The Big Picture on Pharmacy

Scott: We've had this recent wave of biologic products and I think one of the recent bright spots is really the emergence of biosimilar options for biologic drugs such as Humira® and Stelara®. You know, these are products used to treat conditions like rheumatoid arthritis, psoriasis, and Crohn's disease. Where are we in terms of biosimilar adoption now and what do you anticipate going forward?

John: When you're thinking about cost, there's clearly an importance to biosimilars because they provide a real opportunity to get clinically equivalent products at less expense. At Optum we have defined formular strategies and principles around biosimilars that we are beginning to deploy. 

For example, we've excluded Humira starting January 1st and we're working with providers to get people on biosimilars without sacrificing the clinical care model and making sure that it's appropriate for patients. 

A really important key for us is that alignment with providers to make sure that they're on board with clinically equivalent products. Then we also need to make sure that patients who may have been used to a certain therapy in the past realizes this new biosimilar is just as efficacious and safe but at a lower cost. 

Obviously, there is a significant impact that can happen to trend in savings, but there are also complexities beyond what the provider impact is and the patient impact is. Having a significant number of patients on the product with a client is really important to making those savings really count. So, we're really trying to take all of that into consideration. We do not want to sacrifice the patient experience but it represents a really important lever for us with our clients.

Scott: You know, I'm not sure that a day goes by without a plan sponsor asking me questions about GLP-1s and how we should look at them. The first GLP-1 medication was approved in 2005 and over the last few years we've seen a surge in utilization for products like Mounjaro®, Ozempic®, Wegovy® and Zepbound®. I have a two-part question for you here:

1. What guidance would you offer plan sponsors as they develop their strategy for GLP-1 medications? 
2. And from a clinical standpoint, what do you foresee for the future of this class of medications?

John: This is a real complex one, right? GLP-1s, which have been around for a while on the diabetes side, are really important when you think about people that truly have issues with obesity, which can lead to a whole host of other chronic conditions including diabetes, sleep apnea and congestive heart failure. So, this is an important class of medications.

I would say even before talking about plan sponsors, some of the things that we think about, especially with new medications coming to market, is to be very aware of what ultimately is the side effect profile of these drugs going forward. 

I think right now we have some good experience with GLP-1 use and diabetes, but frankly we haven't had the long-term experience yet with the use of GLP1-s for this other type of patient at higher doses. So, being mindful of what the impact to patients is over the long haul is something to consider into the calculus. 

I think with plan sponsors everybody wants to offer what's right for a patient. The challenge is really trying to wrestle with what this does to the overall cost of care and whether in the short term you can afford these medications. So, for a lot of folks, it is challenging to afford these medications and we've had reports of some of the plans in the New England area that have had a significant financial hit trying to cover these patients. 

The other part is that we also don't have a clear sense from a long-term perspective of whether patients stay on the medication. There's a lot of data out there but I don't think there's anything really concrete yet on the persistence or staying on the medications for a longer duration of time. It's unclear whether that persists, why it's not persisting, what impact it might have to a person’s overall weight.

And then you couple this with all of the new indications that are coming down the pipeline for cardiovascular events and for chronic kidney disease. There's a really significant population in the United States, 26 million people, with CKD.

So, trying to determine who the medication is best for and at a cost in which there's true value for the client, who has to run the benefits for the entire for their entire member population, that's challenging. There’s also hope that with more competition and new entrants into the market the prices might get a little bit better. 

There's been actually some really interesting data out there. Most recently there was an article from ICER (Institute for Clinical and Economic Review) looking at GLP-1s and thinking about novel ways to look at this.  At Optum, we've sort of taken more of a holistic approach. One is to be very mindful about what our clients’ needs are and work with them to figure out what's the best way to offer coverage in a manner that is clinically appropriate for patients but also think about other things when you're treating somebody with obesity, including offering some sort of behavioral modification. 

Our program, Weight Engage, tries to contemplate that perspective. Whether it’s help with nutrition, or whether it's working with a provider to determine whether the right drug is being used, there are many things that we can do to improve outcomes before we even think about a GLP-1 medication.

Scott: Moving beyond these GLP-1s, are there other clues we can glean when we look into the drug pipeline?

John: When you think about the drug pipeline, one thing that stands out is that over half of the medications that are being approved are high-cost medications with pretty narrow indications. So, think oncology, orphan and rare diseases. These medications are expensive. 

Thinking about what their true value is will be important. For example, there was a new medication approved for schizophrenia that will likely impact particular clients that have that patient population. The flip side is that there are medications that are interesting and exciting to see. There’s a new medication for pain which is non-opioid based that was recently approved. It’s called Journavx® and works through an interesting mechanism to help with pain, a sodium channel mechanism

There’s are a lot of other drugs that we're thinking about and watching, including those for blood disorders, hemophilia, as well as neurology and Alzheimer's. All of these are really exciting because it offers something for patients but then the other side is you really need to think about appropriate use and doing something in a cost-effective way.

Scott: Last question for you, Dr. Wig. As we anticipate future developments, what key emerging trends within the healthcare industry should people keep an eye on?

John: Just from an innovation perspective an obvious one is artificial intelligence and how that can be impactful for patients.

We have done a lot of work at Optum on predictive analytics and more recently with generative AI. We are really thinking about ways that we can make our processes more efficient and seamless such as knowing how to talk to a member in a way that is most effective for them, whether it's a phone call or a text message or even choosing the appropriate time of day to contact them based on whether they work or not. 

There are other things, even looking at ways to mitigate fraud, waste and abuse or help managing the supply of medications that I think are really exciting for us.

There are other innovations beyond just AI that may not be as exciting but are just as impactful. When you think about prior authorization (PA), there's been a lot of discussion about trying to make this simpler, not only for providers, but for patients to make sure they're getting their medications. 

We've just announced a program to simplify PA for specific medications. These are medications that impact patients who are taking them for long periods of time for chronic conditions. We're eliminating up to 25% of the reauthorizations for these medications and that is going to have a significant impact, not just for those patients but also lessen the burden on providers.

I think we're all wrestling with the trend of affordability. A lot of different things are being talked about on Capitol Hill and we're trying to stay at the forefront. We've made announcements on passing through 100% of rebates back to our clients and hopefully if that's also passed back to the point of sale it's going to have a real impact on the patient out of pocket expense. 
 
And then there are other things that we've looked at including, how do we use our footprint for other things that might be important such as opportunities for patients to engage in clinical trials. And a lot of patients may not have access to these trials which could really impact their health. 

And then lastly, we're spending a lot of time on behavioral health with our Genoa pharmacies. We see that the integration of behavioral health is going to be a pretty significant trend going forward. 

So, we are innovating in a environment where there's a lot of puts and takes and trying to be mindful of that while making sure that patient care isn't compromised.

Scott: Dr. Wig. I enjoyed our time together today. Thank you for joining us.

John: Thanks Scott.