Navigating the GLP-1 regulatory landscape: Part 2

In the first part of this two-part series, we ended with a call for employers to reevaluate their contracts with their healthcare vendors and carriers and push for a full scale reevaluation of their health plan. In part 2, we dig into strategic plan design and implementation strategies.

“We’re entering into a new world and we need a new approach towards this,” says Adam Berkowitz, President at Level Health. “We need to attack this problem head on. But how does this fit into a broader strategy? Because after GLP-1s there will be the next thing, and the next big thing after that. So we need more flexibility, control, and holistic solutions to be ready.”

While traditional step therapy — try a lower cost drug first, and if it fails, move on to the more expensive version — has been shown to work for many types of treatments, Adam believes GLP-1s require a different approach entirely. “The net cost of these drugs after the rebate is going to be in the ballpark of $700 to $800 per patient per month. There has to be a thoughtful approach about lifestyle and changing behaviors to ensure the overall success of a program.”

We’ve long acknowledged that obesity is not simply a matter of overeating or lack of willpower. It's a chronic medical condition influenced by a complex interplay of genetic, environmental, and behavioral factors. And while GLP-1s are already proven to be an effective tool, they're not a silver bullet. Long-term success requires deeper lifestyle adjustments, with some 58% of patients discontinuing these medications within 12 weeks, according to the findings of a Blue Health Intelligence study, which are based on data from more than 170,000 commercial health plan members dating back to 2014. Research has shown patients taking GLP-1s should “complete at least 12 weeks of continuous treatment” in order to see clinically meaningful results, i.e., at least a 5% weight loss, according to the study.

Beyond changing habits, there’s physiological reasoning behind the need for GLP-1s to be one part of a holistic weight loss program.

“The way you lose weight [on GLP-1s] is you lose fat, but you lose muscle mass as well,” says Danish Nagda, CEO at Rezilient Health. “The data shows in about a year of taking Tirzepatide, you actually end up losing a significant amount of lean mass — around 40 percent, depending on which study you look at.” Muscle burns calories, so it follows that when lean mass is lost, the ability to burn calories also decreases. “That means that when you get off the drug, there’s almost certainly going to be a sudden increase in your weight,” Danish continues. “That can cause insulin resistance, which means that it might actually push you into diabetes faster than if you had never been on the drug in the first place. So these rebound effects matter.”

“The first thing we need to do is to tie GLP-1 coverage to mental health and metabolic health programs,” says Josh Butler, President at High Plains Health Plan. “Things like stress, emotional eating, and trauma are all real contributors to obesity in this country. Lifestyle coaching, nutrition, activity, and sleep are all very important to losing weight, and also regulating type 2 diabetes and other chronic disease management.” 

This creates a potential conundrum for employers, however. 

“Employers have found themselves between a rock and a hard place without a real plan,” says Danish. “On one hand, if you're a manufacturer that makes shampoo for dogs, for instance, should you really be worrying about making sure that people eat well? On the other hand, you have to worry about it because either you're going to cover the drug, or you're going to cover the effects of not being on the drug.” 

Ideally, employers should communicate that they’re covering a holistic medical weight loss program, and rely on their chosen vendor or plan to explain the details of the program. “Employers should emphasize that they want to have a holistic approach towards health,” Danish continues. “The drug is just a mechanism to get you healthy, this program is about your health. Then they need to separate themselves from it and allow the experts they’re putting in place to educate their people on the program.”

There are many collaborators in these programs that all have to align, but the good news is that, if approached strategically, all parties benefit. “If employers choose to focus on this, they’re going to see the health of their population improve,” says Adam. “They're going to see their margins improve, so their profitability goes up, and hopefully they start to see employee turnover go down.”

Adam also believes that brokers and consultants who focus on this will likely see their book of business increase. “We know we need to solve obesity because it's leading to cancer and all these other downstream diseases. And now we have something that can help us with that.” It can't just happen in a vacuum, however — the strategy also needs to consider health equity. “How are we going to protect people that can't afford these medications?” Adam continues. “Because they also deserve to have access to a better lifestyle. This is a sentinel moment within our industry and there will only be winners if we tackle it head on.”

‍