Optum Care's Dr Ken Cohen Advocates for Comorbidity-Based GLP-1 Tiering for Patients With Diabetes

Ken Cohen, MD, executive director of translational research at Optum Care, discussed the potential impact of tiering glucagon-like peptide 1 (GLP-1) therapies for patients with diabetes, emphasizing that their use should be based on comorbidities like body mass index (BMI), cardiovascular disease (CVD), or chronic kidney disease (CKD) to ensure cost-effectiveness.

Similarly, he highlighted concerns about low-value care in diabetes, stressing the importance of aligning treatments with patient comorbidities. Lastly, looking ahead, Cohen pointed to the rising issue of metabolic-associated fatty liver disease, which may become a leading cause of liver transplantation by 2030.

This transcript has been lightly edited for clarity.

Transcript

CMS recently announced the negotiated drug prices for the first 10 drugs under the Inflation Reduction Act (IRA). What is your reaction to the announced prices? Do you see this impacting the commercial space?

I certainly hope that it will spill over into the commercial space. I think it is long overdue, whereas the rest of the health care system in this country, although our prices are not well controlled, it does operate as a free market, whereas the pharmaceutical industry really doesn't.

There haven't been price controls, and the prices that are charged for our drugs are not a function of the cost-effectiveness of those drugs; that's been a major problem.

Earlier this year, Managed Healthcare Executive reported that Optum was conducting negotiations to allow for tiering covering of GLP-1s. What would a tiering structure mean for patients with diabetes looking to access GLP-1s?

Well, I haven't been part of those negotiations, so I don't know exactly what they have in mind, but when I think about tiering around GLP-1s, I think about what the comorbidities are that would make it the appropriate choice for any given patient.

So, if you had, for example, an individual who did not have an elevated BMI and did not have underlying CVD or CKD, it may not be the appropriate choice. Certainly, in the context of significant obesity or diabetes with obesity, ultimately, those drugs might be cost-effective.

What are some areas of low-value care in diabetes that we can better address and remove when possible?

I think a lot of the low-value care around diabetes is related to the lack of alignment of drugs and comorbidities. For example, there are patients that have underlying comorbidities that clearly indicate the need for an SGLT2i [sodium-glucose cotransporter-2 inhibitor], for example.

On the other hand, if you had a diabetic who had no underlying CVD or CKD, it may not be the most appropriate drug in terms of the cost. So, I think it comes down to cost-effectiveness and low-value care.

What changes in the cardio-renal-metabolic landscape are you keeping an eye on for 2025?

One of the areas that I'm most interested in because I think it gets the least attention is the spectrum of metabolic-associated fatty liver disease progressing to MASH [metabolic dysfunction-associated steatohepatitis] and cirrhosis. The spending on that is going to be about $175 billion in the next decade, and, by the end of the decade, may be the most common reason for liver transplantation.

Those individuals have a much higher risk of underlying CVD, and I think we are not screening for it adequately, and we're not adequately treating it.