Episode Transcript
[00:00:00] Speaker A: Proactivemd.
[00:00:08] Speaker B: From ProactiveMD, this is healthcare Explained. I'm Jeremy Vanderck.
[00:00:12] Speaker A: Knife. And I'm Vinay Patel.
[00:00:14] Speaker B: Well, Vinay, you know, we've been circling back on certain topics that we introduced, and I think one that is top of everybody's mind right now is GLP1s. I don't think I can have a single conversation with professionally or personally that doesn't at some point involve mention of Ozempic or Wegovy or Manjaro. And so a lot has happened this year.
[00:00:37] Speaker A: Yeah.
[00:00:38] Speaker B: And so let's, let's kick it off. Tell us, tell us about the year in GLP1s. What's new? What's changed?
[00:00:46] Speaker A: Yeah, absolutely. I think that it's important that you mentioned it's, you know, it's sort of top of mind now. I feel like it's been top of mind all year.
It seemed like every quarter there was some new story about GLP1s or something or someone going on about what's changed and why. We started the year in 2025 with a GLP1 shortage carryover from 2024. With so much demand for these medications, it caught the drug manufacturers off guard and how quickly it accelerated and how much it exploded. It's almost like it went viral. And all of a sudden, overnight, everyone wanted a GLP1. So because there was a shortage, a FDA declared shortage of GLP1 medications. That's drugs manufactured by these drug companies available through pharmacy sources, licensed state pharmacies that you can, that you can get access to compounded GLP1. And so now you have compounding pharmacies. I know that was an episode that we covered this year about what is a compounding pharmacy and how is it different and what are some things to be aware of when you interact or interface with a compounding pharmacy and how can you verify it's a legitimate compounding pharmacy? So you were able to Access these compounded GLP1 medications through compounding pharmacies. And what that did was it unlinked the price of the medication that you typically get from the pharmacy to now a new sort of wild, wild west pricing for compounded GLP1 medicine. So, and they were the same exact active medicine inside of these vials of compounded GLP1 medicines of the traditional, you know, supply available for GLP once available through the pen forms from the drug companies.
And so, and then the shortage, they finally resolved the shortage. The drug company said, we're going to ramp up production. And they got new plants online, new production lines and the shortage was declared over in the spring of 2025. Shortage was the FDA announced that the GLP1 shortage is over and that we compounding pharmacies were notified to stop sourcing or supplying these medications. What has happened though since then is that compounding pharmacies have customized the doses. So now it's not just semaglutide or tirzepatide, which are the active medicine, the active GLP1 compounds in these products, but you're getting it mixed with a B vitamin or, you know, other, other minerals and nutrients or maybe slightly different dosing of these when you get it through the compounding pharmacy. And they still come in vials and they found, you know, the, the market research showed that people wanted to take all different types of doses of these medicines. And so vials are now being offered by Lilly Direct when you buy it through them.
And so we still have some access to sort of pockets of access of compounded GLP1s. And the pricing's still quite different. There was a significant price pressure on the GLP1 products through what the federal administration did this year in negotiations with the drug companies. But still you can't beat the price you can get it for through compounding pharmacies for these GLP1 medicines. And now they're customized for what you may need and the minerals and vitamins you may need.
[00:04:07] Speaker B: And what are we seeing from FDA or from drug manufacturers? Is this a battle against these compounding pharmacies that they're continuing to try to fight or has resolution already been been settled like these are here to stay? There's no taking this away now that it's so pervasive in the market.
[00:04:27] Speaker A: There's ongoing litigation. It's actually directly coming from the manufacturers targeting high volume comp or large compounders that, you know, have a significant market share or supply across the country.
And so now you see these manufacturers going after them. They're still pending. You know, they're going to go back and forth in the courts.
But I just, to the best of my knowledge, I don't know of anything the FDA is doing directly to head on to address that problem. It's really the manufacturers that have the resources and the motive, if you will, to go after these compounders. I haven't seen the small mom and pop shop compounders get affected. Some of them may have gotten letters, but outside of that, I haven't seen any direct litigation. And as a corollary to this, Novo Nordisk did a deal with hims and hers. It sort of Goes to the comical nature of what, what, you know, happened with GOP1s this year. So Novo Nordisk does a deal with, with Hims and Hers and everyone.
If you watch tv, watch the super bowl, you've seen any sports show you can, guaranteed you're seeing an ad for Hims and Hers. And Hims and Hers is an online virtual platform where you can go to for hair loss and ed and now weight loss.
And they ship medicine out to you from centralized mail order pharmacy in the country directly to your home. Discreet packaging, so on, so forth. So Novo Nordisk said, hey, we're going to let, we're going to offer WeGovy through hims and hers for a discount price in April.
And then turns around, Novo Nordisk terminates that partnership due to Hims and Hers continuing to offer compounded versions of the drug. And so then, you know, that sort of flip flop in April and then I think in June we see a reversal and you no longer can get access to WeGovy. I think that has normalized now. The relationship has normalized now. And I think you can now start getting access to weight loss drugs through Hims and Hers.
[00:06:26] Speaker B: Again, the brand name weight loss drugs.
[00:06:30] Speaker A: World Health Organization releases obesity guidelines or updates their obesity guidelines that now recommend using GLP1s as a treatment option for obesity. This is the first where they've come out and actually now have embedded GLP1s in the treatment of obesity in the World Health Organization guidelines.
Additionally.
So every year Kaiser Family foundation does a survey, an employer health survey. In 2025 it showed 16% of firms with employees from 200 to 999 employees and 30% of firms with 1,000 to 4,999. And 43% of firms with over 5,000 employees reported covering GLP1 specifically for weight loss. It just seems like that number's inching up. The demand is still very strong and folks are asking about access to these medicines through their employers.
And it's on the flip side. The employers are seeing, and we saw this in 24 and we're continuing to see this in 25 where they have just seen shocking increases in their health plan utilizations for these medicines. And they aren't cheap. It's about 1,000, $1,200 a pop every month for these medications through traditional health plan PBM accessed drugs for, for these medications for the weight loss GLP1s and they're just seeing shocking increases in their health plans. The larger employers can absorb it and they have ways to manage this. But the smaller ones, as you get downstream, the smaller ones are really seeing sticker shocks in terms of health, health premium increases due to some of this utilization.
[00:08:06] Speaker B: No, I think, you know, you raised some really good points there, Vinay. And the employers that we talk to are struggling with the cost of GLP1s and the coverage.
You know, I think it's a, it's a difficult topic for employers when they're looking at going through their pharmacy benefits manager, their PBM and their insurance plan that the drug might cost 1200, $2000 per month for a single patient. Yet they're able to, you know, you mentioned Hims and hers. There's ro, there's a number of these other groups that are selling compounded versions of these drugs directly to consumers. And they're able to see the exact same drug my employee can go get from an online pharmacy for 200 bucks or 300 bucks a month.
So, you know, and we covered in a recent episode trumprx.gov right. Which is another way for individual retail consumers to be able to, you know, get direct cash pricing and purchase these drugs directly from the manufacturers. So we're seeing this, this very rapidly shifting landscape where as you said at the beginning of the year it was handful of companies offering these drugs. Everything else was compounded. There was the shortage. Now you can't, I mean, walk down the street without seeing an ad for somebody who's trying to sell you.
[00:09:29] Speaker A: Right.
[00:09:29] Speaker B: GLP1.
[00:09:30] Speaker A: Right.
[00:09:31] Speaker B: And the market dynamics have shifted tremendously. So what can employers expect? Because, you know, they are faced with this pressure of, they're seeing, it's a race to the bottom on direct to consumer, but they're not feeling any of that relief and yet still being challenged by their employees to provide coverage for these drugs for, from, you know, weight loss, medical weight loss as opposed to just for type 2 diabetes or things like that.
[00:10:01] Speaker A: That's, it's a tough one. We continue to debate this, lay out the options, lay out what you know, what are, what do you have to consider? Every employer is unique. Every employer has a unique culture and unique needs to serve their employee population.
And so there isn't, there isn't one sort of a one size fits all. But, you know, employers need to have conversations and involve their pharmacy benefits companies and then an advisor, you know, whether it's a primary care advisor because you have nearsight on site clinics on site like Proactive MD or you know, or local community physician, maybe a majority of your employees are going to a health system primary care physician or providers or they're going to local direct primary care doctor, those folks involving the team and getting of course, a pharmacist involved to just give you the full context and picture around what's going on with these drugs and where's the safest place and most affordable place for your employees to access these medicines. There are some unique creative programs available in local communities that pharmacies can help address these situations. With the employers involved, it's not as seamless as saying, hey, it's available on the insurance. Go to your doctor and get a prescription for it and get it at the pharmacy. That's the most expensive route now. And so you really got to get creative and get a coalition of stakeholders together to figure out where can we access this and what's the best sourcing for it.
And that's really what you just continue to have conversations around this. We've seen as well several employers push back and saying, we can't cover this. This is what it'll do to our health plan and explaining it to employees and saying the best option right now is for you to go out and get it on your own, get the coverage because it's the cheapest. If we get involved as the employer, it's going to create severe impacts to our health plan. And that's the last thing we want for everyone because everyone's on this health plan.
So different strategies, different strokes for different folks. Right. So we're just here to help be a resource. And you know, speaking of that, again along the lines of this comical nature, we also, anecdotally, I saw an article about it, heard that Novo Nordisk apparently failed to renew their patent for a sempic in Canada.
And so Canada is now going to be seeing the generic equivalent of Ozempic available on their, in their country for their consumers at significantly reduced prices because it's going to be available as generic and there'll be some competition for it, apparently.
We'll see, we'll see what remains, what happens in 2026. But there was just like, I bet some group or someone got fired over this.
[00:12:46] Speaker B: That's if that's true, that's renewing this. Yeah.
[00:12:52] Speaker A: And so there's been. So, you know, I think the, so the drug manufacturers know they, they've maximized or optimized the direct to consumer route. They've, they're marketing this as, as strongly as possible.
But they also know that they're missing 55% of folks of the US country that is through, that gets their health insurance through an employer health plan.
And so they are now pivoting, innovating, however you want to call it, to a direct to employer model. There's a couple examples of this that we've seen in the news so far.
One, Mark Cuban announced at the Forbes Healthcare Summit, a partnership between Centerwell, which is Humana's mail order pharmacy, and Cost Plus Drugs, which is Mark Cuban's Cost Plus Drugs website. Access Drug drug mail order service to create a new direct employer model bypassing, explicitly said bypassing PBMs. I'm sure that ruffled more than just a couple feathers in the industry. But now you have this public announcement and specifically, you know, they're going to start with these high demand drugs and figuring out how we can get access to some similar pricing or away from the traditional model, which is pay the list price, get a rebate and abide by these strict formulary guidelines like you can't cover other drugs, you can't source it other way, so on so forth. Now you have these innovative models coming aboard. Lilly announces in a press release that they are developing a direct employer model for 2026.
And there was a company known as Walt's Health that also announced that they have a model. They are essentially a platform where employers can access a pricing, upfront pricing for these medications for their employees to access them as medicine. So we're going to see a lot of disruption coming in 2026 with some of these models that are going to be unfolding and access for employer health plans that will be different than just the traditional, you know, get it on your insurance PBM form.
[00:14:53] Speaker B: No, I think, you know, we've had conversations offline before, Vinay, and you know, disruption can be an exciting word. It can be a terrifying word when you're talking about people's health. And but if ever there were a market that needed a shakeup, I think definitely the pharmaceuticals and I think GLP1s. It doesn't make sense when I can go to a, go to a store and purchase a product for $200 myself, but if I go and get 999 of my best friends and we're all going to go buy it in bulk and they charge me 10, 10x the price per unit. Right?
And I think that's where we're really seeing employers feeling this.
And it's, it's the whole rebate game is, is kind of being turned on its head just by this sudden, very rapid rise in demand. And again, it's a demand that, you know, Ozempic and these other drugs can be a life Saving drug. A lot of people are also choosing it as a lifestyle thing, right? It is, I want to lose weight, I want to feel better about myself. So it's, it's harder for a company to be able to say this is the drug that is saving your life. And there are very few people who are on.
Seems like every, every third person is, is on it, has been on it, considering it or has been reading some very interesting articles about microdosing and what that can do.
So yeah, we're definitely seeing the disruption and but let's talk again with all this happening so quickly.
I mean it was a drug nobody had heard of and then everybody wants it. What feels like almost overnight, you know, there's still concerns around what is the efficacy, what are the long term impacts. You know, what's the science saying now that we've had definitely more users of these drugs, more opportunities to study impacts, good or bad.
[00:16:44] Speaker A: I can tell you that the data is still mixed. We know early on in the year we heard that people will regain the weight if they are on the medication and stop. Then we saw studies later on in the year that refuted that and said no, people are continuing to keep most of the weight off. There is some weight gain on it. But there's another study that showed that there was some benefit to just being on the medication even for a short term losing weight.
And then there's also been some ancillary benefits outside of weight loss that we've seen for these medications as well. And there's a couple of studies that were done this year that studied the effects of GLP1s outside or independent of weight loss for other organs in the body and to see what that looks like. The other thing to keep in mind in context, in a broader context with all of this is we, there's, you know, a lot more people using this, these medications and there's still a lot of information still unknown in terms of the long term effects of these medicines. And so we got to keep that in mind as we look at, you know, some of the benefits as well. Just to just in full disclosure of, keep, keep this in the back of your mind of what are these adverse effects that we may not see until people have been on it for know, two, three plus years and you don't have diabetes.
So we'll go into just a few, couple studies that, that were released this year.
One was the select trial that demonstrated ozempic or semaglutide 2.4 milligrams. So that's the wegovy dosing of semaglutide, not the ozempic dosing, but they're similar. There's 2 milligrams of Ozempic or 2.4 milligrams of WeGovy weekly. Reduced major adverse cardiovascular events by 20% in patients with established cardiovascular disease and overweight or obesity, but without diabetes. So these were overweight patients who had established cardiovascular heart disease, but they did not have diabetes. Cardiovascular benefits were independent according to the analyses that were done. These are statistical analyses of baseline fat measures and the magnitude of weight loss achieved. So just initial indication that there could be heart protection effects and some of the theories around this is. And to your point where you were just talking about microdosing more than just the effects that the, this GLP one has on your gut brain stomach relationship in terms of how fast you, how full you feel and hunger and how hungry you are, there seems to be some anti inflammatory effects to the medication that's just reducing inflammation in the body when you take it. That's again independent of what it does in this brain gut access with keeping, you know, with the hunger issues and losing weight. And so that could be connected to the cardiovascular protection.
There's also some, there's also some blood vessel stabilization, plaque stabilization as well effects that again, this is all just theoretical, but they're saying that this anti inflammatory effects could have these downstream effects in helping with cardiovascular heart disease. Patients with heart disease second trial, the essence trial demonstrated that again ozempic 2 or semaglutide 2.4 milligram weekly was superior to placebo. So these were patients that either didn't take anything, they took a sugar pill versus taking semi glutide, 2.4mg injection weekly for achieving what's called fatty liver metabolic dysfunction associated with what it's called steatohepatitis, which is fatty liver without worsening of fibrosis in your liver and for reducing liver fibrosis without worsening the fatty liver in adults with obesity. So these are two studies, one on the liver, one on the heart, showing some initial benefits likely due to some of its independent effects of weight, fat and weight loss.
[00:20:56] Speaker B: So Vinay, I mean it's sounding more and more and sometimes you'll see the sensationalist headlines that GLP1s are the wonder drug. Right. I mean it's help us lose weight, feel better, reduce appetite. Yes.
You know, prevent secondary side effects of diabetes, prevent heart disease.
You know, I've, I've. And I think you were alluding to it autoimmune disorders. Right. There's been some initial studies showing that there may be a correlation where the impacts of autoimmune disorders that traditionally people take biologics for, there could be some positive impacts from GLP1. So other than, you know, we've heard, probably if you've talked to somebody who's gone on Ozempic or a similar drug, you've heard some stories about, you know, there's some gastrointestinal distress that some people experience early on, some nausea, diarrhea, things like that. And you know, then again, sensationalist headlines. Ozempic face was the, was the thing a few months ago around, you know, people who experience rapid weight loss and being able to see it. But have there been any studies you mentioned? We don't know the long term effects, but have there been any studies that we've seen this year that indicate, you know, potential areas of, of significant concern, adverse effects from these drugs?
[00:22:24] Speaker A: Nothing, nothing outside of what has already been reported. So we know that patients who have medullary thyroid cancer, it's a, there is a risk that this will, if you have a history of a family history of medullary thyroid cancer that you shouldn't be taking this medication, it could cause that to become cancerous in your body.
And there was some stuff around pancreatitis.
And again, these are all very rare side effects, but they are surprising. They're all recorded in the, just the labeled, indicate labeled medication information for these drugs. And so there's nothing extraordinary sensational, outstanding from, in terms of drug side effects that we already know about. Mostly GI side effects with the nausea, especially with the higher doses. Some people can't even go past the initial dose. If they do one click above the starting dose, they'll feel very nauseous right away. And so it's very sensitive and very unique to each person.
But commonly it's just in the nausea. GI side effects. Yeah.
[00:23:28] Speaker B: So with, with that in mind, there's nothing that's an immediate red flag that says people are going to stop taking these. So I would anticipate then we're going to continue to see an increase in usage at least over next year. So what are some new advancements? You know, we've, we've already rattled off a few drugs but what's new in the pipeline for drug development?
[00:23:47] Speaker A: So there, I mean drug companies are doubling down on, on GLP1s given the success and the growth that they've seen in this market. So there's several new molecules. That one molecule is called retatrutide that's retatrutide which is. So here's how we divide up the class. So we have drugs that are semi glutide which is Ozempic and Wegovy. They target primarily the what's called GLP1 receptors in your body. They activate those GLP1 receptors to have the effects that we see around weight loss, hunger, so on and so forth and anti inflammatory effects. Then we have Mounjaro and Zepbound which is Tirzepatide and they impact GLP1 receptors just like Ozempic and Wegovy do. But they also have effects on a separate receptor in the body called gip.
And now we have Retatrutide which is going to be a triple agonist which is going to affect GLP1 receptors, gipsy and glucagon receptor agonists and glucagon in the body. Glucagon receptors in the body help stimulate. It's like when you do exercise, your body's going to be activating these receptors to help absorb sugar from your bloodstream, release sugar that is getting taken out of your bloodstream to help stabilize that. So it can lead to weight loss, additional weight loss and essentially mimic exercising in the body when we stimulate those receptors.
And what, what they've seen initially for from the trials from retatrutide is that it's showing a 24% weight loss after 48 weeks, about a year. So keep in mind we're not talking about within the first month. It's losing 20% of, of your weight in the first year of taking the medication. We don't know, you know, what other clinical effects there are to this medicine, side effects on forth. It's all just going under clinical trial evaluation right now.
And then we have another medication that's being developed called Orforglipron, that's an oral agent. So you know, typically what we've been talking about before for these GLP1 medicines are injectables. There is one other oral medication that is a GLP1 receptor agonist and that's Rybelsis, that's the oral form of semaglutide. But it doesn't seem to have as much weight loss effects as the injectable does. But this or for Glipron is an oral agent that is now a non peptide small molecule GFO1 agonist. Whereas the Rybelsis is a peptide form or just a small protein essentially string that just get, it'll get absorbed, they think better and have better effects around weight loss. In an oral formulation versus what exists out there today.
And then as of October 2025 there were, there are over 40 agents, including these multi receptor agonists that are in active development yet to see what these drug companies will come up with in the coming years around weight loss medications and novel ways to really help address this, address this issue in the country.
[00:26:59] Speaker B: So let me ask this, put on, grab your crystal ball with all these potential new entrants, right? Typically what we've seen is drug companies rush to release new patented medications because they can jack up the price, right? They can charge whatever they think. You know, the PBM market will bear with rebates and things like that with, you know, this race to the bottom on the direct to consumer. And now as you're talking about next year, we'll see more direct to employer plans. Would you anticipate that these new molecules, these new formulations of these weight loss drugs are going to enter the market at, at the high price point or do you think right off the bat they'll feel the market pressures and you know, be released more consistent with what some of the other offerings on the market are today?
[00:27:51] Speaker A: Here's the, the X factor in all this is what will the direct employer models do once we start seeing them rolled out next year? We just don't know what kind of effect that will have on the marketplace speaking today and what we know of today, here's what I anticipate is that there's going to be both just like we see it today in the direct to consumer market. I believe in the Trump Barx negotiations, they already negotiated a price for or for Glipron when it comes out. And I think they set the price for that already. And that's going to be inexpensive. They said it's going to be super cheap through the direct consumer platform. And then you're going to see the traditional model, which is still the majority.
The, the best way that pharma can access the market share in the commercial market, in commercially insured market is to go through the PBMs. And so they're going to offer the higher, just like we see today with Ozempic and Mounjara and all those they're going to offer. The higher list price is probably going to be priced right around what we see, you know, around $1,000 I imagine. And then there'll be a rebate given to the PBM to be able to offer that on their formulary. So I think we're going to see both for sure, both models, high, high list Price high, rebate through the health plans, and then low. Really, really inexpensive offering through direct to consumer for those that can afford it.
And then the X factor is really, what's the direct employer market going to do? If we have enough employers go to this model and say, this is what we want and vote with their feet to say we're going to, you know, disrupt the market by utilizing a third way to get access to this drug, then, and we get enough demand there, then I think that's going to be the leverage or the lever point that really pushes against pharma or pushes against the insurance model to say, you know, we're gonna, we're not going through you guys anymore. There's enough demand where pharma will just utilize the direct employer model. But we'll see what the fight is. There's gonna definitely gonna be a fight. There's too many stakeholders that are gonna be losing money in this to not put up a fight. So we'll see what that looks like and, and, and where the market goes. I think employers have a lot of power and they can definitely change markets, change behavior in healthcare, in the insurance industry, by choosing what they want to do and really being cognizant how that, how their decision affects what will happen in the future.
[00:30:04] Speaker B: You know, Vinay, I think I'll just restate it so I can claim it as my words of wisdom. But I think for this week's episode, it is, I think it's always good to remind our listeners, many of whom are working in, you know, in employer benefits and employee benefits, that they do have power. It can feel powerless.
[00:30:24] Speaker A: Yeah.
[00:30:24] Speaker B: But we are seeing a rapid and unprecedented change just over the last 12, 24 months in the purchasing power and seeing an increase in healthcare consumerism.
Employers remembering that they do have purchasing power, that they do have buying power, and 2026, I think is, is going to be a very interesting year for health care, but particularly pharmaceuticals.
Any other parting words, Vinay?
[00:30:55] Speaker A: I can't agree with you more, Jeremy, and we'll be here to talk about it when it happens.
[00:31:01] Speaker B: That's right, from Proactive md. I'm Jeremy Vanerknuys.
[00:31:05] Speaker A: And I'm Vinay Patel, Proactive md.
