Bariatric surgery cuts cancer risk by 25%, obesity as a key public health threat in the US, only 9% of anti-obesity meds prescriptions are filled, and payer strategies for GLP-1 drugs.

Hello everyone,

I hope you are all enjoying a late summer weekend with family and friends.

Key items this week have included news of a 25% reduction in the risk of cancer after bariatric surgery; that only 9% of prescriptions for obesity medicines were filled over 60 days; that obesity is believed to be one of the top three threats to American public health; and that payers are engaged in trying to figure out how to manage costs in the face of increasing demand for expensive GLP-1s (see the work of Deanna Bell and her colleagues at international actuarial and consulting firm Milliman).

Closer to home, I am thrilled to report that twenty30 health is nearly nine months old, and we are growing and thriving! Our team of employees and advisors has exceeded twenty folks now, a combination of clinicians, data scientists, technologists and business people focused on pioneering a truly multimodal approach to obesity medicine to achieve the optimal outcome for our patients; one which is focused upon whole-person, individualized care journeys, encompassing nutrition, behavioral, exercise, medication and surgical therapies. It is the honor of a career to be a part of this mission with these talented colleagues.

Kind regards, Raj

AT A GLANCE

  • The National Alliance of Healthcare Purchaser Coalitions, ‘…expects to issue best practice guidance by the end of the year on covering Wegovy and other weight-loss drugs…’ according to Michael Thompson, President and CEO of from Sara Hansard at Bloomberg.
  • Teladoc, Found, Hello Alpha, and Calibrate ‘…have advanced enterprise products that pair virtual visits and prescriptions with lifestyle coaching,’ mentioned in reporting from Katie Palmer at STAT News.
  • Matthew Herper reports on the ‘ground truth’ of the SELECT trial whereby ‘…Overweight volunteers who took Wegovy were 20% less likely to have either a heart attack, stroke, or to die from cardiovascular causes…’
  • The top three answers to the question, ‘what do you think is the #1 threat to American public health at this moment?’, in order, were opioids and fentanyl [26%], obesity [23%], and access to guns or firearms [20%]; this from global market research firm IPSOS, based on interviews with over 1,100 American adults.
  • From a total of 1,563 patients, with a mean body mass index of 38.4 kg/m2 who were all prescribed an anti-obesity medication between 2012 and 2019, only 9% of patients filled their prescription within 60 days, as per research published in the Journal of Managed Care + Specialty Pharmacy.
  • Bariatric surgery recipients had ‘…a 25% lower risk of developing any cancers compared with a nonsurgical comparison group’ over four decades. This is according to research published by Dr. Ted Adams on over twenty thousand patients who underwent bariatric surgery.
  • Deanna Bell and colleagues at Milliman publish a white paper on ‘Payer strategies for GLP-1 medications for weight loss…’ in order to help ‘…payers understand the landscape, develop a coverage strategy, and minimize waste.’

NEWS

  • Michael Thompson, President and CEO of The National Alliance of Healthcare Purchaser Coalitions, which represents employer and union health-care coalitions that spend over $400 billion a year covering more than 45 million Americans, ‘…expects to issue best practice guidance by the end of the year on covering Wegovy and other weight-loss drugs…’ from Sara Hansard at Bloomberg. Jeff Levin-Scherz, population health leader for management consulting company WTW added that Novo Nordisk’s findings of cardiovascular and other health benefits ‘…will strengthen the case for covering the GLP-1 drugs.’
    • Levin-Scherz adds ‘…employers might not cover the drugs because of the cost… (they may) adopt prior authorization requirements, and limit coverage to those who will benefit most, such as people who are obese and have heart disease.’
    • Long-term clinical and financial outcomes of patients on GLP-1 therapy, a multimodal approach to care, and competition to drive down drug pricing are all levers to pull us through the current challenges.
  • In Greenville, North Carolina, Thermo Fisher is reportedly ‘…doing the filling of the Wegovy injection pens…’ on behalf of Novo Nordisk, as the latter focuses on meeting exploding demand in part by turning to contract manufacturers. The source declined to be named, in a brief article from Maggie Fick at Reuters.
  • In Denmark, well known to many as the home of Novo Nordisk, ‘…Copenhagen-based Embla, a digital weight management clinic, has just raised a €10m Series A to conquer the British market…’ in a news story from Zosia Wanat at sifted, a media brand focused on the European startup community. The two founders, ‘…medical doctor Nicholas Syhler and serial entrepreneur Laust Wilster Axelsen, insist that their app is much more than an Ozempic-vendor… [with] …access to doctors and nurses, and regular check-ins with personalised health coaches.’

OPINION

  • Teladoc, Found, Hello Alpha, and Calibrate are mentioned in reporting from Katie Palmer at STAT News for how they ‘…have advanced enterprise products that pair virtual visits and prescriptions with lifestyle coaching.’ This is with recent news of payers such as University of Texas and Ascension Health putting a halt on GLP-1 medications for their health plan beneficiaries, and many more trying ‘…to figure out how to sustainably cover GLP-1 receptor agonists.’
    • Sarah Jones Simmer, CEO of virtual weight care company Found, says it well in that ‘They can’t suddenly have 70% of their employee base taking a medication that costs $17,000 a year and has to be taken in perpetuity.’
    • Sami Inkinen, CEO of Virta Health adds ‘…many employers said, we just need to give something. We kind of know they don’t work, but we need to offer a diet program or weight loss program.’
    • Kudos to Isabelle Kenyon, CEO at Calibrate, who almost takes the words out of my mouth in that ‘…the only way to align payers and providers is research and outcomes to basically say, I have a way to drive down the total cost of care.’
    • Interestingly, Ms. Palmer reports on ‘…Found’s pitch to payers, in some ways, is the anti-GLP-1. It offers a broad formulary of obesity medications — mostly cheaper drugs that have long since gone generic…’ with Jones-Simmer wanting ‘…to set expectations with members that they should not be coming to us if their only desire is a GLP-1.’
    • Tejaswi Kompala, clinical strategy director for cardiometabolic health at Teladoc states that through ‘…its app-based coaching program and connected devices, it can identify potential candidates for clinical care — and possibly a GLP-1 script.’
    • A digital front door to triage all customers is the approach at Noom, as per Dr. Linda Anegawa, be it ‘…its behavior-based weight program, some to its diabetes prevention program, and others to Noom Med.’
    • Through this gaggle of responses from well-known leadership at digital health companies, my message is clear – we need to leverage data science to stratify the population at risk and who merits treatment, then apply decision science to prescribe a system of multimodal and dynamic care, be it behavioral, nutrition, exercise, medication or surgical therapy, underpinned by high quality precision nudging taken from the field of behavioral science, to deliver clinical and financial outcomes of value, to all stakeholders – patient, payer and provider, and ultimately to broader society.
  • Tamar Haspel at The Washington Post puts a stake in the ground with her newest article titled ‘Yes, calories in/calories out really is the key to weight loss.’ The article focuses upon calorie absorption with hard-to-digest carbohydrates, particle size and your microbiome as key factors, and calorie burn based upon macronutrient content, metabolism boosting and hormonal effects. Marion Nestle, co-author of the book Why Calories Count refers to studies where ‘…if the calories were lower, they lost weight at a predictable rate, regardless of the composition of the diet.’
  • Matthew Herper reports on the ‘ground truth’ of the SELECT trial whereby ‘…Overweight volunteers who took Wegovy were 20% less likely to have either a heart attack, stroke, or to die from cardiovascular causes…’ and aligns this with the massive impact on reduction in heart attacks of those taking cholesterol-lowering drugs, or statins.
    • The statins do possess ground truth, with over three decades of research studies; this is different to a single, trial, only reported in a press release and without full data, of over 17,000 subjects, 70% of whom are male, with a mean age of 61 years and mean BMI of 33 – how is this skewed data going to apply to a real-world population?
    • In addition, Mr. Herper refers to the long lead time, often two decades, for a drug to go from clinical trial to mass adoption and drug company windfalls, as well as the risk of serious side effects.
    • The story of rimonabant, a cannabis receptor blocking drug, was found in a 2010 clinical study to include ‘…four suicides in the rimonabant group and one in the placebo group…’ which prompts deeper and timely review of the recent reports of suicidal thoughts in those taking GLP-1 medications. Eric Topol, a cardiologist at Scripps Research rightly notes ‘…a risk of suicide whenever people lose a lot of weight, and that this won’t be the result of the specific drugs…’ which is similarly seen in a small minority of patients who have undergone bariatric surgery.
  • In a call to action on the scarcity of obesity specialist physicians, the average medical student spends ‘…Just 10 hours on [obesity medicine] across the four year curriculum… [and] only 21% of family medicine residency leaders and 2.5% of internal medicine residency leaders believed their trainees were very prepared to manage obesity…’, Simar Baja reviews the current state.
    • Stigma and bias, mediocre knowledge of obesity as a chronic disease, its impact on co-morbidities, and treatment options and outcomes, in addition to a lack of time, are all pervasive in the sub-optimal and often non-existent specialist treatment for patients with obesity.
    • Kimberly Gudzune, medical director of the American Board of Obesity Medicine suggests ‘…the field should focus on empowering primary care providers to treat simple obesity, or uncomplicated cases… that hopefully, prevents the development of some of the complications.’
    • A one-year fellowship in obesity medicine is available at just 25 sites across the US for graduating resident physicians, though over six thousand clinicians have opted for ‘…a 60-hour online continuing medical education (CME) course to receive board certification.’
    • Lee Kaplan, a clinical gastroenterologist with a deep knowledge of obesity science, is skeptical of the online course and does not ‘…believe that people who are not fellowship trained get enough education in what it means to be a specialist.’

DATA

  • An IPSOS poll is not something that I would usually review and pay attention to, until my eye was drawn to it this week by Dr. Ted Kyle writing at ConscienHealth. Ted is a healthcare professional who has dedicated his career to understanding how to address health issues and needs created by obesity. IPSOS, a global market research firm, interviewed over 1,100 American adults earlier this month; in response to the question ‘What do you think is the #1 threat to American public health at this moment?’ the top three answers, in order, were opioids and fentanyl [26%], obesity [23%], and then, access to guns or firearms [20%]. Next, and a fair way behind was cancer at 11%, with Covid-19 only receiving 2% of the vote.
    • In addition, two-third of respondents were somewhat or strongly opposed to ‘…People who are not obese or diabetic using weight loss drugs to lose weight…’ though just over half of respondents were not familiar with ‘…People who are not obese or diabetic using weight loss drugs to lose weight.’
    • Most telling, and despite the media hype around us, only 5% of respondents had they themselves or anyone in their immediate circle ‘…Used prescription drugs for weight loss (e.g., Ozempic, Wegovy, semaglutide, Alli).’
    • This poll is certainly one to keep on my radar for national sentiment on key public health issues across America, and adds significant weight to the need for greater focus, visibility and long overdue dialogue, with concomitant funds and action to impact the obesity crisis. 
  • From a total of 1,563 patients, with a mean body mass index was 38.4 kg/m2, who were all prescribed an anti-obesity medication between 2012 and 2019, only 9% of patients filled their prescription within 60 days, as per research published in the Journal of Managed Care + Specialty Pharmacy. Which means that over nine out of ten of patients did not initiate therapy as suggested by their clinical provider. The medications prescribed were liraglutide, lorcaserin, naltrexone-bupropion, orlistat, and phentermine-topiramate. The researchers, who are also employees at Eli Lilly, Optum and Boehringer Ingelheim Pharmaceuticals suggest ‘…barriers in effective medical management of patients with overweight and obesity.’
  • From over 500 patients with heart failure and obesity [BMI>30] without diabetes, half received once-weekly GLP-1 therapy in the form of semaglutide, in a new study published in The New England Journal of Medicine this week. Those in the semaglutide group had ‘…larger reductions in symptoms and physical limitations, greater improvements in exercise function, and greater weight loss than placebo.’
  • Elaine Chen reports on this study from her desk at STAT News, with ‘…the growing body of data showing that Wegovy has benefits beyond just cutting weight.’ Mikhail Kosiborod, lead investigator of the trial and vice president of research at Saint Luke’s Health System notes ‘…the growing notion among cardiologists that obesity is not just a condition that coexists with HFpEF [or heart failure with preserved ejection fraction], but in fact could be a primary driver of the disease.’ In admirably responsible reporting, Ms. Chen notes while the ‘…trial wasn’t set up to evaluate hospitalizations and deaths, but during the study, 12 patients on placebo were hospitalized or had an urgent visit for heart failure, compared with just one patient in the Wegovy group.’
  • Huge news this week from well-known epidemiologist at the University of Utah and Intermountain Health, Dr. Ted Adams, in published research on over twenty thousand patients having undergone bariatric surgery within the past four decades, resulting in ‘…a 25% lower risk of developing any cancers compared with a nonsurgical comparison group.’
    • Even more impactful, ‘…female surgery patients had a 41% lower risk for obesity-related cancers (i.e., breast, ovarian, uterine, and colon) compared with nonsurgical females…’ and a striking 43% lower all- cancer mortality too.
    • The suggestion is of ‘…a possible hormonal mechanism driving cancer risk reduction with bariatric surgery… [and] …especially obesity-related cancers in females.’ This should spur ‘…bariatric surgery–driven mechanistic research aimed at cancer prevention…’ in the same manner that bariatric surgery has been an influential tool to assist in the development of GLP-1 medications for weight loss.
  • Deanna Bell and colleagues at Milliman, an international actuarial and consulting firm based in Seattle, Washington, publish a white paper on ‘Payer strategies for GLP-1 medications for weight loss…’ in order to help ‘…payers understand the landscape, develop a coverage strategy, and minimize waste.’ The extensively researched paper notes ‘…in 2021 alone, Americans spent an estimated $72.6 billion on weight loss…’ in the form of diet programs, surgeries, drugs, supplements, apps and so on, with recent social media hype focused upon the GLP-1 class of drugs. Most commercial payers cover GLP-1 medications for weight loss, with 33% to 63% of employer-sponsored coverage, and exclusion from coverage in Medicare Part B and Part D.
    • Utilization management strategies are at play, with prior authorization to validate diagnosis, and some insisting upon prior use of less effective medication therapies for weight loss.
    • Development of a comprehensive approach to encourage member adherence once they are on the medication are suggested, to avoid weight regain and recurrence of co-morbidities; otherwise leading to an estimated 26% of wasted spend, coming in at $4.6 million for a commercial payer with 100,000 enrollees.
    • The four key strategies for payers are:
      • first, to evaluate coverage of obesity medications,
      • second, to ensure appropriate utilization for benefit coverage decisions,
      • third, to develop a patient engagement strategy to ensure optimal value from this drug class, and
      • finally, to evaluate the pharmacy supply chain strategy to ensure optimal pricing and value.
    • Exemplars to operationalize the four strategies include alignment of coverage with a broader benefits strategy such as for weight-loss surgery, consideration of a smart prior authorization strategy, inclusion of comprehensive and wraparound behavioral change support in the form of intensive lifestyle therapy, and total cost of care analytics that are both reliable and credible, through to value-based contracting to help reduce waste and spend.
    • Finally, there is a framework for a GLP-1 patient engagement strategy, based upon stratification, analytics, intervention, and measurement.
    • All great stuff here, and the authors are to be commended – and whilst I appreciate this was not the intent of the article, it would have been helpful to espouse a truly multimodal approach – which is not focused upon GLP-1 therapies, rather upon whole-person, individualized care journeys, encompassing nutrition, behavioral, exercise, medication and surgical therapies, to achieve the optimal outcome for all stakeholders.

Kind regards, Raj

80 thoughts on “Bariatric surgery cuts cancer risk by 25%, obesity as a key public health threat in the US, only 9% of anti-obesity meds prescriptions are filled, and payer strategies for GLP-1 drugs.”

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