GLP-1s, Health Policy, and VBC

Let's explore some research on GLP-1s today!

I started putting together a post on GLP-1 recently, but obviously hadn’t sent it yet.

And I’m glad!

Because today, the Center for Medicare and Medicaid Services (CMS) released the 2026 Medicare Advantage/Part D Proposed Rule.

Any guess what? They are proposing coverage of anti-obesity medications in Medicare and Medicaid. Here’s a snip from the Proposed Rule’s Fact Sheet posted this morning:

This is a big deal. However, there will not be time to get through the 60 day comment period and for the final rule to be published during the limited remaining time of the Biden Administration. President-elect Trump may well choose not to finalize rules still in the proposed stage once he is in office. It remains to be seen if this proposal is finalized in the near-term.

Last month, the Congressional Budget Office also put out a report looking at the potential impact on the federal budget of covering anti-obesity medication. There are a few good visuals. 👇️ 

👇️ This predicts spend on these medications would reach 6.1 billion dollars per year by 2034 if used for obesity treatment for Medicare beneficiaries.

👇️ And this predicts savings.

The full report provides details on the methodology used to make these and other calculations.

Then in this Forbes article, the authors point out 85% of people taking GLP-1s for obesity are no longer taking it after 2 years. 71% of people stopped taking it by the one-year mark.

And this Kaiser Family Foundation Health Tracking Poll from May 2024 includes some great takeaways, like over 60% of Medicare beneficiaries believe Medicare should cover GLP-1s for obesity treatment.

There’s also an interesting nugget in there given the above Proposed Rule developed by the Biden Administration:

Democrats (66%) are more likely than Republicans (55%) to say CMS should cover GLP-1s for obesity.

So…

Is the price justified by how much these medications can impact chronic illnesses (more on that below)? The short answer in my own mind is that it’s a case-by-case clinical decision based on evolving evidence and other factors like individual patient characteristics.

In this article, this time from Health Affairs Scholar, the authors made some valid points to consider when thinking about the cost-benefit analysis of large scale use and other factors. The authors cite several issues they see, such as:

  • A lack of long-term safety data

  • Considering the option for planned, short-term use for obesity before transitioning to lower cost, more traditional weight loss mechanisms (partly to save financial resources so more patients have access at the most impactful times)

Bonus takeaway from this piece: Zepbound may be more effective than Wegovy for weight loss with fewer side effects and a lower price point 👇️ 

As we know, GLP-1 receptor agonists have potential applications that extend far beyond these initial applications.

I’m trying to think through the most important data points to consider when comparing the value of these medications to other treatment options. What constitutes “value” (in this case) of these blockbuster drugs with the lofty price tag?

And—

Who really are the right candidates for GLP-1s?

Here are some considerations as you think about it:

Who will have the right medical indications

and the commitment to medication compliance

and be able to tolerate the (primarily) gastrointestinal side effects 

and be comfortable with the self-injections

and remain on the medications long enough to see meaningful impacts on their health

 and have the patience to see the long-term results?

What else am I missing?

Yes, GLP-1 receptor agonists have demonstrated remarkable efficacy in managing type 2 diabetes and obesity, two conditions that significantly contribute to primary and secondary healthcare costs.

And…

GLP-1s seem to align with the principles of value-based care when prescribed for the right individuals.

Why might this be a value-based treatment option?

I like to think of it this way. 

How do we incentivize prescribers to offer this medication to the right patients at the right time?

Support users’ compliance and success?

Proactively outreach to patients to improve the likelihood of positive health outcomes?

This is the crux of what value-based care does. It aligns incentives and it rewards coordinated, patient-centered care. This is often “care” and activities without associated fee-for-service billing codes.

In VBC arrangements, taking more time to identify the best treatment option for an individual patient, communicating effectively with them and in collaboration with the care team, and then supporting their success is rewarded through dollars saved in reductions in total cost of care.

Those savings in total cost of care come from a prevention and avoidance of downstream spending related to unmanaged conditions, urgent concerns, provider access constraints, etc. The dollars can then be redirected, in whole or in part, to providers in the VBC arrangements.

I’m also pretty impressed with what I’ve been reading about the potential for GLP-1s to address cardiovascular disease.

The below is a snip from a pdf downloaded from this New England Journal of Medicine study showing the impact of GLP-1s on cardiovascular death, nonfatal MI, or nonfatal stroke. Notice this was a 40 month study 👇️ 

Expanding Applications of GLP-1s

As in the example above, GLP-1 medication appropriate use cases may extend well-beyond diabetes and obesity. Emerging research indicates promising applications in treating:

  • Cardiovascular Disease: A meta-analysis published in The Lancet (2023) demonstrated that GLP-1 therapy reduced the risk of heart failure hospitalizations by 30% in patients with established cardiovascular disease.

  • Non-alcoholic Fatty Liver Disease (NAFLD): The Journal of Hepatology (2024) reported significant improvements in liver function and reduced liver fat content in NAFLD patients treated with GLP-1 agonists.

  • Neurodegenerative Disorders: Preliminary studies in Alzheimer's Disease & Associated Disorders (2023) suggest potential neuroprotective effects of GLP-1 medications, opening new avenues for research in neurodegenerative diseases.

  • Obesity Associated Cancers (OAC): This JAMA investigation demonstrated a reduced risk of OACs for those who used GLP-1s compared to those who used insulin or metformin to treat type 2 diabetes.

Additional Reading:

Want to keep going down the rabbit hole? Here’s more relevant GLP-1 content I pulled for you!

More about the expanding applications of GLP-1 agonists from the American Diabetes Association: Pharmacologic Approaches to Glycemic Treatment: Standards of Medical Care in Diabetes

For a deeper understanding of the role of GLP-1 agonists in diabetes prevention, refer to this clinical trial: Liraglutide and Cardiovascular Outcomes in Type 2 Diabetes

This May 2024 University of Chicago piece talks about complex concerns about GLP-1s, despite their effectiveness

GLP-1 medications represent some level of a paradigm shift in the treatment of a growing number of chronic conditions. While there are nuanced considerations, GLP-1s may also support the goals of value-based care when used to treat the right patients at the right time. By helping to effectively manage high-cost chronic conditions, helping to prevent medical complications, and showing promise in an expanding range of applications, these medications offer an option in prescribers’ toolboxes to improved specific patients’ outcomes and long-term cost savings.