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SHOULD EMPLOYERS COVER GLP-1S? THREE CONSIDERATIONS FROM A CHIEF MEDICAL OFFICER

By James Wantuck, MD, chief medical officer of Accolade & PlushCare | July 11,
2023 | 5 min read



In both my role as a practicing physician and business leader, I shape clinical
strategy for employers across the country and a large virtual primary care
practice with hundreds of physicians. In these capacities, I have the privilege
of caring for people managing chronic illnesses and have the opportunity to
advise employers that grapple with complex questions and concerns. In recent
months, weight management and the search for healthcare guidance on promising
GLP-1 drugs has become a frequent topic of discussion. Patients are looking to
improve their health and, ultimately, their quality of life, while employers are
wondering how they should address GLP-1s as part of their health benefits
offering.

The current swirl of debate in the news media and in the market raises questions
about the cost and appropriate utilization of GLP-1s. This has left some
employers pondering about whether they should cover these drugs at all. As HR
(Human Resources) and executive leaders strive to make informed decisions about
their company’s policy and coverage, I consistently see good intentions from HR
teams as they seek to care for employees in a financially sustainable way.

Forty-two percent of Americans are affected by obesity — a complex health
condition that often includes comorbidities like diabetes and joint and heart
disease.[1,2] Thus, obesity is a condition that can drive up healthcare costs
and drive down quality of life and productivity. When you combine the prevalence
of this condition and its resulting costs, the ramifications of how employers
manage the GLP-1 question in their benefits design may be the most critical
benefits decision they make this year.

Of course, that statement might raise your pulse, so allow me to propose that
the swirl of GLP-1 debate may be pushing decision-makers into a false dichotomy.
There appears to be an implied pressure to either 1) make potentially
life-saving pharmaceuticals broadly available to employees without restrictions
or 2) avert potentially unending and unsustainable healthcare spend increases by
not covering the drugs carte blanche or by imposing strict limitations. Let us
examine a more nuanced approach.


THREE GLP-1 CONSIDERATIONS TO ADDRESS

If GLP-1s feel like an urgent and precarious issue for which you are unprepared,
allow me to offer three prudent and practical factors to consider as you move
forward.

1. Obesity is expensive. Mismanaged GLP-1 approaches will be, as well. Roughly
78% of employers have historically not covered weight-loss drugs – perhaps due
to now outdated views that weight is a purely cosmetic problem or because the
lack of compelling clinical results made it difficult to formulate an employee
health plan business case — you may find yourself needing to revisit previous
conversations with your CFO. Of course, if you run some basic back-of-the-napkin
math, you and your CFO will realize quickly that GLP-1s are not sustainably
affordable for all populations. Does this, however, mean that the case for GLP-1
coverage is closed?

From a physician’s point of view, consider that we now know obesity is a
bio-social health condition, not a lifestyle choice. It is a result of your
genetics, your psychology, and your mental and physical environments.
Clinically, we also know that obesity is closely associated with other chronic
illnesses, and that collectively these illnesses cost a staggering 9.3 percent
of the U.S. gross domestic product. Add to this the interconnectivity of obesity
and other health conditions that employers are already paying for, along with
the promise of what GLP-1s deliver that previous weight loss pharmaceuticals did
not, and you have a circumstance that demands a fresh look.

Not only does a jump to restrict GLP-1s not solve the total cost of obesity that
employers already bear, but it is also an approach that may prevent employers
from enjoying the benefit of short- and long-term cost reductions. A
forward-looking organization would do well to assess the needs of its employees,
the clinical considerations and the organizational fit. If you want to address
the cost of diabetes, heart disease, cancer, and even orthopedic surgery, you
should start by addressing the underlying cause of a large portion of these
conditions: obesity.

2. Center on the doctor-patient relationship with your GLP-1 policy. Doctors
wrote more than 500,000 prescriptions for GLP-1s in February, an increase of
152% from the year prior. As we know by now, consumers have pursued these drugs
even when it meant paying 100% of the cost out of their own pocket. While you
evaluate how GLP-1s fit into your benefits offering, consider that while they
may sit in your Rx spend line-item, prescriptions are written by physicians who
are best qualified to determine if GLP-1s are the right fit for your employee.

I believe that primary care doctors (PCPs) are best positioned to view the full
picture of an employee’s health and order the bloodwork and other diagnostics
necessary to determine who will benefit from GLP-1s. It is important to put
PCPs, who form trusting relationships with patients and have expertise and sound
judgement, at the center of employee health decision-making, not solely pharmacy
benefit managers or health plans.

3. If you are not already, embrace virtual advanced primary care in your health
benefits plan. You might be reacting to consideration number two above by asking
several questions. “Isn’t the primary care system struggling?” "Aren’t
telehealth companies just pill mills that churn out GLP-1 prescriptions with no
thought to the long-term improvement of the patient’s health?”

The concerns behind these questions are valid, and they underpin the final
consideration for leaders grappling with the promise and challenges of GLP-1s.
As you weave together your provider network and point solution benefits – e.g.,
diabetes care, MSK programs, center of excellence for heart health – that will
work together to address the total health, and total costs of health conditions
related to managing weight, consider how they can more effectively work together
in an advanced primary care model.


WE ARE HERE TO HELP YOU DEVELOP A GLP-1 STRATEGY

Accolade’s advocacy-led virtual advanced primary care model, which has proven
population health results in both clinical outcomes and cost trend reduction
(explained in this video in under two minutes by my colleague and chief health
officer, Dr. Shantanu Nundy) provides a map for how to effectively incorporate
GLP-1s. It is a new class of groundbreaking medications, but not a silver bullet
and must be part of a comprehensive population health plan that puts
advocacy-embedded primary care at the helm. Accolade can serve as a strategic
extension of your benefits team. Reach out to us today to learn how.

[1] https://stacks.cdc.gov/view/cdc/106273

[2] https://www.cdc.gov/healthyweight/effects/index.html 




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