GLP-1 payback time

Sergey Kornilov thank you for sharing and for your analysis! Interesting results that point to problem areas and raises some questions... but the results come with enormous caveats. The biggest, I think, are:

1️⃣ Time horizon: spending for only up to 5 years post-initiation. It's possible that important cost offsets materialize over longer periods (10+ years), particularly as GLP-1s prevent transitions to more severe disease states.

2️⃣ Limited data on newer GLP-1 medications: we should be cautious about extrapolating these findings to current clinical practice. Semaglutide was approved in 2017, so relatively limited data in early study years. Tirzepatide is virtually absent from the study period (approved only in May 2022 for diabetes and November 2023 for obesity). In addition, much of the data (2016-2023) covers a period before widespread approval and use of GLP-1s specifically indicated for obesity. The modal patient has type 2 diabetes rather than obesity as the primary indication. The semaglutide-specific results hint at possible (though statistically insignificant) partial offsets, suggesting newer molecules may perform somewhat better.

3️⃣ The claims data cannot directly measure health outcomes: weight loss, glycemic control (A1C levels), quality of life improvements, mortality effects, spillover effects.

I am personally cautiously optimistic about the overall offset potential of the new generation (and the tidal of upcoming) incretin and metabolic medicines. However, the 5-year horizon is both short and too long: short for the patient who may benefit greatly over a longer horizon; and too long for US health insurers since it exceeds the typical participant tenure. Brooks Tingle said as much at DOC: "One of the CEOs of the Blues the other day said they’re going to stop covering GLP-1s for obesity. That’s so shortsighted, why. [They said], Well, we need to have a 2.1 year payback period, and we’re not seeing it in our business and our industry."

Sergey reply: Thank you! I think what is going to happen is 20-40 years from today we will discover a new generation of metabolic dysfunction potentially caused by the loss of metabolically active tissue ie muscle, in already sarcopenia-prone older populations and those eg who do not exercise regularly etc. That is my fear - we will replace some faster-burning problems with some slower-burning ones, at least in part. The net effective is supposed to be positive, I am cautiously optimistic (with you) on that - but this will create a separate subspecialty. These medications are a gift, no doubt. But it's not free :(