We haven’t seen evidence of that approach surface within our pharmacy data as of yet, but this is not beyond the realm of possibility given the attention these drugs are receiving for weight loss effects,” Nikki Wilson, senior director of clinical pharmacy services at Enlyte LLC, wrote in an email. 

“I see the main roadblocks being the issues of compensability,” Ms. Wilson wrote.

Rich Ives, Hartford, Connecticut-based vice president of business insurance claims for Travelers Cos. Inc., said the industry is cautious when paying for comorbidities that are not part of a claim but understands the need to address issues outside of an original injury and is looking for ways to work with employers and benefits programs on issues such as obesity. 

“If that condition is making the overall workplace injury more expensive because the recovery is longer, why wouldn’t you help? And that’s where we’re trying to find ways that we can help provide aids that don’t necessarily add to the cost of the workers compensation claim but can help make it better without paying for something that we don’t own.” 

State court rulings provide precedent for weight loss in comp claims

Court rulings shed light on how the workers compensation industry could continue to grapple with paying for weight loss that is not related to an original workplace injury.

Such rulings include: 

  • In 2022, the Court of Appeals of North Carolina, in Robin Kluttz-Ellison v. Noah’s Playloft Preschool and Erie Insurance Group, ordered a workers compensation insurer to cover bariatric surgery for a preschool owner and operator who needed knee replacement surgery related to a workplace injury, but was told she needed to lose a significant amount of weight in order for the surgery to be successful. 
  • In 2019, the Arkansas Court of Appeals, in Shela Lybyer v. Springdale School District, ordered a school district to cover weight loss costs for a custodian who injured her back while moving wrestling mats and whose doctor said back surgery was necessary but could not be successful unless she lost weight. 
  • In 2009, the Court of Appeals of Indiana, in Boston’s Gourmet Pizza v. Adam Childers, ruled that a pizza restaurant must cover an injured cook’s temporary total disability benefits related to weight loss surgery that his doctor said would be required to fully recover from a back injury the cook suffered after he was hit by a refrigerator door at work. 
  • In 2009, the Oregon Supreme Court, in SAIF v. Sprague, ordered a workers comp insurer to reimburse for gastric bypass surgery an injured salesman had in 2000, nearly 25 years after he had injured his knee while lifting materials. The court ruled that the weight loss surgery was necessary for knee surgery to be effective. 
  • In 1993, the Supreme Court of Minnesota, in Hopp v. Grist Mill, ordered an employer to cover bariatric surgery for a production line worker who was obese when she injured her knee and whose doctor said weight loss was “essential” in the treatment of the injury. 
  • In 1988, in Fontenot v. Citgo Petroleum Corp., the Louisiana Court of Appeals affirmed an order that required the energy company to pay the cost of a swimming exercise program at a local YMCA for an injured utilities worker and a reasonable allowance for expenses in attending the sessions. 
  • In 1987, the Oregon Court of Appeals, in Van Blokland v. Oregon Health Sciences University, reversed an earlier ruling that found a weight loss program was not compensable and unrelated to a workers compensation claim. The claimant in the case had suffered a work-related knee injury that she argued caused her to gain weight. 
  • In 1983, the Supreme Court of California, in Braewood Convalescent Hosp. v. Workers’ Comp. Appeals, affirmed an order for an insurer to cover an injured worker’s post-injury participation — on the advice of three doctors — in a weight loss program in North Carolina, along with temporary disability compensation during participation in the program and associated expenses.