Researchers published a comprehensive review of electronic medical records from the Veterans Administration (VA) to demonstrate the benefits and harms of GLP-1 medications. The research was recently published in Nature Medicine. The study was large (following almost 2 million people for an average of 3.7 years) and included over 215,000 people on GLP-1 drugs. These results might not apply directly to employer-sponsored health plans because the VA’s population is older and more male than the populations of employer-sponsored health plans. The sample included about 18% Black people and 5% women, and about 30% of those studied were under 60 years of age.
The researchers looked at 175 potential adverse outcomes and found that GLP-1 drugs lowered the likelihood of 42 of these outcomes and increased the likelihood of 19 adverse outcomes. The likelihood of drug-induced pancreas inflammation is about 2.5 times higher with GLP-1s.
This is an observational study and doesn’t prove causality. This study looked at the benefits and harms in people with diabetes. So, it isn’t certain that the same results would be achieved by treatment with GLP-1s for obesity without diabetes.
Implications for employers:
Cancer care is a key driver of the increase in medical care costs. New cancer drugs are very expensive, often costing between $10,000 and $20,000 a month. Newer cancer drugs are often oral, have far fewer side effects than traditional chemotherapy and are much more effective at prolonging life for many cancers that were previously resistant to treatment.
The American Cancer Society (ACS) recently published its review of incidence and mortality data through 2022. Cancer deaths continued to decline. They used data from SEER registries (Surveillance, Epidemiology and End Results program) and national cancer registries, and comparisons are based on registries.
Lung cancer cases and deaths are tapering off as fewer people smoke, although cigarette smoking represents the largest preventable cause of cancer. Although incidence of breast and prostate cancer is up, death rates continue to decline.
The ACS notes that if rates of cancer deaths had continued to increase at the 1990 rate, there’d have been almost 4.5 million excess cancer deaths from 1990–2022. Disparities persist, and the researchers estimate that if Black people received colorectal cancer screening at the rate of white people, that would decrease colorectal cancer deaths by 19% in that population.
Implications for employers:
Colon cancer screening detects precancerous and early cancers, and this screening has led to an impressive decrease in colorectal cancer death rates in the U.S. However, most screening is done by colonoscopies, which require an (often unpleasant) colon cleanout and some anesthesia, so many people lose a day or even two days of work to get screened. Some can’t afford the time away from work, and some simply don’t want to go through this procedure. Many employers and health plans are looking for a way to bring the benefits of screening to this group of members.
Researchers used a microsimulation model to evaluate cost-effectiveness of different approaches to screen this population, and published their results in JAMA Network Open. They created the model for a community health center using a simulation of 10 million people who turn 50 years old in 2025. The population in this simulation was majority Hispanic. The Hispanic population has a lower rate of colorectal cancer detection and death but higher rates of metastatic disease than non-Hispanic white people, so these data aren’t exactly applicable to other populations. The researchers considered likely test adherence when building their models, so not all who were assigned to a specific test would follow through.
They found that offering annual FIT tests (fecal immunochemical test) for colorectal cancer screening saved the most lives and saved the most money in medical care. This requires members to send a stool sample from the toilet, and no special diet. Cologuard requires sending an entire stool, and also requires no special diet. Blood tests for colon cancer screening (such as Guardant Shield) require no special diet and no handling of stool. These researchers found that blood test screening increased total costs, and the other screening modalities led to lower lifetime costs. Most research has shown colorectal cancer screening to be cost-effective, but this simulation showed that this screening was cost-saving. Many of the projected savings would be realized later in life when people would be less likely to be covered by employer-sponsored health plans.
Implications for employers:
Metabolic Associated Steatohepatitis, or MASH, doesn’t roll off the tongue, but is very common and surprisingly deadly. MASH is an inflammation of the liver that can lead to cirrhosis (liver failure) and liver cancer, and affects about 5% of the population in North America. Those with obesity, diabetes and hypertension are at higher risk for MASH. Twenty percent of those on waiting lists for liver transplantation in the U.S. have MASH.
The first drug to treat MASH, Rezdiffra (resmetirom), was approved last year and has a list price of over $48,000 annually. GLP-1 agents also appear to decrease liver inflammation in many, although this is not yet an approved indication for either semaglutide (Ozempic/Wegovy) or tirzepatide (Mounjaro/Zepbound). Novo Nordisk plans to submit an application to the FDA for Wegovy to treat MASH in the first half of 2025.
A new study in Nature Medicine shows that treating obesity effectively can decrease the liver inflammation of MASH, even if treatment is started when there’s already substantial liver damage. The study showed that those who had bariatric surgery were 72% less likely to suffer from a MASH-related complication, including liver failure, transplantation or death. The study was small (62 who had bariatric surgery and 106 who didn’t), but the average observation period was long (10 years). The study wasn’t randomized, but the controls were well-matched.
Implications for employers:
We often focus on how personalization can improve medicine. Pharmacogenomics can predict which antidepressants will be most effective, and genetic tests help oncologists choose the best and safest treatment for cancer. Many of the most promising new treatments, like CAR-T (chimeric antigen receptor T cell) therapy, involve genetic manipulation of a patient’s own cells.
But an effective, inexpensive treatment that can be used uniformly across a large section of the population is more scalable and could lead to genuine health improvement. Researchers have been evaluating the use of a “polypill” to prevent cardiovascular disease for over 15 years. Such a polypill would include a statin (to lower bad cholesterol), and low doses of blood pressure medicines. Some polypills have also included a medicine to decrease blood clotting. Putting modest doses of these medications together in a single pill could prevent many heart attacks and strokes, while causing a relatively small number of side effects.
Researchers recently published projections of cost-effectiveness of such a polypill in JAMA Cardiology, using data from a clinical trial that included a low-income predominantly Hispanic population. They found that this treatment saved money in almost all (99%) of simulations if the pill cost less than $443 a year. This price is based on current costs of the component generic medications. There’s no polypill on the market in the U.S. But such a pill could save many lives at a very low cost.
Implications for employers:
Jeff is an internal medicine physician and has led WTW’s clinical response to COVID-19 and other health-related topics. He has served in leadership roles in provider organizations and a health plan and is an Assistant Professor at Harvard Chan School of Public Health.
Plan redesign outweighs cost-shifting to reduce the cost of care, WTW survey finds
