Rae Woods (00:02):
From Advisory Board, we are bringing you a Radio Advisory, your weekly download on how to untangle health care's biggest challenges. My name is Rachel Woods. You can call me Rae. I bet you are hearing about weight management drugs. You either heard about them in the monologue to the Oscars, or maybe you saw the sketch on SNL or maybe you live in New York City and you're riding the subway and seeing ads for them everywhere or you're just on social media. We are getting a ton of questions about these drugs and obviously not from the general public. We're getting them from purchasers and employers and we're getting them from providers who have questions about how to prescribe these medications.

(00:45):
I'm going to be honest, this topic is a little bit controversial and our own research teams are grappling with different views on what these drugs could mean for our industry. For this week's episode, I've invited three advisory board researchers to talk about their questions, frankly, to talk about their fears and the role that every stakeholder should play as weight management drugs become more accessible. Let me introduce Kara Marlatt, a physician expert who also spent a decade doing clinical research on the intersection of women's health, obesity, and metabolism. We also have Gaby Marmolejos, our service line expert who focuses on women's health, obesity and diabetes. And Chloe Bakst, who is our pharmacy expert. Hi Kara. Hi Gaby. Hi Chloe.

Kara Marlatt (01:34):
Hi.

Chloe Bakst (01:34):
Hi.

Gaby Marmolejos (01:36):
Hello.

Rae Woods (01:39):
Deep breath. Are you ready to talk about all these new growing weight management drugs?

Gaby Marmolejos (01:44):
Ecstatic to talk about them. They're all on the news.

Rae Woods (01:47):
Ecstatic. Who's nervous to talk about it? This is a hard conversation. We've had a lot of confusion, even internally, about what we want to say to the market about this.

Gaby Marmolejos (01:59):
There's a lot we could say.

Rae Woods (01:59):
Yeah, there is a lot We could say.

Kara Marlatt (02:00):
I feel like my heart rate is like 15 beats higher when you ask that question.

Rae Woods (02:19):
We are in a moment where we're going to be asking more questions than having answers, but I do think there is value in putting those questions out to the market because that's exactly what real leaders and real listeners are grappling with every day. So let's make sure that we're actually on the same page. What even are these new generation of weight management drugs? What are the brand names that maybe people are aware of and how are these medications different or similar to ones that we've had in the past? Kara, why don't you go first 'cause I know you have quite a bit of history here?

Kara Marlatt (02:52):
Yeah, I've spent the last 10 years doing research in this space, and I can tell you there's a lot of complexity around this, and so it's hard to decipher the differences. Ozempic and Wegovy are both GLP-1 receptor agonist medications and they both come from the same active ingredient, semaglutide, and they're sold just under different brand names. So Ozempic is indicated for or intended for the treatment of diabetes, whereas Wegovy is indicated for more chronic weight management, but they're both developed by Novo Nordisk and they have slightly different dosing schedules.

Rae Woods (03:29):
When you say these are how they're intended to be used, you mean this is how the FDA has approved these drugs actually be used by real people?

Kara Marlatt (03:36):
Yes, absolutely. And they're on some different dosing schedules. Wegovy has a higher maximum dose than Ozempic, and then there are even other medications that are coming out on the horizon that are even slightly different than these medications.

Rae Woods (03:53):
Chloe and Gaby, what else is essential that we know about these drugs from the outset before we talk about what it means for our industry?

Gaby Marmolejos (03:59):
Well, just to note that they're injections, they're not pills and I would hope that most people know that, but sometimes the way people write about, it's not clear.

Chloe Bakst (04:08):
I'd also add that these drugs feel like just the beginning looking at clinical trials, things in the work. They're over a dozen similar drugs in the pipeline right now. Mounjaro, I think it's Eli Lilly's response to the Novo Nordisk products. So we're just going to see a lot more of these enter the space in the conversation.

Rae Woods (04:29):
I want to spend a little bit more time talking about the drugs that are out today, even though there may be more coming. I want to specifically talk about Ozempic and Wegovy. Kara, you mentioned this briefly. Can we go a little bit deeper on how these drugs are intended to be used? How the FDA has said that they are supposed to be used because they're for different populations, right?

Kara Marlatt (04:47):
Yes, absolutely. Ozempic is indicated as an adjunct to diet and exercise to improve glycemic control. So to improve glucose levels in adults with type two diabetes. Wegovy is different. We had just talked about, it comes from the same active ingredient, semaglutide, but again, it's indicated as adjunct to diet and exercise. But this is specifically for chronic weight management of adults with either one of these two things. It's either a BMI of 30 or greater, so indicated as an obese status or it's a BMI of 27 or greater. So you could be overweight or obese. However, you also have at least one weight related comorbidity, so it's hypertension or type two diabetes or a dyslipidemia or something like that.

Rae Woods (05:41):
And both of these drugs induce weight loss.

Kara Marlatt (05:44):
Both of them are the same active ingredient. And so they're all used to, first and foremost improve a patient's blood glucose levels, but they also reduce appetite. And so that's what can lead to weight loss with both of these medications.

Rae Woods (05:58):
What are the limitations of these drugs?

Gaby Marmolejos (06:00):
The weight regain, particularly if you're being prescribed them for the purpose of weight management, there's some clinical trial data that shows that once you stop using the medication, like any drug, you might gain the weight back.

Rae Woods (06:18):
Even with lifestyle management, even with diet and exercise?

Gaby Marmolejos (06:19):
Even with diet and exercise while you're taking the medication. So in the study I'm thinking of, they actually didn't continue the lifestyle intervention after they stopped using the drug, but that is definitely a potential because you gain your appetite back when you stop using the medication. So if you didn't incorporate any lifestyle changes it's likely that you would go back to the same lifestyle habits as the past. And then there's also the FDA requires Wegovy to include a warning label around the risk of thyroid cancers or tumors. I'll say the studies that they use this risk on are on rodents. So it's not really known if this risk is going to happen among people.

Rae Woods (06:55):
Chloe, how expensive are these drugs and who currently covers the cost because they are something that is injected and they're injected weekly?

Chloe Bakst (07:04):
Yeah, you're right. It's a weekly injection. If it's something that is prescribed as the FDA indicates, then it's something that your health plan would cover, your PBM would cover. What we haven't mentioned yet is off-label prescribing. So that would be instances where perhaps it is a time where you get the drug from a telehealth company, for example, to help with weight management. In that case it would be patient out of pocket spending.

Rae Woods (07:28):
And how much out of pocket spending are we talking about?

Chloe Bakst (07:32):
It's around a thousand dollars a month.

Rae Woods (07:34):
So pretty expensive.

Chloe Bakst (07:36):
Yeah.

Kara Marlatt (07:37):
Of course. But just remember that providers are the ones that are prescribing these medications in the first place. They have to be the ones that are prescribing these. And so if the provider is doing what they're supposed to do and prescribing as appropriate, as intended for, they shouldn't be getting these when they shouldn't be.

Chloe Bakst (07:57):
I know I just mentioned that this is something that health plans and PBMs would with theoretically cove. That remains true as the drug stand as diabetes treatments. But I have had conversations recently with employers and employer groups and there is a mixed bag in the sense of whether or not this is something people are interested in incorporating into their weight management programs. Most employers already have weight management programs as part of their benefits packages, and they're not sure if they want to spend the money to cover these drugs if they already have something in place.

Rae Woods (08:30):
That's exactly right, because the expense isn't just something that somebody is perhaps paying out of pocket if they want to get these drugs off label. The expense is something that is going to have to be swallowed by a variety of purchasers in healthcare. So we're getting to this point of, "All right, this is what the landscape of weight management drugs looks like today, and we know it's going to change." Let's talk about the impact on the industry. I wonder if one of you can walk me through a potential patient journey. What should it look like if all of the rules are being followed for a patient to qualify for, get access to and ultimately experience the clinical benefit that these drugs intend, based on FDA's approval?

Gaby Marmolejos (09:15):
Kara, I think this is all you.

Kara Marlatt (09:17):
Yeah, and this is something that Gaby and I have gone back and forth on quite a bit. And if we just pick Ozempic, the ideal candidate for Ozempic would be somebody that has type two diabetes that would potentially benefit from weight loss, chronic disease management that could be improved. And if a doctor identifies a patient or if a provider identifies a patient as potentially having a benefit from going onto Ozempic and that being a good treatment option, the doctor should discuss the benefits and the risks for taking these sort of medications, just like with any medication that they would be taking. And some of the risks include the side effects that go with some of these medications.

(10:02):
A provider could submit a prior authorization for the patient and the payer can either approve or deny it. But what Gaby and I have been hearing in some interviews as of recent is that getting prior authorization for these medications is sometimes more challenging than expected. And so it's creating some medical waste within the system. It's burning through a lot of hours for different providers and their support staff, and it's not as easy to get their hands on these medications.

Rae Woods (10:32):
And so they could be potentially paying more out of pocket for these medications that even if we say in theory, payers should be covering some or all of the cost.

Kara Marlatt (10:40):
Payers and PBMs. I want to give Chloe that shout out. And the goal here for this population, I want to be clear, is to induce a clinical change. That is why we're not saying weight loss, even though that might be a outcome or a side effect of these medications. But the goal is more about the underlying chronic disease or diseases that these patients have. Let's roll the tape forward. Let's say that that is repeated across thousands, maybe hundreds of thousands of patients. The good news for those people is that they will have improved health outcomes. That's the whole goal of this. I want to talk about the downside. Most health systems still have a business model that is rooted in fee-for-service. I am thinking about what the impact might be if these drugs mean fewer bariatric surgeries, maybe not even just bariatric surgeries, fewer cardiac procedures, fewer stents or CABGs, fewer orthopedic surgeries. The list kind of goes on. And those are key revenue generating procedures and surgeries for today's health systems. What do these drugs mean for hospitals and health systems today? Gaby, do we actually have numbers on this?

Gaby Marmolejos (11:52):
We do have numbers on this, but the important takeaway when you're looking at these numbers is we are expecting to see a rise in bariatric procedures over the next few years that is concurrent with the rise in obesity prevalence in the United States. But when we look at the numbers, we know that these volumes wouldn't be catastrophic to the average hospital.

Rae Woods (12:10):
If the volumes went down because of these medications?

Gaby Marmolejos (12:13):
For sure. But it's really the associated volumes with obesity, thinking about all the different cardiovascular procedures, all of the different procedures that are related to obesity management or weight management. And if those go down, then we could see a dire situation to be dramatic about it.

Rae Woods (12:29):
And you mentioned that health systems are already in a fragile place. How worried should hospital and health system leaders who are in fee-for-service be of these drugs?

Gaby Marmolejos (12:40):
Well, it depends because we're making a few assumptions here. We're assuming that there would be chronic disease prevention at this point. We don't have long-term data on the effectiveness of these drugs for us to be freaking out quite yet. But in terms of the volume backslide, it would take time to happen, if at all. And it's not like bariatric surgery's going away, and at this point, bariatric surgery is not considered a third line treatment. So basically, it's not necessarily the case that you would be on these drugs first and then move on to bariatric surgery, and then if the drugs are successful, you move on. Sometimes a physician might just prescribe or suggest bariatric surgery instead of the drugs. And we don't necessarily know that it's going to shift volumes for bariatric surgeries as a whole. We don't know if it would change the need for cardiovascular or orthopedic services moving forward necessarily.

Chloe Bakst (13:31):
I think one thing to note is that there are certain orthopedic surgeries that can't even be performed unless a person achieves a certain health status. So in some instances, if somebody were to be able to lose weight with these medications or what have you, they would then be able to have an orthopedic procedure.

Rae Woods (13:52):
That's true. And so we're getting at all of the complicating variables and why it's so hard to make a prediction about what these drugs will mean for things like revenues, volumes, and of course the health outcomes of people. But if I'm thinking I'm a hospital leader, that's business models in fee-for-service, and I'm thinking about how the dominoes could fall, this doesn't sound good for me.

Gaby Marmolejos (14:15):
There is a world from the pharmacy side where this isn't necessarily a nightmare scenario. So right now, these medications are not considered specialty medications, which I personally think is a little weird. It's an injectable drug. They're pretty high cost. Those are usually two things that would make a drug a specialty drug. But right now, perhaps because it's for diabetes patients who have a lot of history with injections, it's not that. If we see that sort of expansion of a patient population, if this now becomes a drug that a patient can take if they have a certain BMI, we might see it move to a specialty classification that would be dispensed by a specialty pharmacy. And if you're a health system and you have a specialty pharmacy that could bring in some revenue, that could help augment maybe some of the losses in different parts of the system.

Rae Woods (15:06):
We've been talking about the fee-for-service business model. I want to shift to total cost of care business models. We just aid that in most scenarios, maybe specialty pharmacy aside health systems and fee-for-service might be feeling some pain if these drugs lead to an erosion of profitable procedural volumes. But isn't that a good thing for total cost of care?

Gaby Marmolejos (15:28):
Maybe. Like I said, there's a lot of assumptions we're making there. I envision two potential scenarios. There's probably more, but I'm just going to go with two based on a number of assumptions. And so we know these drugs are really expensive, a thousand dollars a month. Scenario one assumes that you're on these medications for a short amount of time. The way that the clinical trials were run, were about one to two years for each of the drugs. And then you have clinically meaningful benefits. You stop using the drugs and you maintain those benefits long-term. In that case, then we could see it as potentially being cost-effective.

Rae Woods (16:01):
Cost effective because those patients are being treated through a medication as opposed to expensive surgeries and procedures, which again, we would not want in a total cost of care model, even though they are revenue generating in fee-for-service.

Chloe Bakst (16:17):
,To jump in here too, Gaby, I think that there is a world, a model that we've floated out. I haven't seen this happen yet, but I could see a potentially happening where there's some sort of value-based payment or capitated model between the manufacturers of these drugs, maybe between clinics or telehealth companies who have those weight management programs where they take on maybe like a capitated risk for patients enrolled and the drug costs get folded in there. This is again, not something I've seen happen yet, but I could potentially see it happening moving forward. And when we floated this idea on calls with manufacturers, payers, and even providers, everybody seemed really interested and intrigued by it. So I think we'll see a lot of innovation there.

Rae Woods (17:03):
And the success of that innovation is going to come down to, are we able to lower the cost with switching to this medication and being in a risk-based model as opposed to doing surgeries and procedures. But Gaby, you said that that might not be the only path forward. What's the other scenario?

Gaby Marmolejos (17:21):
The other scenario, the other extreme of this, we have data that shows that people who stop treatment gain the weight back. And so what that means is we're talking about they may not be able to get off the treatment after one to two years. They may stay on the treatment, maybe for the rest of their lives. It depends. And so if that's the case, we're talking a thousand dollars a month for the rest of someone's life, and that's just one person. So imagine just lots of people. There was a recent analysis that found even if only 10% of Medicare beneficiaries with obesity took we Wegovy, it could cost close to 27 billion dollars a year.

Rae Woods (17:58):
Wow.

Gaby Marmolejos (17:58):
The cost would exceed the entire Part D budget if all Medicare beneficiaries with obesity took Wegovy. And I'll note that in this analysis, they actually assumed a $200 discount on the list price of Wegovy. So that is actually a conservative estimate if we're talking about list price.

Rae Woods (18:17):
And something that ultimately would actually increase the total cost of care, the opposite of what your first scenario suggested?

Gaby Marmolejos (18:24):
Yes. So it depends.

Rae Woods (18:26):
Neither of those scenarios are guaranteed. And again, I want to reiterate to our listeners that there are a ton of variables that exist and questions that exist in this world that we're trying to grapple with real time as I know that our listeners are as well. So for you all as researchers, what variables are you watching that might hint or tell us what path our industry might go down?

Gaby Marmolejos (18:49):
Yeah, like I said, these scenarios are based on a lot of assumptions. And the biggest one for me is I want to see the long-term data. I want to see what happens. I'd love a cohort study, real world study, something to show what happens long-term. I'm talking five, 10, 15 years after somebody takes this drug and see what the clinical outcomes are, especially when I'm thinking of adherence, because with any medication, there's a trouble with adherence to using the medication. So I'm curious, are the clinical benefits still maintained even if someone doesn't take the drug as recommended in terms of, maybe they don't take it every week, maybe they take it every two weeks. Maybe they stop after six months, take it again after six. What does effectiveness look like there? And then that will tell us whether it's the clinical effectiveness, whether there's any cost-effectiveness related to that.

(19:40):
And then also clinical guidelines. I want to see if they change. At this point, these drugs are recommended as a second line treatment, which means that if a clinician wants to prescribe these medications, they have to prove that the first attempt failed. So if these clinical guidelines change, and let's say a medical body decides this is a first line treatment now, that would change the game completely. And also just insurance coverage as a whole. And then of course the biggest variable is price.

Chloe Bakst (20:08):
Gaby made a really good point that adherence to medications is challenging. It's really hard to get patients to regularly or as prescribed take their statins or their hypertension medication. And so these drugs will likely not be different. The benefit of these particular injectables is that this newer generation, like the Wegovys or the Ozempics, it's once weekly, whereas previous generations were once daily. And so that helps a little bit. But we know that people don't necessarily want to be on a medication their whole life. Some people might need to be on a medication longer than others, maybe really want to. And so it'll definitely be highly individualized with how this medication is not only prescribed but is also used by patients.

Rae Woods (21:45):
I want to come back to the price of these drugs 'cause it sounds like that is a huge variable that could be a big problem for our industry. This is, by the way, a good moment for us all to remember that the healthcare industry doesn't actually have cost-based pricing on anything. And there are a whole bunch of players that impact the price of these drugs. So I don't want to play the blame game here, even though that might be something that feels comfortable for us or for our listeners. But I want to know what would actually need to change for the price of these drugs to come down in say the next five, 10 years.

Gaby Marmolejos (22:31):
And I'm assuming we're talking about the list price?

Rae Woods (22:33):
Yes.

Chloe Bakst (22:34):
Oh, 'cause I was going to start talking about the net price.

Rae Woods (22:38):
Oh, okay.

Gaby Marmolejos (22:38):
You go ahead, Chloe.

Chloe Bakst (22:40):
Well, okay. The question here is, who is the price coming down for? Because there are a lot of different players in this game. For health plans for employers, I can see the price decreasing once these drugs get into the hands of PBMs more broadly and the PBMs can then do their job in negotiating with manufacturers, getting those rebates and ultimately lowering the cost for the employer for the health plan. I don't know how that trickles down to patients. That's not something that we have a lot of insight to. They could still see pretty high co-pays. I expect that they probably will. That's just something I'm watching.

Gaby Marmolejos (23:17):
And honestly, so when we saw with insulin pricing and everything, how there was a public outcry and there was federal legislation to reduce copays and prices for these medications. So theoretically that could happen. Again, I don't actually think this would be eligible for negotiation under the inflation reduction act, but things could change. It could actually be the case, but at this point, just because it has to be on the market for at least seven years to be eligible for negotiation. So I'm not really sure if that will happen with these drugs. Another factor is competition. Right now, there's only one manufacturer that we've mentioned in this call that are developing both Ozempic and Wegovy, but we know Eli Lilly's coming up with another drug, Mounjaro. It's already on the market for diabetes. Amgen has AMG 133, and so if these come on the market, it could potentially reduce price because there's more competitors.

Chloe Bakst (24:10):
I will say though, when we look at data in 2028 for the top revenue drugs in the US, Mounjaro, Ozempic, they're on there. So it's not that competition is necessarily going to lower costs maybe as much as we'd like. It's just going to be a lot of high cost players in the game.

Rae Woods (24:31):
It could be that people are trying to get their hands on some of this revenue that that's coming in.

Kara Marlatt (24:36):
And Chloe and Gaby, to your point that these medications, they have a higher price tag to them and there's going to be more medications like this, but even improved as the years go by. And so however the healthcare system decides to tackle this issue, now we'll set the tone for what happens within the next five to seven years.

Gaby Marmolejos (24:57):
And also, I just want to note that the only reason I care about prices equity from a health equity standpoint, whenever there's a high list price, that often just makes it unattainable for people with lower incomes, especially if they don't have health insurance. And so I think it's important to recognize the downstream impacts of these prices being very high and then the people that need them the most, not being able to access them because of price barriers.

Rae Woods (25:24):
There's another elephant in the room that I want to call out that we haven't really touched on yet. We've been talking about how these drugs are intended to be used, how they are approved to be used today, but allow me to get a little vulnerable for a second. These drugs also induce weight loss, which is something that for a lot of personal cultural reasons that we can agree or disagree with, is something that is desired by a lot of people, whether or not they have underlying health needs or not. And that's the big reason why the conversation around these drugs has gone outside of just healthcare leaders and is something that people in the general population are talking about. And I want to make sure that we're giving voice to that part of the problem. Can you talk me through an example of how these drugs might not be used as intended today?

Kara Marlatt (26:16):
That's a hard topic for me to discuss because I always revert back to if they're not intended to be used that way, then are we making a bigger deal out of it than we need to be? And I just saw recently the latest New York Times magazine that said over half of Hollywood is looking thinner and taking these medications. And my gut is to say that that is a gross exaggeration of how many people are getting their hands on it. But I always revert back to, "Do we have the data to show that they are getting into the hands of people they're unintended for?" And I don't know if we have that data. I'm not saying that that's not happening, but I just don't know. It's as big of a problem as the media is making it out to be, but it's something that we should obviously continue to watch.

Rae Woods (27:07):
Or to your point, because we don't have the data, we don't actually even know how big of a problem it is.

Kara Marlatt (27:13):
Yeah, we have no idea. And of course the gatekeepers of this, we have big pharma that's creating these newer, improved medications, but the physicians, the providers, they are the ones that are prescribing these medications. And so I think it's important for physicians to understand the utility of these medications and that they are prescribing as they're intended for. Because if this were to get out of hand and they're prescribing for unintended purposes, the states and the medical boards would eventually have to intervene. And that would be a problem for physicians. It would be their medical licenses that would be on the line.

Rae Woods (27:53):
What are you either seeing in the data or hearing anecdotally about off-label prescribing?

Gaby Marmolejos (27:59):
I do hear a lot of off-label prescribing.

Rae Woods (28:01):
So do I.

Gaby Marmolejos (28:02):
Most of the people that I know personally who are on these medications, they don't have type two diabetes. They're going on these medications to control their cholesterol maybe, or really to lose weight with the guise of managing a different health condition. But the real purpose, the real motivation is that weight management piece.

Rae Woods (28:20):
Yeah, exactly. It's the opposite of how the FDA has thought about it, which is the primary purpose is the underlying condition. And, "Oh, by the way, it also induces weight loss." You're saying the opposite, where the primary desire is being smaller and, "Oh, by the way, if there's good health benefits too, that's great and maybe that's the reason why I was able to get the prescription."

Chloe Bakst (28:40):
Yes. And I think that's what I'm worried about and what I'm watching. The way that we understand health and weight right now is going to make it very easy for folks to say, "Well, I really want to lose weight and my blood sugar is a little bit elevated at the moment. I can get this prescription, I can go to the pharmacy, I can be smaller now."

Rae Woods (29:00):
If I can be totally honest with you all, I don't think my family and friends really know what my job is. And I often get questions from them about healthcare that up until a few weeks ago, frankly, usually ended up being them being upset about a bill that they got and wanting me to explain co-insurance to them. But lately it's really changed and I have gotten phone calls and text messages from people that I know that say, "Hey, what's this Ozempic thing? I want it." And because the underlying desire is the weight loss, not necessarily the other benefits, that to Kara's point, is the reason why these drugs exist and why they need to be focused for the population who needs it the most. So let's talk more about what worries us about this scenario. Even if we don't know how many people are potentially taking it and getting prescribed it off-label.

Kara Marlatt (29:52):
To distinguish between being prescribed and off-label. A physician can still get it off-label, but they actually do still qualify as indicated by the FDA. They're just not getting their insurance to cover it.

Chloe Bakst (30:05):
That's a good point.

Gaby Marmolejos (30:06):
What worries me is something that I think Chloe and I've talked a little bit about is just the negative repercussions for behavioral health and thinking about the cultural standards that we already have in this country. And we already have pretty stressed mental healthcare systems. There's not enough providers. And I've talked to a lot of leaders actually about, specifically from the women's standpoint, there's a lot of issues with body dysmorphia and just other behavioral health challenges that these drugs could perpetuate potentially. Also, just thinking about the health inequities that is going to continue. So people who need the drugs won't be able to access them because they're unaffordable. And then people who already have pretty good health outcomes now have access to a drug to improve their health outcomes. So I think just those pieces are standing up to me.

Rae Woods (30:56):
There might be a question in our audience's mind right now that we should clarify that. I've heard some folks worried about is there enough supply of these drugs to go around? If there is a world where everyone in Hollywood is taking it and where everybody who sees an ad for this in the New York subway is going ahead and saying, "Yep, I'm going to do telehealth and I'm going to get prescribed this, I'm going to pay whatever it costs because I want weight loss." If that's true, is that affecting the supply of these drugs to get to the people who need it?

Kara Marlatt (31:25):
What's confounding this whole discussion in the first place, is that Novo Nordisk did not anticipate how popular these medications would be when they were first... Rae, I can see that.

Rae Woods (31:37):
You saw the eye roll?

Kara Marlatt (31:40):
I saw the eye roll. They did not have as much supply as they needed to to service everybody that was requesting this medication. I've seen articles that have talked about how the supply of this medication is going to be more so fixed at some point in 2023, but it's very hard to link if more people are getting these for unintended purposes versus those who are getting them for intended purposes. It's really hard to link what's actually driving low supply or a difficulty in getting these medications.

Rae Woods (32:15):
And my understanding is it's not so low that there is a systemic problem. This is another example where we might have be hearing some anecdotes where it's hard for people to get the drugs. And to your point, is it hard because there is not enough of them or is it hard because of the prior authorization or any other 1 million barriers that exist in our healthcare system?

Chloe Bakst (32:33):
I think we are going to see too, to going back to that prior auth point. I think that's going to end up being the bigger issue because I think PBMs and health plans are going to get a lot stricter with that prior auth process as it becomes a drug that more and more people are want to take just as a way to control costs and make sure that it is appropriate that patients are getting the drug. Prior auths are designed to slow care down so they can make sure that patients are getting the lowest cost drugs, so it can be really annoying, but it is a utilization management strategy for a reason.

Kara Marlatt (33:04):
Yeah, when you were talking, I was just nodding my head because hearing anecdotally from physicians that the prior authorization piece is sometimes the hardest hurdle to get over, and they have already tried behavioral modification and that has failed. And then they have tried the lower priced medications that are currently the GLP ones that are already on the market, the the first generations, they've tried those and they have failed, and those are the requirements that a lot of insurers look for. But even still, when patients have failed on those first two, they're still getting denied prior authorization, and there's no explanation for why they're getting denied. So it's challenging to navigate that, especially for physicians that are just wanting to treat their patients and they have their patients best interests in mind.

Rae Woods (33:55):
I want to make sure we give voice to all of our fears or questions that we have about this alternate scenario where patients are getting it outside of how the FDA necessarily intended for Wegovy view or Ozempic to be used. What other concerns do you have that you want to want to put out there for our listeners to know?

Chloe Bakst (34:12):
I'm just concerned about the idea of there being a magic solution to weight management in the United States now, and that may be putting pressure off of governments or off of other institutions to create more collectivist policy solutions to things that are perpetuating obesity and weight issues in the country, like our food system, having safe spaces to exercise, all of these factors that become the social determinants of health web that make controlling obesity so complicated. I don't want there to suddenly be a feeling of, "Well, we have this great shot now that you can just take and maybe it's expensive, but at least you'll be thin.

Rae Woods (34:57):
And we also should remind folks that again, we are trying to focus this conversation on underlying health issues and health benefits. And if somebody is taking this medication for the express purpose of being in a smaller body, and by the way, it makes them feel like garbage because it makes them feel nauseous, they're probably not exercising, they're probably not eating nutritious foods. And if they have to take the medication for a long time to keep inducing the kind of physical change that they want, that also has the potential on a long enough timeline to impact their overall health. But none of these things are happening in a vacuum. Even the example that I just gave would require somebody to be on that drug for years in order to prevent them from seeing the benefits of something like exercise long-term. We just don't know if that's what's happening yet. To Gaby's point about needing long-term data and frankly needing real world evidence about what this means.

Kara Marlatt (35:50):
Yeah, the important thing to note about these particular medications is that they aren't to be used as just a solo treatment. They're meant to be used alongside behavioral modification and any other treatment that the patient would need to have a clinically meaningful benefit. And so part of the reason why behavioral modification, so this diet and exercise is prescribed alongside of it is because those are very important things for people just to do anyway. But behavioral modification is very difficult for people to utilize and achieve meaningful weight loss. And so we've tried that for so many years in the weight loss management space, that we recognize as an industry that we needed additional help for certain individuals. And so it's like a comprehensive plan that incorporates medications and shouldn't be used as just a standalone.

Rae Woods (36:46):
That is absolutely true, and we need to be thinking about the ripple effects if these drugs are used as intended for the express purposes that you just described, Kara, and if they're used not as intended. So with that, I'm going to ask you to leave our audience with one final question. One final thought. What are the biggest things that you think our industry needs to find answers to or decisions that we need to make collectively to understand how the impact of these drugs will play out for healthcare business?

Gaby Marmolejos (37:14):
My biggest question is, so we always talk about winners and losers at Advisory Board, and I do want to know, who are the winners and losers when this all plays out, when it comes to how the long-term clinical benefits will play out, and then how it will affect and ripple out throughout the industry.

Chloe Bakst (37:33):
Building off of Kara's point, I think my main question is, are you ready as a health system, as a health provider to use this drug effectively, appropriately to work with patients who we'd be able to use it for A, a health related reason, not a weight related reason, they're separate things, and just, are we ready as a system to use this drug, to use it well?

Kara Marlatt (37:59):
And Chloe, you gave me a perfect jumping off point because it has to be a collective solution that all the players in the healthcare industry need to get behind. And history shows that a lot it's hard to work together sometimes, but we have an obesity epidemic that is going on right now, and there needs to be appropriate solutions to help tackle that and to ensure that our costs of healthcare don't continue to rise. And if we don't come up with solutions, then we're going to have an even bigger problem 10 years from now than we do now. And so I think we just need to come together to figure out how the healthcare industry can come together with a cohesive plan to tackle this, and it's not going to be easy, as we all know and have just discussed.

Rae Woods (38:50):
It is not. Well, Kara, Chloe, Gaby, thank you so much for coming on Radio Advisory, being honest about all the questions that you have, and we're clearly going to have to have you back when we actually have answers.

Kara Marlatt (39:02):
Thank you.

Gaby Marmolejos (39:03):
Thanks so much, Ray.

Chloe Bakst (39:03):
Thank you for having us.

Rae Woods (39:10):
We clearly have a ton of questions about how these drugs will impact healthcare business, but there's another set of questions that this episode brings up. Chloe mentioned this already, which is, what is the role of the healthcare industry and frankly, beyond our own industry in addressing obesity? That's a question that I want to get our own teams on at Advisory Board. It's something that our pharmacy team, our life sciences team, our health equity team, everybody needs to be working on. So expect to hear more from us because remember, as always, we're here to help.

(39:52):
If you like Radio Advisory, please share it with your networks, subscribe wherever you get your podcasts and leave a rating and a review. Radio Advisory is a production of Advisory Board. This episode was produced by me, Rae Woods, as well as Katy Anderson and Kristin Myers. The episode was edited by Dan Tayag with technical support by Chris Phelps and Joe Shrum. Additional support was provided by Carson Sisk and Leanne Elston. Thanks for listening.