Hello everyone, I hope you are quite well on this beautiful weekend (at least, here in the US Northeast). Virtually everyone I know, including yours truly and family, are out & about enjoying it.
In this edition of our twenty30 newsletter, we continue to see keen media attention on GLP-1s, helping facilitate public fascination and concurrent growing demand for them. This is contrasted with increasing alarm among those entities (insurers, self-insured employers) on the hook to pay for the meds. As we’ve heard at twenty30 health from one key contact, “the barn is on fire” with respect to the burgeoning demand and resultant skyrocketing costs.
An editorial comment: the amazing biotechnology advances in the development of GLP-1 meds have the opportunity to help many hundreds of millions of people across the globe. To capture their full promise, what is needed is an individualized approach to obesity care, one which can employ best evidence and rule-based approaches, onward to AI-based personalization, and so on. Such an individualized approach should utilize all available tools to achieve an optimal outcome, over a multi year period, delivered in an evidence-based and clinically driven manner.
Kind regards, Raj.
AT A GLANCE
- As the noise around payors balking at GLP-1s gets louder, Peter Loftus at The Wall Street Journal reports: ‘…the University of Texas System said it would end insurance coverage of Novo Nordisk’s Wegovy and Saxenda for its employees and others covered by its health plans.
- In a similar vein, Elaine Chen — a regular on the obesity reporting front at STAT News — refers to the date patient’s ‘insurance companies will stop covering (GLP-1 medications)’ as ‘D-day’
- And yet: Shannon Young at Healthcare Brew focuses on the ‘…skyrocketing demand…’ and how ‘…drugmakers have struggled to keep pace…’ with the 2,000% increase in prescriptions from some GLP-1 drugs since 2019.
- And GLP-1 “Miracles” continue to receive prominent press: in The Telegraph, a UK daily newspaper, Anonymous author writes ‘…the miracle weight loss drug changed more than my dress size… it changed my brain too and made me understand why I became obese.’
- Pushback from bariatric: Dr. Marina Kurian, bariatric surgeon in New York City, current president of the American Society for Metabolic and Bariatric Surgery, and a good friend, counter-plays the rising ‘bold claims that medication could soon trump bariatric surgery’, stating ‘We actually think we’re going to see an increase in patients coming to surgery…’
- Growing public acceptance of weight loss meds: KFF (fka The Kaiser Family Foundation) reports their latest Health Tracking Poll, with key findings including ‘Most adults (80%) say that insurance companies should cover the cost of weight loss drugs for adults who are overweight or obese, while half of adults (53%) say insurance should cover the cost of these drugs for anyone who wants them to lose weight’
- In the meanwhile on the device front, Allurion Technologies, a newly public company with a commercial gastric balloon for people with obesity, was featured by MedCity News via Frank Vinluan.
NEWS
- Peter Loftus at The Wall Street Journal reports on ‘…the University of Texas System said it would end insurance coverage of Novo Nordisk’s Wegovy and Saxenda for its employees and others covered by its health plans effective Sept. 1.’
- The university benefits newsletter stated: continuing to pay is ‘…unsustainable due to the current rate of prescription drug expenditures.’
- And further, the U of T ‘…health plan said it isn’t seeing any of the expected reduction in costs for other health conditions that weight loss could avert’ … likely based upon a shorter one-year timeline for which the return on investment is expected to be realized.
- Ascension Healthcare, a large health system provider in the mid-west and South ‘…stopped covering anti-obesity drugs including Wegovy and Saxenda for its health plan members July 1.’ This ‘…also applies to older weight-loss drugs such as phentermine…’ which is odd – phentermine may not be the most clinically effective in terms of weight loss, though is considered cost-effective when ROI is calculated across the broad gamut of all available medications for people with obesity.
- Some employers ‘…continued to cover the drugs, but have taken steps to try to curb costs.’ For example, The University of Michigan ‘…earlier this year increased the monthly copay for Wegovy and Saxenda to $45 from $20… to encourage health plan members to first try other, less expensive options.’ As per my note above on Ascension, at U of M, the ‘…copay for phentermine tablets, for instance, is only $10 a month.’ Indeed, Brian Vasher, assistant vice president for benefits and well-being programs at the University, whose health plans cover about 120,000 people notes ‘…We do want people to try those lower-cost options…’ to which I would add that lower cost is great, as long as there is value creation too. Of additional interest, Novo Nordisk declined to comment to Mr. Loftus at WSJ.
- Found, a digital health start-up with a focus on clinical weight care reportedly with 200,000+ members released new data that ‘…69 percent of patients do not have insurance coverage as of June for GLP-1s for anti-obesity or diabetes, a 50 percent decline in coverage since December 2022.’ Found CEO Sarah Jones Simmer told Jakob Emerson at Becker’s Healthcare ‘…a lot more prescriptions are being written…’ and ‘…payers are putting more pressure on their PBMs to introduce prior authorization or create more hurdles to getting access or just dropping them from the formulary entirely.’ Found chief medical officer, Rekha Kumar refers to a decrease ‘…from 27 percent of diabetes patients covered in December to 12 percent in June…’ that is ‘…concerning on a lot of levels.’ The ‘…vending machines for Ozempic…’ model is noted, with need for ‘…a comprehensive evaluation, an understanding of the patient and a full lifestyle plan.’
- Elaine Chen, a regular on the obesity reporting front at STAT News, refers to D-day for patients on GLP-1 medications, as ‘…the date their insurance companies will stop covering the drugs.’ The exponential increase in GLP-1 prescribing has led to insurers ‘…aggressively cracking down on the medications, which have a list price of at least $900 a month and are meant to be taken indefinitely.’
- Eileen Pincay, vice president and national pharmacy practice leader at consulting firm Segal refers to the situation as ‘…very scary…’ for the plans, and the off-label use that has spiraled too – referring to patients being prescribed GLP-1 medication Ozempic in absence of a diagnosis of diabetes. For example, ‘…Ozempic accounted for 4.7% of spending so far this year, compared with 0.6% in 2019…’ as per consulting firm Segal; the seven-fold increase cannot be attributed to a greater prevalence of type 2 diabetes.
- Alternative strategies are to employ more restrictive coverage policies, such as only covering ‘…people who are considered morbidly obese, with a BMI over 40, rather than the BMI threshold of 30 that’s in the FDA label…’ or requiring patients to first have tried older, and less effective, obesity medications.
- Shannon Young at Healthcare Brew focuses on the ‘…skyrocketing demand…’ and how ‘…drugmakers have struggled to keep pace…’ with the 2,000% increase in prescriptions from some drugs since 2019. Carolyn Jasik, chief medical officer at virtual-first healthcare provider Omada Health wants to ‘…make sure that the patients most in need are getting their medication.’ And yours truly, as a GI surgeon and founder of twenty30 health, is quoted by Shannon that ‘…the worst thing you can do is stop…’ in regard to a patient’s medication, with rationing as ‘…not how we deliver healthcare in this country.’
- At NBC News, Berkeley Lovelace Jr. reports on the ‘26-page lawsuit, filed on behalf of a Louisiana woman who says she was severely injured after taking the two diabetes drugs…’ Ozempic and Mounjaro. The said ‘…Jaclyn Bjorklund, 44, of Louisiana, is accusing the drugmakers of failing to disclose other health problems allegedly caused by the medications, including severe gastroparesis, also known as stomach paralysis…’ which is a known complication of type 2 diabetes, that Bjorklund was diagnosed with in 2017. Dr. Shauna Levy, a bariatric surgeon at the Tulane Bariatric Center in New Orleans was ‘…surprised by the lawsuit…’ and ‘…not worried about this being a common problem.’
- Allurion Technologies, a newly public company with a commercial gastric balloon for people with obesity, supplemented with an AI-driven platform to guide and manage the patient’s progress, and remote monitoring from ‘…a scale, watch, and a mobile app…’ was featured by MedCity News via Frank Vinluan. CEO Shantanu Gaur’s intent is ‘…to lead to permanent behavioral changes that last long after the capsule deflates and passes out of the digestive system.’ The balloon has ‘…treated about 100,000 people in more than 50 countries…’ with $14 million in revenue for the first quarter of 2023, though is still working on FDA approval for us in the US, which it plans to receive in 2024. I remain unclear on the role of the balloon and other endoscopic technologies for obesity care, which are likely to get squeezed into a small middle by GLP-1 medications on one side, and bariatric surgery on the other.
- AXIOS refers to ‘…new research from the USC Schaeffer Center for Health Policy and Economics…’ that ‘…Medicare coverage of obesity drugs could save taxpayers as much as $245 billion over a decade by reducing demand for hospital care and skilled nursing.’
- In addition, weight loss medications may lead to a reduction in ‘…the incidence of related conditions like heart disease and diabetes that each independently raise medical spending.’
- Unfortunately, we are some way away from this kind of impact, as just ‘…1% of Americans eligible for treatment have access…’ to either medications or bariatric surgery.’
OPINION
- In The Telegraph, a UK daily newspaper, Anonymous author writes ‘…the miracle weight loss drug changed more than my dress size… it changed my brain too and made me understand why I became obese.’ The narrative commences with ‘…at my BMI, [I] qualify for bariatric surgery…’ and how ‘…this was something for proper obese people – American ones with their own reality shows, like the 1,000lb sisters.’
- The conversation was between the writer, as a patient at London Medical, a private clinic, and Dr. Ralph Abraham, a specialist in diabetes, referred to as ‘…the first doctor in the UK ever to have prescribed Ozempic…’ but more importantly for the patient, I would say, ‘…the first person to address my obesity head on…’
- The article continues with a narrative known well to many, of the slow creep, from demolishing a packet of chocolate biscuits in one sitting [or cookies as you call them in America], to eat to socialize, to alleviate stress, to combat a bout of bad depression, fueled by incessant snacking, through to ‘…no full-length mirrors in my flat [or apartment…], and I’d shower in the dark.’
- The onward piece on weight loss is a common thread ‘I have tried to lose weight: SlimFast. The Atkins Diet. Noom. Basic calorie-counting. Mad exercise routines. HIIT classes. Boxing against competitive men. Boot camps…’ and so list goes on. And how this affected her too, in that she ‘…internalized all possible criticisms… No self control. Greedy. Burden on the NHS. You’ll die of a heart attack.’
- The first thirty days on Rybelsus, the brand name for an oral version of semaglutide, are described with ‘…the stomach cramps that come in waves…’ and ‘…the side effects are horrible…’ though tempered by ‘…I’ve already lost one stone and two pounds…’ [which is 16 pounds in America].
- Akin to how my past patients with bariatric surgery have recounted their appetite and food-related experiences to me, the article eloquently refers to ‘…voices are screaming in your head. You can’t turn down the volume… Then, one day, you find a switch and you flip it, and – gone. Silence.’ The author calls it ‘food noise’ and how she is drawn to fresh grilled chicken, crunchy salads, pure soups.
- Dietician Jo Hollington is quoted ‘I don’t think anyone knows the exact way it’s working, which is why it’s so fascinating…’ which are almost the exact words I have used with my patients after gastric bypass or gastric sleeve surgery – it is more than just you have a smaller stomach – there is a clear brain-gut axis impact here, to modify your desire for rich, fat-laden foods.
- And finally how this ‘…has all opened up an honest conversation with myself about my weight…’ and ‘…the only way to lose it – and keep it off – is to go back to the start, to look deeply at how I got here. And to sit, however uncomfortably, with why. Thank you, Anonymous author for the share of your experiences, which I know will resonate for many, not just patients, but providers and others too.
- Caitlin Owens at AXIOS strives ‘…to better understand possible health risks that are still emerging in a market projected to be worth tens of billions of dollars…’ in reference to the ‘…new blockbuster obesity drugs.’ Weight loss drugs as a cultural phenomenon, recently published clinical studies, potential side effects, including suicidal thoughts, the worrying loss of muscle mass in older adults, tempered by the ‘…pharmaceutical arms race to capture a potentially lucrative market…’ are nicely summarized.
- The note on ‘bold claims that medication could soon trump bariatric surgery…’ is counterplayed by Dr. Marina Kurian, bariatric surgeon in New York City, current president of the American Society for Metabolic and Bariatric Surgery, and a good friend, stating ‘We actually think we’re going to see an increase in patients coming to surgery…’ as per Claire Bugos at Verywell.
- The new weight loss drugs indeed borrow from the bariatric surgery playbook, and ‘…an improved understanding of obesity as a chronic condition and how the treatments work.’ The long term data on bariatric surgery outcomes is spectacular in that ‘…weight loss surgery decreased the risk of all-cause mortality by 50%. People with diabetes who underwent surgery saw an extra nine years of life, on average…’ which is being supplemented by GLP-1 medications.
- I love the analogy from Dr. Daniel Drucker in Toronto, that it is ‘…like an orchestra. You have the end result, which is this great symphony or tremendous weight loss. But there are multiple different instruments contributing to the fantastic result, just like there are multiple different mechanisms all contributing to telling the person they’re just not as hungry as they used to be.’ Importantly, Dr. Drucker adds that ‘…you’d say that bariatric surgery has more data for long-lasting, durable improvements in health…’ in reference to a comparison of weight loss drugs and bariatric surgery.
- The way forward, as with every other branch of medicine that manages chronic disease, is multimodal care – the exemplar is cancer therapy, which nowadays includes medication in the form of chemotherapy, radiation therapy, and surgery, as and when needed for the individual patient, and has spurred the definition of medical oncology, radiation oncology and surgical oncology as medical specialties, to treat the whole person, over a multi-year period. The patient journey is managed by a cancer care navigator or care coordinator, and routinely reviewed by clinicians at tumor board meetings, that at their utmost best involve a social worker too – true multidisciplinary and patient-focused care. Dr. Kurian agrees, in that ‘The question shouldn’t be one or the other, but how and when can the two modalities work together?’ to enable the right patient receive the right treatment/s at the right time, to achieve the right outcome.
- The blue syringe pens, almost an iconic image these days ‘…might as well be made from spun gold…’ in reference to the Ozempic assembly line at drugmaker Novo Nordisk, with the name Ozempic ‘…as readily understandable as Kleenex is for facial tissue.’ Karsten Munk Knudsen, chief financial officer at Novo Nordisk is quoted by Vivienne Walt, writer at FORTUNE, that the Wegovy boom ‘…happened very, very fast…’ and further referenced by Deutsche Bank research analyst Emmanuel Papadakis, as a ‘…complete game-changer’.
- My query is whether this state is as much a gamechanger for the almost four billion humans across the globe that will be overweight or obese by the year 2035, as it is for those who are in line for the financial rewards of the next Prozac, Viagra, Humira or similar.
- Walt puts it astonishingly well that ‘…Novo could ride the Ozempic and Wegovy wave to untold riches, but the problem of obesity is so enormous – affecting some 1 billion people globally – that it can’t be prescribed away.
- And further, Emily Field at Barclays Investment Bank in London states ‘Novo and Lilly are the winners, and everyone else is tripping over themselves to try and catch up.’
- Novo chief scientific officer Marcus Schindler, with a PhD in pharmacology from the University of Cambridge [and a nod to my alma mater, with the fast approaching thirty year reunion of yours truly this September], is on a journey to help redefine obesity as ‘…a chronic medical condition causing widespread suffering instead of the self-inflicted result of bad habit…’ and now a ‘…treatable disease, and that is a game changer.’
- World Health Organization’s nutrition director Francesco Branca told reporters back in May that medications in the form of Ozempic and Wegovy ‘…is not a silver bullet.’
- Novo Nordisk has launched an in-house transformational obesity prevention unit, led by head strategist Camilla Sylvest together with Schindler, with a focus on prevention of obesity. That ship has sailed in my mind, and we are beyond a halting of the massive numbers and onward rate of increase of people suffering with obesity across the US and the globe. Prevention is critical, but over the next decade and likely two or more decades, we must work to halt the development of type 2 diabetes, hypertension, sleep apnea, and certain cancers in people who already are suffering from obesity, and onward to prevent those with obesity and diabetes in their progression to kidney failure, and vascular disease.
- The ever-rising numbers of ‘…weight loss entrants in the virtual health industry…’ such as Teladoc, Noom, Ro Health and others, are of concern to Dr. Robert Lash, chief medical officer at Endocrine Society, and Dr. Caroline Messer, a New York City-based endocrinologist at Mount Sinai School of Medicine, in reporting from Brock Turner at Modern Healthcare. The two physicians reference ‘…that many clinicians prescribing the (GLP-1) drugs are not endocrinologists or trained in weight loss medicine or in how to deal with GLP-1’s side effects.’ Dr. Lash added ‘…I think it’s very hard for patients to understand which digital health companies they can trust and which ones they can’t.’ Dr. Anthony Millard, at Chicago-based Northwestern Medicine worries that with ‘…more fleeting interactions you’re less likely to develop enough of a relationship that gets people to stay on the medication long term.’ There is nothing inherently wrong with telehealth, for which I am a true advocate to expand access; the issue at hand is to deliver comprehensive, multimodal, and long-term care to our patients, in an evidence-based and clinically driven manner.
DATA
- KFF, formerly known as The Kaiser Family Foundation, a non-profit and non-partisan organization focused on health policy, reports the latest KFF Health Tracking Poll of just over 1,300 U.S adults conducted online and by telephone. Of those surveyed, ‘…nearly half of adults (45%) say they would generally be interested in taking a safe and effective prescription weight loss drug.’
- Indeed, ‘…interest decreases substantially once people are asked if they would take a drug administered as routine injection (23% of all adults would still be interested), if it was not covered by their insurance (16%)…’ and onward, some ‘…80% say that insurance companies should cover the cost of weight loss drugs for adults who are overweight or obese.’
- From an awareness perspective, ‘…Seven in ten adults say they have heard at least a little about a new class of drugs being used for weight loss…’ with ‘…with at least eight in ten adults ages 65 and older (79%) saying they have heard about them.’
- Only ‘…4% of adults say they are currently taking a prescription drug to lose weight and one in ten say they have previously taken prescription drugs for weight loss…’ though ‘…about six in ten adults (61%) say they are currently trying to lose weight.’
- From a gender and race perspective ‘…Women are significantly more likely than men to say they would be interested in taking a prescription drug for weight loss (51% v. 38%). About four in ten Black adults (41%), nearly half of White adults (45%), and just over half of Hispanic adults (55%) say they would be interested in taking a prescription weight loss drug.’
Kind regards, Raj
