Is there anything GLP-1s can't do? Diabetes and obesity are increasingly looking like the tip of the semaglutide iceberg. The Food and Drug Administration (FDA) has approved Wegovy for cardiovascular disease, and researchers are now exploring the potential of GLP-1s for a host of conditions, including asthma, arthritis and psoriasis, certain liver diseases, depression, eye disorders, Alzheimer's, and substance use disorders. A recent study even found GLP-1s may reduce the risk of 10 different cancers.
The growing list of potential GLP-1 indications suggests the drugs may target the root cause (inflammation, probably) of the most prevalent and costly conditions in the U.S. If even a fraction of the trials now underway pan out, GLP-1s have the potential to reshape health care as we know it.
But they can't solve everything. In fact, the GLP-1 phenomenon is making the fragmentation and dysfunction of our health care system even more apparent. Just as GLP-1s may help us discover the common denominator in seemingly disparate diseases, they are shining a bright light on the root causes of the health care system's ills.
Drugs are too expensive
The price tag of GLP-1s in the U.S.—up to $15,000 per year, far higher than in other affluent countries—has become one of the single biggest drivers of rising health care costs. Private employers, already facing an unsustainable cost trend, are feeling the pressure from their workforce to cover the drugs, yet they quite literally may not be able to afford it. Some studies suggest widespread GLP-1 adoption, absent cost controls, could bankrupt Medicare and the health care system as a whole.
GLP-1s are also shining a harsh light on the inefficiency and inequity in health care. Those who can afford to pay out of pocket are gobbling up the supply of GLP-1s (in some cases for vanity use), while access remains limited for people on Medicare or Medicaid who are disproportionately burdened by obesity and diabetes. For example, Eli Lilly's recent move to slash the price of Zepbound only applies to patients paying out of pocket; and at several hundred dollars per month, even the markdown price is out of reach for many.
GLP-1s shows how quickly health care can turn into a gold rush
Pharmaceutical companies, telehealth providers, and even supplement sellers are marketing GLP-1s directly to consumers to meet the runaway demand. Exploiting a loophole resulting from the GLP-1 shortage, some providers are prescribing compounded generic versions of the drugs that the FDA has warned may be unsafe.
This is a prime example of the limitations of the transactional Telehealth 1.0 model and the dangers of consumerism running amok. Patients can easily get compounded GLP-1s, even when lifestyle changes or other approaches are more clinically appropriate. But who is looking after their health once the transaction is complete? Who is helping them manage side effects, as well as their overall physical and mental health?
If patients get sick from compounded GLP-1s, they could end up in the ER—and their employer and insurer foot the bill. In this scenario, no one wins.
Fragmented care delivery
The type of clinicians prescribing GLP-1s has expanded rapidly. In their first act as a diabetes drug, GLP-1s were prescribed almost exclusively by endocrinologists. Now cardiologists, orthopedists, internal medicine physicians, and even psychiatrists are prescribing them—presumably with a different lens than an endocrinologist would, and sometimes without full visibility into the patient's overall health. Different specialties are starting to establish their own clinical guidelines for GLP-1s.
Given how siloed specialty care is, it's increasingly likely that a primary care physician (PCP) might prescribe GLP-1s for weight management without the patient's cardiologist knowing about it—and vice versa. Who's looking out for the whole person? Who's looking at clinical outcomes and costs in a holistic way—for that patient, and for the system as a whole?
The prescription we really need
I'm rooting for GLP-1s to be a miracle drug. But the jury is still out, and in the meantime, the GLP-1 frenzy is exposing healthcare stakeholders across the system—patients, employers, insurers, providers—to unsustainable clinical and financial risks.
On the plus side, these mounting risks—and the unprecedented attention from consumers and the industry alike—may finally be what it takes to fix broken health care models. And the solutions to the problems surrounding GLP-1s are the same ones we've needed all along:
- Prevention. The U.S. invests far less in preventive and primary care than other affluent nations. Increasing access to primary care and mental health services—including through virtual care—is essential to sustainably address the upstream causes of the conditions we're now treating with GLP-1s.
- Integrated care. This includes longitudinal care coordination between PCPs and specialists, as well as navigators and patient advocates. The wrap-around financial and administrative support these care team members provide is especially important given the high cost of the drugs and the challenges of managing chronic conditions like diabetes.
- Outcomes-based payment. The recent push to include GLP-1s in Medicare negotiations is a good start, but it's not a silver bullet for the healthcare cost trend. Despite the consumer demand for GLP-1s, studies have shown that as many as two-thirds of patients don't stick with the drugs long enough to achieve or sustain the clinical benefits, which means substantial upfront costs with little to no payoff for patients and healthcare purchasers. Business and payment models tied to clinical and financial outcomes that matter—and that incentivize judicious prescribing and the integrated care needed to boost adherence and long-term results—are a critical step toward minimizing waste and realizing the full value of GLP-1s.
GLP-1s have the potential to transform medicine. But if we continue shoehorning them into our siloed and fragmented health care system, their potential will be stunted. It’s yet another indication that we need to reimagine the health care system from the ground up.
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