Contributor: How Can the US Health Care System Affordably and Fairly Expand GLP-1 Access for the Millions of People Who Need it?

The US health care system faces a critical challenge. The production of glucagon-like peptide-1 (GLP-1) medications like semaglutide (Ozempic, Wegovy) and tirzepatide (Zepbound, Mounjaro) looks to be stabilizing, and new indications are emerging such as sleep apnea and chronic kidney disease for patients with type 2 diabetes. While the treatment could help millions of people, it still isn’t accessible for many. The FDA recently declared an end to the multi-year shortage of tirzepatide, and at the time of writing this, semaglutide has just been removed from the shortage list. However, the high costs of GLP-1 medications remain a challenge.

With a new administration comes a new health agenda. With this, health care has an immense opportunity to come together to create a more coordinated approach to expand access and affordability of GLP-1 medications.

It’s safe to say that many people who’ve been struggling with weight loss want their health insurance to pay for GLP-1s because they have been shown to work, but they are often too expensive to afford out-of-pocket. At an average price of $1000 per month, many individuals rely on their employers to foot the bill, but two-thirds of employers have said “No, not just for weight loss.” For some employers, doing so would break their budgets, an all-or-nothing gambit many have been unwilling to take. And while Lilly has recently announced a self-pay alternative of a single-dose vial at a 50% or greater discount, many Americans still can’t afford $5000 per year out of pocket. However, there’s a third party in the mix—pharmacy benefit managers (PBMs)—who add both another layer of complexity and the potential for a breakthrough.

PBMs are hired by employers to negotiate affordable access to medications for employees and their beneficiaries. Often, PBMs create more affordable, broader access to medications that may not cost a lot and treat diseases with a large prevalence, like medications for cholesterol. They also can create more affordable access to medications that cost a lot more and treat diseases that are less common. But this rinse-and-repeat model doesn’t work so well when you have an expensive medication that arguably can and should be used for tens of millions of people—the math doesn’t pan out. Obesity, which affects more than 40% of the adult population in the US, is 1 of the highest-prevalence chronic diseases in the country. But many employers—as the most common providers of health insurance in the US—cannot afford to facilitate access to treatments that work—making it challenging to help solve the obesity crisis and mitigate the long-term costs associated with cardiometabolic conditions like obesity. PBMs have struggled to facilitate broad access to GLP-1s for weight loss at scale in this unprecedented scenario. I believe that this frustrating problem is solvable, but it requires the 3 major parties to work together in a way they appear not to have yet done.

Here are the moves that I believe pharmaceutical companies, employers, and PBMs can take to solve this problem:

• An annual GLP-1 expenditure that employers can afford, which means GLP-1 access would vary by employer, and not everyone who wants one would get a GLP-1.
• Narrower (but fair) clinical criteria set by PBMs that would limit patient access but would still incentivize pharma companies to provide rebates to bring net prices down.
• Longer medication persistence among patients through lifestyle change support helps to offset the reduction in pharma revenue due to narrower clinical criteria and lower patient volume—this is critical so that pharma companies are incentivized to maintain meaningful rebates for employers.
• Robust PBM utilization management systems that can adjudicate a variety of clinical criteria.
• Affordable co-pays for patients.

For employers who aren’t providing coverage for weight loss, let’s look at plausible scenarios that will enable them to offer GLP-1s in a way that will be acceptable to all parties. Think of it as a sliding scale—as the clinical criteria become broader (more patients are clinically eligible), the pharma rebate to the employer increases accordingly, and the PBM adjudicates this process. I believe this is a workable model that can get us to scalable access at a more affordable price—if everyone gives a little.

Source: Omada Health

Employers could choose what they can afford, finding a reasonable place along the all-or-nothing continuum. As oral GLPs for weight loss are launched, patents expire, generics become available, and prices come down, companies can choose to broaden access among the choices.

In this framework, PBMs would be arbitrating the options between the pharma company and the employer. For it to work, PBMs would need to drastically expand robust utilization management systems and guarantees to ensure that each tier along the sliding scale is managed seamlessly and adhered to.

Of course, the pharmaceutical companies would want to be confident they wouldn’t have a revenue drop in a rebate-driven model. To maintain relatively high rebates in lower-access scenarios, PBMs will need to demonstrate longer medication persistence to make up for lost revenue. Frankly, pharma companies could come out ahead of where they are now, with potential access to more employers and more patients.

The final remaining piece to this solution is patient support. I believe it’s to everyone’s benefit for pharma, PBMs, and employers to pay for evidence-based lifestyle intervention programs focused on GLP-1 patient support. In the current system, lack of wraparound support may contribute to the more than half of GLP-1 patients who quit the therapy too early to meet benchmarks. A lack of medication persistence would undermine the balance this rubric seeks to create. Employers who are paying for these medications need to see positive, sustained outcomes to justify their continued investment. Without the combined incentives to support longer use, and if weight is regained after the GLP-1 has been paid for, employers will surely decide that the cost isn’t worth it. Pharma would likely reduce rebates because GLP-1 persistence would be too low, and PBMs would then have failed to provide a workable solution for both employers and pharma. In that eventuality, pharma companies, PBMs, employers, and their members would all lose.

If the parties each gave a little, they might all get a lot back in return. The real winners are patients.

We’re lucky to have this problem. GLP-1s have been a breakthrough. They help people lose weight and manage chronic conditions like diabetes and there’s great demand. Yet, their cost has vexed the system. We—as PBMs, providers, pharmaceutical manufacturers, employers, and virtual care companies—can’t solve this problem in silos. Helping to provide a GLP-1 solution is a responsible and moral thing to do for the millions of Americans who are challenged by the obesity and weight health crisis.

If we all work together to solve this problem, we can make the most of this golden opportunity. I speak to leaders in all of these groups, for whom not a day goes by when we don’t talk about GLP-1s. We’ve got a rare opportunity for all of us to work together on behalf of people struggling with chronic disease.

Now is the time.