This Minimally Invasive Weight-Loss Procedure is Cheaper, as Effective as Wegovy

Weight-loss treatment options include diet, medication and surgery

Neil Floch, MD, with Yale University and director of bariatric surgery for Greenwich Hospital, said weight-loss interventions fall along a spectrum, increasing from non-invasive options to more surgically invasive procedures.

Floch was not involved in the study.

On one end are lifestyle interventions, such as making changes in diet and increasing physical activity. These approaches can be low-cost, but are often challenging for people to stick with, and may not work for long-term weight loss.

At the other end is gastric bypass surgery, which is effective but requires invasive surgery. This may turn off some people who might benefit. In addition, insurers don’t always cover this procedure.

“The Roux-en-Y gastric bypass is considered the ‘gold standard’ for weight loss, leading to the most weight lost,” said Kirsten Frederiksen, MD, chair of the Obesity Medicine Association’s Bariatric Medical-Surgical Committee. “But is it always covered by insurance? No. Do patients always want it? No. So we need these other options.”

In between the two ends of the spectrum are the interventions that the authors of the new study compared.

Semaglutide is a glucagon-like peptide-1 (GLP-1) receptor agonist, sold under the brand name Ozempic for the treatment of type 2 diabetes, and as Wegovy for weight loss and for reducing the risk of cardiovascular disease events.

Given as a once-weekly injection, semaglutide is thought to work by delaying the emptying of the stomach, which increases the sense of fullness and decreases appetite.

While GLP-1s such as semaglutide have been shown to help people lose weight they come with a high price tag.

In contrast, ESG is a minimally invasive weight-loss procedure that changes the size and shape of your stomach. After the procedure, you will feel full after eating less food and absorb fewer calories, which will help you lose weight.

During this procedure, a doctor inserts an endoscope — a flexible tube with a light, camera and suturing device attached — down the throat and into the stomach. The procedure does not require an incision through the skin, as with gastric bypass surgery.

Floch said this procedure is a little more “palatable” to some people, because there is no incision and there is no need to remove part of the stomach.

Studies show that ESG is effective for weight loss. However, this procedure may not be covered by insurance.

The cost and effectiveness of different weight-loss treatments

In the new study, researchers compared the cost-effectiveness of semaglutide and ESG as treatments for obesity in the U.S. healthcare system.

To do so, they simulated three groups of middle-aged patients with obesity, who received one of those treatments or no treatment. In their model, researchers looked at weight changes and healthcare costs over the course of five years.

Based on earlier research, people who didn’t undergo any treatment for weight loss would be expected to gain some weight during that time.

Those who received semaglutide would lose weight and keep it off while they were on the medication. But some people would be expected to stop taking the drug due to side effects — researchers estimated this to be about 20%. People who stopped treatment would regain the weight, the model assumes.

Patients who underwent ESG would lose weight, but would also face a risk of adverse events. This includes ones related to surgery — such as bleeding, infection and stomach tears — that might require another procedure.

Researchers also assumed that some patients who didn’t lose enough weight after ESG would undergo the procedure again, or would switch to another treatment, such as medication or another type of surgery.

GLP-1 drugs had the highest costs

In addition, researchers estimated the costs to the healthcare system for each group of patients, taking into account the effectiveness of the procedures, complications from treatment, and other factors.

They assumed that the cost to the healthcare system for patients who received no treatment would be zero. Thompson said this was a conservative estimate.

However, “people that have ongoing obesity are going to definitely have increased healthcare expenditures in a variety of ways,” he said, such as needing insulin because they developed diabetes, or having complications from heart disease.

“But the problem with [the complications of obesity], it’s a little more subjective,” he said. “So it’s harder to get the actual numbers on the healthcare costs for those.”

The researchers’ model also took into account healthcare costs associated with an initial ESG procedure or a repeat ESG, adverse events related to ESG, and the monthly cost of semaglutide.

Over a 5-year period, treatment with semaglutide cost $33,583 more per patient on average than ESG, with people also losing more weight after ESG, the model showed.

Quality of life was also slightly higher in patients who underwent ESG, compared to those who received semaglutide.

In addition, researchers estimated that in order for the two treatments to have about the same cost-effectiveness, the price of semaglutide would have to drop by almost three-quarters — from $13,618 to $3,591 per year.

The current price for semaglutide represents the list price, not out-of-pocket costs. Patients with insurance coverage may pay less for this drug, although their insurer may have to pay additional costs.

In contrast, the initial surgery for ESG is around $16,000. This is a one-time cost, unless a patient requires a repeat procedure or other medical care due to adverse events from the ESG.

“In this study, you see that ESG does have an advantage [over semaglutide],” Floch told Healthline. “If you compare them at about two years, you see that they’re almost equal, and at five years there’s a definite benefit of the surgical procedure.”

While researchers attempted to take into account many things that could affect their cost-effectiveness estimates, other factors could influence this in the real world. This includes patients’ other health conditions, and actual insurer and out-of-pocket costs.

How to pick the best weight-loss treatment

Thompson thinks there is value in assessing the cost-effectiveness of other medical devices and procedures in a similar fashion, something that could be done even before they are on the market.

“We have a responsibility to estimate the economic impact of these devices or procedures to the healthcare system,” he said. “Is it going to reduce overall costs or increase them?”

Frederiksen agrees, but pointed out some of the challenges in accurately assessing costs. For example, the authors’ model did not take into account all of the factors that could affect these costs, she said.

“They found that about a third of patients who had ESG needed to be on an anti-obesity medication — in addition to having had the procedure — in order to keep the weight off,” she told Healthline. “So would that increase the cost? It could potentially by a lot.”

The authors acknowledged in the paper that their model may not take into account all factors, but Thompson emphasized that their estimates were on the conservative side.

While the new study compared the cost-effectiveness of these two treatments, when it comes to patients deciding with their doctor which treatment is right for them, other factors come into play.

One is whether or not patients actually take their medicines regularly.

“Compliance with medications can be extremely unfavorable,” said Floch, due to reactions to the medication, cost, people not wanting weekly injections indefinitely, and other reasons.

For semaglutide and similar drugs, that can be a problem.

“The problem with these [GLP-1] medications is if you stop them, you gain the weight back,” said Thompson. “That’s the beauty of a one-time procedure [like ESG]. You’ll have the procedure once, and keep these benefits for 5 or 10 years.”

Although cost-benefit analyses can be a useful way to estimate the impact of certain treatments on the healthcare system when it comes to deciding on weight loss treatments, it is more about individualizing care, said Spencer Nadolsky, DO, an obesity and lipid specialist, and medical director at WeightWatchers.

Nadolsky was not involved in the study.

“All options should be discussed with patients, and there should be a shared doctor-patient decision-making process to decide which therapy is best for them at that time,” he told Healthline.

“[Doctors] should also discuss the risks and benefits [of all treatments] with patients based on their individual needs,” said Nadolsky. “Patients ultimately have autonomy on what they want to do. While GLP-1s are expensive, we still see patients wanting to pursue them.”

Takeaway

Researchers modeled the costs and effectiveness of weight-loss drug Wegovy (semaglutide) and a minimally invasive procedure called endoscopic sleeve gastroplasty (ESG).

ESG was more cost-effective than semaglutide due to its greater weight-loss effects, the challenges of ongoing treatment with semaglutide, and the high cost of the drug.

While this kind of analysis can show the impact of treatments on the healthcare system, decisions about obesity treatments should be individualized and made by a patient and their doctor, experts say.