AH036 - The Rise of GLP-1s & Partnering to Manage Chronic Diseases, with Vida Health

Transcript

Lightly edited for clarity, sources linked at the end.

[00:27] Justin Venneri: Hello and thank you for joining us for this episode of the Astonishing Healthcare podcast. This is Justin Venneri, your host and Director of Communications at Capital Rx. Today in the studio we have Joe Murad. Joe is the CEO of Vida Health. Vida is our partner on Rx Activate for chronic condition management. And we also have Sara Izadi with us. Sara is our Chief Clinical Officer. We're going to be discussing GLP-1s, chronic condition management programs from a pharmacy benefit and from a digital health perspective. Joe, is that fair?

[00:58] Joe Murad: Fair enough, yep.

[01:00] Justin Venneri: Awesome. Well, can you share a bit more about your background and experience that you brought to Vida? And then give us a quick update on how things are going and what you're up to at Vida for listeners who may not be familiar with what you do?

[01:13] Joe Murad: Well, thanks. I appreciate the invitation. Justin. So, I'm a lifelong entrepreneur in the digital health/healthcare IT/healthcare services space. Been doing it for close to three decades in varying forms and stages of businesses. I joined Vida roughly a year ago, and if those who are not familiar, we're a virtual cardio anabolic clinic. That's a differentiated clinical model, and we support cardiometabolic disease across the acuity spectrum with integrated mental health support.

[01:39] Justin Venneri: Awesome. Sara, you've been on the podcast before, but for anyone who didn't catch that or hasn't seen your/our blogs or your bio, tell us a little bit about your role here at Capital Rx and your background, please.

[01:51] Sara Izadi, PharmD: Thanks for having me back Justin. I'm a pharmacist by training and have spent the last ten or so years in a variety of settings, from the community and hospital settings to here at Capital Rx, where I'm the Chief Clinical Officer. As part of that, I oversee our clinical program offerings and that includes our partnership for clinical services or programs with Vida, who we have a great partnership with.

[02:13] Justin Venneri: All right, so GLP-1s. Joe, I was just reading one of Kaiser Foundation, KFF's, studies and it's amazing. I think over 40% of privately insured people in America, it's like 57 million Americans, could take GLP-1s based on the current labels. We're here talking about cardiometabolic health and obesity and diabetes, and this is obviously one of the hotter topics out there over the last year. So, what are some of the latest stats and what are your thoughts on everything going on in and around this space?

[02:47] Joe Murad: Well, you're correct, I think, and I'm going to have Sara as the clinician back me up here on occasion. I don’t want to get over my skis.  

But short of it, you're correct. 42% of Americans meet the clinical criteria for clinical obesity. About 70% are overweight or obese. One in eleven are greater than 300 pounds, which is just an astonishing fact. Of employed Americans, about 30% are classified as obese and about 34% of those are overweight, costing employers real dollars in productivity loss. Wegovy for example, you know, has been approved for chronic weight management. Adults with obesity have a BMI of greater than 30, are overweight, BMI with greater than 27, with at least one weight related comorbid condition. And really the intent is to reduce the risk for major adverse cardiovascular events, everything from heart disease and heart attack, strokes and who are effectively overweight or obese. But you know, additional indications are certainly coming to your earlier comment. Cardiac, CHF, kidney disease, sleep apnea, depression. It's really interesting to see even inflammatory diseases. So I think were kind of early in some of this discovery and these are going to increase not only the need for Rx spend controls, but really the complexity around evaluating some of the appropriateness as well.

[04:02] Justin Venneri: That makes sense. And Sara, with tens of thousands of people starting on GLP-1s for weight loss every week, I think Joe, correct me if I'm wrong, but the stats as they stand, those percentages of the population that are suffering from these conditions, that's all continuing to rise, right?

[04:18] Joe Murad: Correct.

[04:19] Justin Venneri: So, with like 40ish percent of our clients, I think that stats about right, covering these for weight loss, but they're generally covered for diabetes, right. How are you looking at the situation.

[04:32] Sara Izadi, PharmD: Justin, I think it's important to understand the client perspective, right. Rising costs for plan sponsors is obviously a concern here. I think compounded on that is some of the clinical considerations.  

So, when you look at the studies, there are several factors to consider. One is that these drugs were studied in conjunction with diet and exercise. Number two is if you look at some of the real-life evidence, and particularly an article published in JAMA, discontinuation rates are high. Over 20% discontinuation. That continues to rise to about 71% at the year mark. That's significant, right, for a drug that requires appropriate management and titration.  

And you need to get to - third point - you need to get to an effective titrated dose to get the clinical outcomes and benefits. Plan sponsors are all very different, but they're faced with the same challenge. Is this worth the investment? They all want to do the right thing by their members, but what are they getting out of it? And when you look at weight loss or some of these cardiovascular indications, we know Wegovy just had an expanded indication earlier this year. Some of these cardiovascular outcomes, really the hard outcomes, the cost avoidance associated with them, take years to be realized.  

And so this is a challenge. And I think this is why it's so important to ensure appropriate management of these drugs, to ensure that patients have the right behavioral and dietary support, to ensure that doses are titrated to the most effective, tolerable doses to address the side effects, so that we limit this continuation, all of this compounded by the fact that we are in the midst of a shortage. So, plan sponsors are looking for solutions to ensure that they get the most out of their investments, and they're looking for options. And Capital Rx, our job is really to provide them with those options. We do that with some of these partnerships through Vida and others, and I can pass it over to Joe to really add more to that.

[06:34] Joe Murad: Now, broadly speaking, I think you hit the nail on the head. I mean, spend and trend is a concern, right? And I think trying to get out in front of that, all this off label prescribing and use for vanity purposes, wasted investments, to your earlier comment about those who regain the weight loss. It's going to be a tricky one to navigate over the course of the next 12 to 24 months. But I think broadly speaking, we're pretty bullish on the market. Adoption and proper utilization with the right mechanisms and guardrails in place.

[07:03] Sara Izadi, PharmD: And I'll add that our partnership is uniquely positioned because Capital Rx, obviously, we have, Judi, our adjudication platform, we have our own prior authorization tool that sits on top of that, and we employ our clinical strategies and utilization management and work with Vida for their unique strategies. So Joe touched upon the non-FDA approved reasons. We account for all of that using utilization management today. Hence the review of tens of thousands of really requests a week Justin.

Related Content

• How to Manage Pharmacy Benefit Spend in a GLP-1 World
• AH021 - Managing Pharmacy Costs in a GLP-1 World, with Bridget Mulvenna
• Pharmacy Benefits 101: Prior Authorizations
• GLP-1s are No Laughing Matter

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[07:36] Justin Venneri: Joe, so when the FDA says, Wegovy is now approved and appropriate for cardiovascular risk in this population, what happens on your end with your team? Do clients and prospects, they say, hey, what are you doing about this now?

[07:49] Joe Murad: Well, I think the one thing we've done at Vida is we've taken a pretty dramatic and clinical approach, right? So the way we've constructed some of our clinical protocols are evaluating all of these members based upon an aggregation or assimilation of a bunch of information that we can garner, whether it's, and if not just claims data, right. And then we use that to bang it up against some of our clinical models and protocols to determine where do we intervene and what is the right path for those members. And it's one of the benefits, I believe, of kind of what we constructed on our service delivery.  

So it's everything from preventive to chronic condition management. I think most employers, and Sara can attest, they don't look at this through the lens of just one individual, and everybody's kind of, you know, managed the same. It's really stratifying across those conditions where they can have the most material impact. And we're starting to see some of this impact early, really, by preventative use and some of these medications that can have long term positive impacts on the expense associated with supporting them.

[08:46] Justin Venneri: It's interesting because that's the one thing -- when is there going to be enough data to actually see the ROI on this? So, you're starting to see for other conditions or for weight loss or other, where are you starting to see some of the positive impact already?

[08:59] Joe Murad: I think there are kind of two things, and maybe we need to take a step back. And Sara, again, you keep me in check here, because I don't want to overstate things.  

But just for everyone to appreciate and understand kind of what a GLP-1 is. Right. And what they're trying to do. And the intention in these medications are really to mimic this natural kind of occurring hormone that regulates appetite and blood sugar. And originally this was developed for type two diabetes that you mentioned, and it's now also being treated for obesity. And really the mechanism is to stimulate this insulin release and slow digestion and reduce appetite and inhibit some of this glucon secretion that we mentioned. And effectively, how do you manage blood sugar, promote weight loss, and you're starting to see some really material impact, 10 to 15% of body weight loss. That is significant and the implications in a positive way that that can have on someone's health.  

And it's probably a reason why we've seen just this explosive growth, right, around this projection of potentially -- reaching $25 billion by 2027 and some crazier number by 2030. And I think Sara just mentioned, like, sometimes the demand often exceeds the supply, and that's one of the constraints. But there are also these other newer developments that you just mentioned. We have a dual GIP/GLP-1s that are receptor agnostics like Zepbound. These happen to offer, you know, enhanced benefit around blood sugar control and weight loss.  

And this is something that's, I think, is really piquing some interest. And again, it's fairly early, but the physiological impact is really significant, and it can affect multiple body symptoms, including the pancreas and fat tissues and heart and bones and brain. And this class of drugs in and of itself has shown some significant promise. And I think treating diabetes and obesity is potentially kind of the first pass. But there's ongoing research to really explore the full potential and application, and that's evolving routinely.

[10:53] Justin Venneri: As Sara mentioned, our partnership with you for Rx Activate, and I'm definitely not trying to go over the top here, be too salesy, we are excited that we've got at least a handful of clients live at this point in under a year since we announced the partnership, which is nice. Sara, Joe, I'd love to hear how the partnership come to be and then what are you hopeful we'll see, since we're already seeing some early positive indications, but there's the discontinuation risk. I'd love if you can just walk us through how it came to be. And what can plan sponsors out there ask their vendors or look for in partners to help with the challenges we’ve been talking about. Sara, do you want to take that first?

[11:33] Sara Izadi, PharmD: I'll take the first pass. So how it came to be was obviously, Justin, as you know, we saw an explosion in GLP-1 utilization at the end of 2022. And its still somewhat of an unknown place to be, but it was even more unknown then. And so plan sponsors were looking for solutions, a variety of solutions. And while we offer many solutions internally, including but not limited to point of sale messaging, prior authorization and such, and as you know, we really just live and die for our plan sponsors and members, and we wanted to do the right thing by them.  

And so Judi makes that very easy. But we also have to pick and choose the right partners, and one of those partners was Vida. They have a very unique offering. They're very easy to work with for certain populations. We have performance guarantees and ROIs. There is robust reporting, and so it was an easy choice for us. And they're one of our partners that we offer our plan sponsors. So everyone's looking for solutions. While we offer some internally, we had to go externally for some. And that's how Vida came about. And it's really a one-stop shop. We're able to exchange data very freely using Judi and Vida's technology, and so we're also able to look at the outcomes on behalf of our plan sponsors.  

In terms of what to look for, the patient experience is critical. For us, we look for formulary aligned prescribing so that plan sponsors still get to really benefit from cost saving initiatives. So we have several things we look at and those are a few of them, as well as robust reporting and looking at certain outcomes.

[13:13] Joe Murad: Yeah. Further to Sara's comments, I think, frankly, we're just philosophically aligned. How we manage populations and the wide range of cardiometabolic conditions that they have. And it's really hard to boil the ocean and do everything, right? So, partnering with the right folks and organizations that are philosophically aligned, I think is a critically important piece just at the onset, as it pertains to some of the attributes that you're looking for in a partner that any employers or plan sponsors should be looking at is, you know, are they rooted in value based care models? Are they putting fees at risk? You know, is the vendor meeting certain quality and cost targets? I mean, this is like, put your money where your mouth is.  

Do they embrace evidence based clinical protocols? Like, to me, that is a peer reviewed data, like all the things that kind of matter. How do they stratify that service delivery with an array of services that I think the providers can manage the entire population, as I mentioned previously, from preventative to chronic condition management that require, whether it's coaches or RDs or other expert clinicians, that's really important.  

And then you know, lastly, do you have a durable platform? Right? Do you have a platform where teams can remain flexible to be able to evolve with the configuration of some of these solutions? Because we don't know what we don't know. So you have to have some malleable kind of flexible architecture and to be able to integrate with Rx Activate platform is one of those examples where we have that capability, they afford us that. Right. And you can actually have a full turnkey kind of solution or suite of services that you're not encumbered from actually servicing other populations as these disease states expanded.

[14:45] Sara Izadi, PharmD: Joe, you said that so well. I will just add to that one of the differentiators that we really loved about Vida was their holistic approach to management and their multidisciplinary teams.

[14:58] Justin Venneri: One thing I've noticed in paying attention to what's going on with a lot of digital health companies, the growth that a lot of providers of digital health solutions had seen over the years, and something thatm Sara, you mentioned Judi, a couple of times now, and the platform approach, I'm curious for your thoughts, and Joe, I'll start with you, avoiding the fragmentation of care and being able to ensure that the party's involved in taking care of the member. You know, if it's the PCP or someone else, aligning all of this stuff has been a challenge to date. Can you share your thoughts on that and the importance of that going forward?

[15:34] Joe Murad: First, it's hard to do, right? This is not a hobby. I mean, I think you have to be fully invested in constructing and operating and service delivery model that's complementary to the party is your survey. And anybody who's ever been owned or controlled or managed their own set of providers can appreciate that. Right? This is an expansion and contraction based upon demand and time of year. And what are the services you're providing? And is it a dietician or a nurse, or is it a coach? Again, depending upon how you're interacting with those members and what type of intervention is required, that's hard, right?  

So I think what you're finding is benefit consultants, employers who have been operating in this marketplace for a period of time are looking for organizations that have an operating history of success, right? And they have proof points that they can point to. You're starting to see a lot of these direct-to-consumer models trying to go weighed into the large, self-funded employer market. Great. I mean, it elevates the topic, but frankly, it's really hard to go execute. And understanding that it does require a coordinated effort with all the folks in the ecosystem in which we operate, you can't just fundamentally step in and sprinkle your technical fairy dust over something and solve a problem. This takes hard work and it's not very glamorous and it takes years to continually refine to ensure that you have a better outcome for the members and the plan sponsors who are providing those services.

[17:01] Justin Venneri: Yeah, that's a great point. I mean, how many folks just popped up right away and said, hey, direct to consumer GLP-1s, here you go. Or another option. We're like, okay, this may not be the best idea.

[17:11] Sara Izadi, PharmD: Sorry, Justin, to cut you off.

[17:12] Justin Venneri: No, no.

[17:14] Sara Izadi, PharmD: You can have very sound clinical strategy. You can have the best technological platform. You're not going to succeed if you're not integrated in the existing very complex structure.  

Patients have so many hurdles to overcome. As it is, doing things in silo is not the way to solve it. I'll give you an example. And this is why, again, formulary alignment and integrations are so important. A direct-to-consumer situation where someone's prescribing a GLP-1, a patient is trying to use their commercial insurance to get that GLP-1, several things can happen. The employer may not cover it. Now they hit a roadblock. They can have a script for a formulary excluded medication; now they've hit another roadblock. And so, these examples I know very detailed are exactly why it's important to fit the existing structure as opposed to doing things in silo. And I think that's what patients get and that's what employers get through these integrations.

[18:15] Joe Murad: Yeah, I think it's a great point, and it's probably one of the foundations of the relationship that we've been trying to construct. And you pointed out earlier, how do you remove the member friction for a better experience? And there kind of a variety of ways in which you can do that integration around prior authorizations. You can minimize waste without limiting access. You can actually access some of these medications from different, any, providers, or you can smooth some of that experience by eliminating some of the PA hurdles entirely. And then lastly, you could actually just construct a relationship where, again, in a value-based kind of network access model, I put in air quotes for the right reasons, where the only way you get access to those medications is if you go through a platform such as ours, and it's integrated with a PBM, that enables us to actually smooth the service delivery and eliminate friction for the member and have a positive outcome.

[19:07] Justin Venneri: And ideally, someday all of the information, medical claims included, is consolidated in one platform and then this can be shared back so there's no fragmentation of care, right? That's the future state we want to, we want to get to.  

Sara one thing that comes up a lot is the potential for price compression for the GLP-1s. Joe mentioned many, many new indications. We expect to eventually expand the potential use cases for these, but there's also many, many products in pipelines that are moving their way through the clinical trials process. When do you expect some of these newer options to hit the market if approved? And what do you think the potential is for price compression?

[19:47] Sara Izadi, PharmD: So, you touched upon the two very critical factors, one being the pipeline is very robust, and some of the agents in the pipeline offer advantages over the agents that we have approved today. Primarily, there are oral agents in the pipeline. Now, we know that there's a portion of Americans who are not exploring the existing options today because of needle phobia. So now we've effectively expanded our addressable market with the oral agents.  

We also have some combination agents with robust mechanism of actions that have produced some really great outcomes, at least in early studies, Justin. The pipeline is very hard to predict, but there's so many products in there that we expect to see these drugs come to market.  

I am more keen on the advantages that these agents may bring in increasing the addressable market. So there's that. Joe touched upon the expanded indication. I mean, really at the core, anything that's rooted in inflammation, these drugs can address, and it's wide -- osteoarthritis, liver conditions.  

And so realizing these two pieces, I think we're going to see some price compression with increased competition. I can't tell you when, I don't have a crystal ball, but I hope to see some as early as the next two years. Generally, the market is a little bit slow for price compression to happen, but I expect to see them in the next two to three years. I’d love to hear from Joe, because I feel like this is really his expertise here, having been in the industry for so long.

[21:22] Joe Murad: As someone said, never wait on legislation or for prices to come down. The other two things, right? And I think to your point, as the costs go down, the application expands. So, if anything, I think the tam continues to grow.  

I would argue that irrespective of price, you still need to have managed access to some of these medications. There are plenty of less expensive medications that are on the market. And if you take, again, a pragmatic approach of just meeting those members at the state in which they are in their life cycle, is start with is it preventative and can you just intervene with diet and exercise regimes? Or do you look at these lower cost AOMs before you get to these more expensive GLP-1s?  

Everyone likes to leapfrog or jump to shark here and go to these more expensive medications. But plan sponsors, I think, are apprehensive to embrace that approach and have unfettered access without having some skin in the game. And it's no different than first dollar coverage, kind of a similar process where, okay, I'll provide a subsidy for these very effective medications, but only if you change your behavior, if you change your routine, if you change your diet. And we're starting to see things as incorporating food as medicine is another alternative option that could potentially impact, that are tailored for specific conditions around diabetes and obesity.  

So, I think we're just at the precipice of some really interesting and fundamental changes inside of the healthcare marketplace as it pertains to these medications.

[22:50] Justin Venneri: Joe, that's a great segue. I mean, based on your experience in and around health tech. You mentioned PBM a moment ago and now Vida. What are you keeping an eye on most closely that you think employers and other plan sponsors should also watch that could help their populations in terms of helping them control costs for members with chronic conditions.

[23:09] Joe Murad: Yeah, it's a great question. Look, broadly speaking, I think the COVID pandemic accelerated adoption of telehealth and digital health services. I think that's irrefutable, right? And as a result, digital health has experienced this dramatic hype cycle reminiscent to the dot com bubble. And despite that, the enthusiasm remains pretty robust amongst employer groups and plan sponsors for a variety of solutions, mostly because they actually improve access, they provide, specifically or especially around chronic condition management, making it more accessible and convenient for their members, which I don't think we've seen previously, but that is starting to be an interesting growth part of the market.  

I think the other kind of clear indications to me are, there's a focus around these specific high-cost conditions, such as diabetes, and heart disease, and obesity, that are driving a significant portion of the healthcare costs. This is not lost on anybody who is fundamentally underwriting the risk of their own population. There's growing evidence to support a bunch of importance around the food with medicine, as I just mentioned. There are value-based care models that I know probably talk about overhyped, but the fact is I think that's growing due to the focus on outcomes rather than fee-for-service, and it's potentially lowering costs, especially for chronic condition and disease management.  

The other things that kind of come to mind, I think, are personalized healthcare, taking into account individuals behavior in particular and their preferences, and that's been trending up in the right direction for the past decade. Preventative care, early detection, as we mentioned previously, lead to, I think, significant cost savings, right? Especially if, again, if you are a self-funded employer. The other pieces that are complementary to our model is an integrated mental health service. That's really a crucial component, right? A crucial component of the overall health and especially for those with chronic conditions. I think this has been a problem where we like to silo out some of these conditions, but the fact is they're all interrelated and interdependent.  

And then lastly, I think this innovation around medication management and these new classes of medications such as GLP-1s, I mean, that's showing some real promising results and albeit very early still, for all intents and purposes. And if self-funded employers or plan sponsors start focusing on these areas, I think they're going to find that they're going to have improved outcomes over the arc of time and especially with chronic conditions.

[25:25] Justin Venneri: I think that what's becoming more clear as I just watch what's going on in the news, read it, what have you, is that the plan sponsors are capable of driving a lot more change and producing a lot better results than maybe people thought. Sara, what's the most surprising thing that youve seen out there related to GLP ones or the most astonishing thing youve seen thus far that you can share, of course.

[25:46] Sara Izadi, PharmD: So not surprising, but astonishing, is just putting together everything I’m reading in the statistics. And although you might expect me to comment on something clinical, this is not clinical, but I just want everyone to stop for a second and think about everything as a whole. One in eight Americans over the age of 18 have had a prescription for a GLP-1 drug. Now you tie that with stat I read, I believe, out of Goldman Sachs that said, if 60% of Americans utilize GLP-1 drugs by the year 2028, we're going to have a 1% increase in our GDP. That's huge. Couple all of this with the fact that we're getting expanded indication, a robust pipeline -- it's exciting, but it's scary. It's certainly astonishing, right?

[26:38] Justin Venneri: I think so. And Joe, how about you? Same question to you. Can you tell us a good story that's safe to share?

[26:43] Joe Murad: Well, it's spot on. This unprecedented market expansion is just nuts by every definition, right? Going from $35 billion in 2023 to potentially $100 billion by 2030. Like that -- just wrap your head around that for a moment.  

When there are a bunch of effective kind of first generation anto-obesity medications that are less expensive that are available. That's the other thing that I think people forget. And it's surprising that these second generation agents have grown in popularity and become the drug of choice around weight loss. But I don't see it slowing down in the immediate term. I think I'm a little weary of the excitement, right. For the right reasons. Just because, yeah, we may be on the precipice of some potential paradigm shift in the obesity treatment, but it's not a silver bullet. And I think this is kind of the key piece, right? A third of patients in year two on Wegovy lost 5% or less of their body weight. So, it requires lifestyle changes, behavioral changes, as we mentioned before.  

I'm also just surprised by the sheer number of potential conditions that it could be favorable, specifically around cardiovascular benefits. Those with a history of heart disease, the positive impact that those medications could potentially have on the entire healthcare ecosystem, just holistically, and how that could potentially reshape chronic condition management and disease management that we've been trying to get our arms around and solve for decades.

[28:08] Justin Venneri: Yeah, it's amazing. Like you said, there's no true silver bullet, but every single time a new indication pops up or there's efficacy data, it's like, wow, they're good for that too. It's pretty crazy.

[28:19] Joe Murad: It’s nuts.

[28:20] Justin Venneri: Well, thank you both for joining us today. Really enjoyed the discussion and hope to have you back on.

[28:25] Joe Murad: Appreciate it. Thank you.

[28:27] Sara Izadi, PharmD: Thank you.

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Sources

• How many adults with private health insurance could use GLP-1 drugs (KFF; 9/5)
• GLP-1 Receptor Agonist Discontinuation Among Patients With Obesity and/or Type 2 Diabetes (JAMA; 5/24)
• Poll: 1 in 8 Adults Say They’ve Taken a GLP-1 Drug, Including 4 in 10 of Those with Diabetes and 1 in 4 of Those with Heart Disease (KFF; 5/10)
• The Use of Medicines in the U.S. 2024: Usage and Spending Trends and Outlook to 2028 (IQVIA; 5/7)

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