None of the public healthcare systems in the ten provinces in Canada authorize payment for these prescriptions. France, the United States, Belgium, and New Zealand also do not provide reimbursement.
Two countries have opened the door to reimbursements. The United Kingdom and Australia reimburse orlistat. The United Kingdom also does so for liraglutide and has given a favorable opinion on semaglutide. All are anti-diabetic medication used to treat obesity. These reimbursements are only allowed if the person receives or signs up for professional dietary, weight management, and increased physical activity advice.
All private insurers should reimburse medications for treating obesity, according to one of Quebec's leading experts in the field, Dr. Yves Robitaille. Currently, approximately 70 % of insurance companies, according to his estimates, follow the lead of RAMQ, the Quebec health insurance board, and still refuse to reimburse weight loss medications, even if they are authorized by Health Canada.
Dr. Robitaille is the Medical Director of the Lanaudière Metabolic Medicine Center, where nearly 95% of his practice is dedicated to obese or overweight patients. Obesity is on the rise worldwide and leads to numerous medical complications and deaths. In Europe, it is estimated to cause 1.2 million deaths each year.
Medications excluded from the public healthcare system
Three medications are available in Canada for the management of obesity. A fourth medication, semaglutide, was added to the list last year but is currently unavailable due to a global supply issue.
In Quebec, these medications are not covered by the public healthcare system, a situation also lamented by Dr. Rémi Rabasa-Lhoret, an endocrinologist and director of the Professional Council of Diabetes Quebec. All payment requests are denied by RAMQ, even for exceptional cases, because they still classify them as aesthetic medications.
Obesity, a chronic disease
"The root of the problem in obtaining medication reimbursement is the difficulty of recognizing obesity as a chronic disease, as the World Health Organization (WHO) and the American Medical Association do. Unfortunately, it is less clear to third-party payers... It's a mindset that is difficult to change," laments Dr. Robitaille.
Contrary to a widely spread myth, obesity is not solely a matter of unhealthy lifestyle habits. Defects in the regulation of an individual's energy reserve, genetics, and habits during the first 1,000 days of life are major determinants in the development of this condition.
Medication serves not only to lose weight but also to maintain that weight loss. It has been demonstrated that 90% of individuals who have lost more than 10% of their weight will regain it after one year because their bodies seek to return to their previous energy reserve level, reveals the doctor. Medication would help them maintain the weight they lost, which is one of its significant advantages. Some patients may need to take these medications for life, and it varies on a case-by-case basis, explains Dr. Robitaille.
Insufficient lifestyle modification
In October 2022, Quebec experts conducted a “state of knowledge report” on the pharmacotherapy of obesity for the National Institute for Excellence in Health and Social Services (INESSS) at the request of the Ministry of Health and Social Services. Dr. Robitaille contributed to the report along with several other specialist physicians. The report describes the benefits of medication but does not make any recommendations.
Depending on the medication used, the average weight loss observed with pharmacotherapy in combination with lifestyle changes could range from 3 to 17% more than with lifestyle modification alone. Achieving a minimal weight loss of 5% through lifestyle changes alone is very demanding for an obese person due to their biological and genetic predispositions, according to the report.
Reimbursing medications for obesity in pediatrics (6 to 18 years old) would provide an alternative to bariatric surgery for children and adolescents.
In the absence of medication coverage by the public healthcare system or insurers, obese patients must pay for these medications, which can cost between $150 and $500 per month. The cost of liraglutide in Quebec would amount to $5,327 per year. As many people cannot afford such amounts, clinicians must explore other options for achieving weight loss, with variable and often modest results.
The INESSS report demonstrates a new sensitivity from the Ministry of Health and RAMQ, which Dr. Robitaille is pleased about. However, for now, it has remained ineffective, and payments are still being denied in May 2023.
"If we don't pay now..."
The doctor estimates that around 30% of insurers in Quebec go beyond RAMQ and reimburse medications for obesity. However, in his view, this is not sufficient, and all insurers should do so in the future. After giving a conference to insurers, one of their representatives stated during the question period, "If we don't pay now, we'll pay later."
According to Dr. Robitaille, he understood that it was better to start addressing the problem upfront to achieve significant cost savings in the future by reducing complications, as managing their effects will be much more expensive in the long term. Few patients suffer from a single complication. By treating overweight individuals, several major diseases can be combated simultaneously starting now, he states.
"It requires a multidisciplinary approach"
"We need it," says the specialist regarding obesity medication. However, he emphasizes the need for a comprehensive multidisciplinary approach involving nutritionists, kinesiologists, and psychologists.
"We cannot solely rely on the use of medication to solve the problem of obesity. Unfortunately, it is a trend that I see and find rather detrimental," he says.
Before embarking on pilot projects, prerequisites must be established to ensure that medication is not inappropriately used. RAMQ has set conditions for reimbursing bariatric surgeries. Yves Robitaille believes that the same could be done with prescriptions.
Most insurers that reimburse these medications require doctors to fill out forms to determine if the patient is participating in a comprehensive management program. Dr. Robitaille supports this type of control to prevent doctors from simply prescribing these expensive medications without the necessary supervision and follow-up.
