The GLP-1 challenge: Finding a balanced approach to employee access and cost control

Reflecting on my time at the HLTH 2024 panel on GLP-1s, I am captivated by the balancing act employers must perform in today's healthcare landscape. Employers are caught between the demand for comprehensive, effective healthcare solutions and the pressures of financial sustainability. At Accolade, I lead teams who directly support over 1,200 customers and 14 million members across our solutions, giving us an up-close view of how equity, access, and cost-effectiveness intersect - particularly around GLP-1s and weight-management solutions. This hands-on experience has shown me just how complex these decisions are, requiring careful consideration of both the immediate and long-term impacts on employee well-being and organizational viability.

The numbers are staggering: U.S. healthcare expenditure on GLP-1 medications for weight management exceeded $50 billion in 2023, but only a quarter of employers currently cover these drugs. Many employers face a difficult choice about including GLP-1s in their benefits, fearing the costs could strain their bottom lines. Yet the impact on employee well-being, engagement, and productivity is a compelling reason to consider coverage. It's a balancing act between sustaining financial viability and fostering a healthier, more resilient workforce.

An equity issue at its core

At Accolade, we recognize significant equity challenges faced by our members from marginalized communities in accessing GLP-1s. These individuals are disproportionately impacted by obesity, often due to barriers like food insecurity and limited access to safe spaces for exercise. To bridge these gaps, we consult with social workers who connect members to vital community resources, addressing basic health needs that play a crucial role in long-term well-being.

Our commitment to equitable access extends to helping members overcome obstacles in accessing prescribed medications. For example, we found members who face language barriers are 25% less likely to fill their GLP-1 prescriptions than others, underscoring the need to account for such challenges. (1) In addition, lifestyle programs requiring in-person sessions or time off work can inadvertently leave behind those who already face systemic barriers.

Equity considerations should be a foundational part of benefit design. When we developed our approach to GLP-1 coverage, we intentionally built with equity in mind, analyzing our data to ensure that the members who need GLP-1s receive them. Too often, well-intended programs exacerbate barriers instead of dismantling them, making it critical to design with inclusivity as the priority from the start.

The rebate paradox and access conundrum

During the discussion at HLTH, my fellow panelists highlighted an equally challenging aspect of GLP-1 coverage - the rebate structure. For many employers, the all-or-nothing approach to covering GLP-1s can be attributed to rebate dependencies. If an employer decides to adjust coverage by setting certain eligibility criteria, they risk losing significant rebates from pharmacy benefit managers or pharmaceutical companies, making nuanced, value-based coverage decisions almost impossible.

This rebate dependency forces employers to make a rigid choice: cover GLP-1s for all eligible employees under the FDA label or cover none. However, from a value-based perspective, it would make sense to prioritize coverage for those most in need - perhaps individuals with higher BMIs and multiple comorbidities - over those with less pressing health risks. Yet, without policy adjustments, employers are left with this blanket coverage choice, often at the expense of more personalized care.

A role for primary care in better, more nuanced weight-loss outcomes

At Accolade, our primary care physicians are at the center of our approach to addressing the GLP-1 dilemma. We have trained our primary care teams on our clinical protocols to effectively serve as "centers of excellence " in GLP-1 management, where each treatment decision is based on evidence-based practice and shared decision-making between the doctor, the patient, and often the patient's family. Accolade's clinical experts carefully evaluate each employee's medical condition to ensure that GLP-1 medications are prescribed only when appropriate, supporting a truly personalized approach to care.

In these discussions, we emphasize the full scope of what GLP-1 therapy entails, including potential side effects such as nausea, diarrhea, and pancreatitis, as well as the risk of weight rebound after discontinuation. This helps set realistic expectations and encourages long-term commitment to lifestyle adjustments, making members more likely to achieve sustained results rather than temporary improvements. Our clinical protocols emphasize shared decision-making, a strategy that has improved adherence rates - currently hovering at 52%, based on our internal data. (1)

Beyond the initial prescription, Accolade's clinical team provides ongoing care to help employees maintain their progress, ensuring that they stay supported and guided throughout their treatment journey. This collaborative, educational approach mitigates the risk of prematurely discontinued treatments. When members enter GLP-1 therapy with eyes wide open and genuine readiness, they are far more likely to achieve positive health outcomes, reducing overall healthcare costs in the long term.

Building sustainable, people-centered health systems

Medications alone can't solve the obesity challenge. As chronic conditions like obesity, hypertension, and diabetes drive down life expectancy, even a modest 10-20% reduction in obesity rates could transform individual health and the nation's outlook. (2)

Employers play a key role not only as benefit providers but as partners in sustainable health. By designing benefit structures that balance cost, access, and support, they can help curb the obesity epidemic. Beyond GLP-1s, employers should invest in proactive, preventative weight-management programs and remove barriers to make healthcare accessible and effective.

The GLP-1 coverage dilemma highlights a bigger issue: building systems that genuinely support people. Access to weight-management medications is critical, but without long-term support, we risk missing the larger goal. At Accolade, we work to bridge these gaps through solutions like Noom Med powered by Accolade, which was recently launched by our customer, a Fortune 50 insurance industry employer, to support their workforce. This solution combines digital support with expert guidance, driving lasting health changes through equitable program design, primary-care-driven guidance, and partnerships focused on health improvement.

Employers striving to balance comprehensive benefits with financial sustainability face a complex journey, but it's one worth taking. By adopting a balanced, empathetic approach, employers can foster a healthcare environment where GLP-1s and other solutions deliver real value-not just in savings but in healthier lives. It's time to create a system where everyone can reach their healthiest potential.

Shantanu Nundy, MD, is the EVP and Chief Health Officer for Accolade.

Sources:

1. Accolade internal data

2. https://irp.nih.gov/accomplishments/extreme-obesity-may-shorten-life-expectancy-by-up-to-14-years

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