Rae Woods (00:15): Hey, it's Rae. I'm here at the HLTH conference. We, and 12,000 other health leaders, we've all gathered together to discuss some of the biggest topics in healthcare. And there are a handful of areas that are so big and frankly, so hairy that the HLTH team has dedicated entire days for their discussion. And you know that on Radio Advisory, we are all about untangling the toughest challenges in healthcare, that's why I'm about to go on stage. I'm talking about GLP-1s, what they can do, what they can't do, and how providers plans, manufacturers, PBMs, and vendors can work together to provide comprehensive obesity care. Honestly, it's a continuation of the conversation we had on Radio Advisory just a few weeks ago. All right, let's do this. (01:19): HLTH devoted an entire day, an entire summit to the conversation about GLP-1s. And this particular session is titled, GLP-1s, What Can't They Do? Now, I think that title is really interesting, because if you are an optimist about weight loss drugs, you probably read that title as GLP-1s, What Can't they do? This is Vegas, after all. If you are a pessimist, you may have read this title as GLP-1s, What can't they do? Now, I'll be honest, I don't want to be the pessimist or the optimist, I actually want to be the realist. I want to give you the real answers to how GLP-1s are affecting patients, members, people in their everyday lives and what it means for healthcare business. And to do that, I've brought three fantastic guests to the HLTH stage and to Radio Advisory. (02:10): We have Rob MacNaughton, who is the CEO of Calibrate. Calibrate is an organization that is devoted to providing intense lifestyle intervention with medication when necessary, to provide better metabolic outcomes and sustainable results. We also have Rita Glaze-Rowe. She's the president of an expert team at Real Chemistry, an organization that exists to provide the right insights to executives to help them understand how new market dynamics, like the onset of weight loss drugs will impact real executives. And then lastly, I have Dr. Spencer Nadolsky. He's a lipid and obesity specialist, who's also been at the forefront of telehealth and direct to consumer primary care. Welcome to Radio Advisory. Spencer Nadolsky (02:53): Thanks for having us on. Rob MacNaughton (02:54): Thank you. Rita Glaze-Rowe (02:54): Thanks for having us. Rae Woods (02:54): Now I am going to admit the conversation about GLP-1s has a ton excitement in the market. It also has some controversy, right? I hear some swirling conversations about are we conflating weight with health? And part of that swirling conversation really has me wondering if we, if our audience, if healthcare executives all actually have the same goal, when it comes to weight management and when it comes to GLP-1s? So I want to ask each of you this, and Dr.Nadolsky I'm going to start with you. What is the goal that you hear from patients themselves when they come to you seeking something like a GLP-1? Spencer Nadolsky (03:34): Yeah, I always preface this and tell everybody on podcasts and during these conferences, that I don't make money from big pharma, and I do that on purpose. But I'm a shill for these medicines. I love them so much, because my patients finally feel like they have hope. They finally feel like they can actually do the things that they know they should do, but can't do. Rae Woods (03:55): Hope for what? For weight loss? Spencer Nadolsky (03:56): Hope for weight loss and improving their quality of life. Like the patient that I had that said she could finally walk around Disney World with her family for the first time ever. And we had some of these older drugs that worked okay, and we had bariatric surgery, but that's only limited to a certain population. So she finally felt like she could do the things that she always wanted to do and perform the lifestyle changes that she always wanted to do, but really struggled doing. Rae Woods (04:24): Rita, you work with health systems and providers and [inaudible 00:04:28]. Rita Glaze-Rowe (04:27): And payers, let's be clear. Rae Woods (04:30): But for the purpose of this question, let's channel the provider mindset. What goals do they have in mind when they think about GLP-1s? Rita Glaze-Rowe (04:36): Well, I think they have several and it's multifaceted. And I just want to build on what Spencer said, is we do hear that. We hear that from providers and health systems all the time, which is we all talked about for years and years and years, how much the system was burdened by obesity, how much cost was burdened on the system by obesity. And here we have these incredible tools now in our toolkit, to be able to offer and administer, which also comes with associated burden, but we also are talking to them and they're finding their happiness. We had a couple of providers that we interviewed basically say, "I use a happiness scale now, because my patients who come in and they're starting to reach their goals, they're literally smiling more. They're telling me the good news about the things that they can do, that they potentially couldn't do." And I think when we look at it from an overall system perspective, we're looking at that from a population health. Are we making the communities healthier? That will then make our systems a little bit flourish in a different way. Rae Woods (05:37): So the physicians themselves are happy about better patient experience, providing some actual hope to patients that maybe didn't feel like bariatric surgery was right for them or it was out of reach. Rita Glaze-Rowe (05:45): Correct. Rae Woods (05:45): From a business perspective, those providers are thinking about outcomes. Rita Glaze-Rowe (05:49): Right. Rae Woods (05:50): Now take me to the purchaser landscape. What are you hearing, Rob from health plans and employers? What goal do they have in mind? Rob MacNaughton (05:57): Well, speaking for employers, I think there's a broader realization and progress that obesity is not a matter of willpower, but it is actually a condition and disease. Rae Woods (06:06): Yes. Rob MacNaughton (06:07): And so we're seeing that in the health community, public policy front and consumer. From an employer standpoint, I think they look at these weight and obesity management solutions as being one of the few points of light in U.S. healthcare that actually has the promise of reducing total cost of care, which has been something that they've been looking For and hoping for literally decades of underwriting cost of care for their employees. So I think there's a general excitement and interest. And then it's offset by uncertainty and concern about what would be the costs of this? Rae Woods (06:39): Yes. Rob MacNaughton (06:39): And so I think that is the stage of the lifecycle we're at with employers as purchaser. Rae Woods (06:47): I want to run directly at that for a moment. And the word cost, I'm going to admit immediately is going to get confusing really quickly. Because when we talk about total cost of care, we're talking about how we are saving money over the long term by improving outcomes. What I hear from employers I'll say, is the cost right now, the price of the medication and the very large indicated population, which by the way is only going to get bigger. And they're saying, "Hold on, I need to avoid paying for this as much as possible." Particularly because I'm not sure that the average employer or private health plan is going to see that long-term benefit of total cost control, because an employee is going to leave after two years or five years, or they're going to see turn in terms of their member population, if you're speaking to a health plan. So my question is, how should purchasers think about covering these drugs? Or maybe the better question is, how do they get value from GLP-1s? Rob MacNaughton (07:37): From an employer standpoint, I think it's really a matter of the drugs are just a powerful tool in a broader care plan. These are powerful, GLP-1s, as Spencer highlighted, are powerful drug therapies. But I think the viewpoint that's coming to the fore, is that they're literally and figuratively not the magic pill. That you can have better results and more sustainable results when the GLP-1 therapies are dovetailed with lifestyle intervention and coaching and behavior change, particularly around pillars of diet, nutrition, sleep, exercise and behavioral health. (08:14): And so I will tell you the journey for employers based on our experience to calibrate, is evolving. And there is employers, I'll say, at different areas of the life cycle. We are seeing, for lack of a better word, a desire for employers to have a social contract with their employees, in the sense that before you become perhaps eligible for a GLP-1 drug coverage, you actually have to commit to the lifestyle intervention and coaching platform first. So you're three to six months on the lifestyle intervention and coaching. You then weave in the drug therapies. And then over time, for a subset of the population, they may be actually able to titrate and consume less of the drug, yet still retain the tremendous healthcare outcomes that you've seen. Spencer Nadolsky (08:58): Yeah, they're trying to gate keep the medicine to keep it cheaper. Rae Woods (09:01): Yes. Spencer Nadolsky (09:01): I think we should just blow up the whole entire insurance industry and everything like that anyway, and make these drugs cheaper so that people are just paying cash and it's not tied to any insurance in the first place. That would be my... Obviously, I can't make that happen. Rae Woods (09:13): All right, let's run at the manufacturers then, for a second. Spencer Nadolsky (09:15): Let's do it. Rae Woods (09:16): No, truly, truly, because from the purchaser's standpoint, they're doing exactly what you said, Rob, which is, "Let's focus on utilization management. Let's make sure the right patients have the right access to these drugs, but not more, because we can't afford any anymore." Now the manufacturers, they have the opposite goal. They want as much utilization as possible, so much so that we see manufacturers say, "No, no, no, you're not going to get a rebate if you add step therapies. If you say you're going to add wraparound lifestyle support." Which is exactly the purpose of this conversation. So then my question is, how do you think the manufacturers are going to change in the future, especially in a world where I'm willing to bet we're going to see a lot more competition for better, cheaper, easier-to-administer drugs. Spencer Nadolsky (10:00): Yeah, I like how Lilly stepped in and started this LillyDirect and now you can get the lower doses. Hopefully they open it up to more doses. And Novo, I hope they are listening, and I don't know if there's any Novo people here, but I hope they start doing this direct. We start cutting out these PBMs and really start making it direct to patients and skip these middlemen. I think it's just ridiculous. Because otherwise, they're going to be... We had a whole thing on compounding earlier. Compounding wouldn't need to be a thing if we just make these drugs cheaper and we use the actual legit FDA-approved versions. Rita Glaze-Rowe (10:30): Well, and also you're going to see competition, right? So the hope is that we see price compression with competition. You will have more than likely, more than 18 come into this market across the next five to 10 years. And that's different doses form, right? We're going to see injections, we're going to see orals. Rae Woods (10:46): That's right. Rita Glaze-Rowe (10:47): We're going to see this market manifest in a number of different ways. Rae Woods (10:49): And orals of course, are going to be less expensive. Rita Glaze-Rowe (10:50): We are very early. And I know that the gate keeping is real, but also on the self-insured side, there's also opportunity for them to design. And this goes to engagement. So we're also looking at it from an employee engagement perspective. Employees are now making choices about who to work for, whether they have the right programs in place. Rae Woods (11:10): That is exactly right. Spencer Nadolsky (11:10): Absolutely. Rita Glaze-Rowe (11:11): That's a pressure that they're feeling from a different way too. Rae Woods (11:14): In fact, we have data that 44% of employees would switch their jobs in order to get access to a GLP-1. Rita Glaze-Rowe (11:20): That is exactly right. Rae Woods (11:21): Which is a number that I think actually terrifies employers, because they're thinking, "Oh gosh, I really need to figure out a way to pay for these drugs." And of course, employers are saying, "My healthcare costs are already wildly unsustainable. What am I to do?" Rob MacNaughton (11:38): Totally agree. We're seeing the uptake in terms of employers offering weight and obesity management as a covered benefit, going up by orders of magnitude year over year. Our research suggests that about a third of all employers do offer it. They tend to be larger employers. So it's probably 40, 45% of the population probably has it as a covered benefit. Now, yes, there's- Rae Woods (12:00): Weight management as a covered benefit? Yes. Rob MacNaughton (12:00): Weight management with, I'm sure utilization management constraints and things like that. And again, these GLP-1 drugs are powerful therapies, but they also don't work for everyone. Rae Woods (12:16): Yes. Rob MacNaughton (12:16): And so that's why we have to think about this I think a little bit more broadly and a little bit more around as part of a more comprehensive care program, because depending on the research you read, there's 10 to 15% of the population who just don't respond to these medications. And potentially, another 10 to 15% that have significant or moderate enough side effects, that they may come off as well. Rae Woods (12:37): Absolutely. Rob MacNaughton (12:38): So you have a material part of the population that this may not be the best therapy for them. And so as an employer, how do you manage that material subset of the population as well? Rae Woods (12:52): I want to actually run at this for a moment. We know that GLP-1s are really powerful drugs. I want to be really, really specific about what the data shows, the clinical trial data shows, that these drugs can do. I want to talk about what we might expect them to do next, based on the clinical trials that are in progress right now, and where that falls short. What do we know in terms of weight loss? Let's start there. Spencer Nadolsky (13:12): Yeah. So when you think of lifestyle, the average is around five to 7% total body weight loss. And that's with a pretty good program and that's over a year. Rae Woods (13:20): A pretty intensive program. Spencer Nadolsky (13:21): It can be a lot less, some people can have a lot more. You look at like phentermine and topiramate, the Qsymia, that's around 10 or so percent total body weight loss. Bariatric surgery on the other hand, is 30%. So when Wegovy came out, semaglutide, in 2021 around that 15% weight loss, now we're starting to bridge that gap in between lifestyle and bariatric surgery. If you look at tirzepatide or Zepbound, we're starting to see 20, even up to 25% total body weight loss if you extend that. Newer agents coming out, we're probably going to see in the 30% range. We're getting into bariatric surgery levels. Rae Woods (13:57): What about beyond weight loss? What do we know that these drugs can do when it comes to say, cardio metabolic health? Rob MacNaughton (14:02): We publish our research every year and at Calibrate every January we publish our results. And in the most recent January report, our results with [inaudible 00:14:10], like 16,000 people. At the end of year one, our members lost on average, 16% of their body weight. And this was in a world of just semaglutide. Tirzepatide hadn't really hit the market. But at the end of year two it was 18%. And these are real world results typically characterized by a period of pretty severe supply chain issues. And on average, our members only had access to the medication for seven of the 12 months. So at the end of year two, having 18% body weight loss is pretty impressive. And that allowed our docs and our clinicians to have an informed view of titration and tapering, and how best to still utilize the lifestyle intervention and coaching in concert with the GLP-1 drugs to drive these, I'd say, over index and better results out there. So it's again, using things combined. And then our research also shows that waist circumference goes down, A1C goes down, frankly, a whole range of metabolic metrics increase. Spencer Nadolsky (15:07): I always have this joke on social media, because people are like, "Oh, what about the long-term side effects?" I'm like, the long-term side effects include decreased risk of heart attack, strokes, kidney disease, liver disease, sleep apnea, you name it. So the select trial was the big trial that came out last year in November, almost a year ago, that showed, "Hey, we already showed in those with type two diabetes, these drugs can reduce cardiovascular events." Rae Woods (15:28): Yes. Spencer Nadolsky (15:29): It was the first time they finally showed that those without type two diabetes, but had cardiovascular disease at baseline, reduced cardiovascular events. So these drugs are not only weight management or type two diabetes drugs, these are cardiovascular disease drugs. Rae Woods (15:42): And by the way, there are clinical trials in process right now for sleep apnea, for chronic kidney disease, for Alzheimer's, for osteoporosis. And so like I said, we're going to see the therapeutic scope get bigger, which means that the very problems that we are discussing now, how do you pay for it? What do manufacturers do in terms of rebates? How do we get this in the hands of patients who need it? Those problems are only going to get bigger. Rita Glaze-Rowe (16:04): They're also going to expand the value discussion, right? Rae Woods (16:06): Yes. Rita Glaze-Rowe (16:07): So we're talking about there's nothing more expensive than hospitalizations, nothing more expensive that we think about every day. So we're going to see this as we see cardiovascular risk reduction go down, as we see these events go down, you're going to stop talking about cost in general, and you're going to talk about value being generated. That's where we have to get to. And it's not on drug alone, but it's about managing this thing we've called obesity for so many years. And we've studied it as a wedge. We studied as a wedge for all of these other things. And so we're going to start bending that cost discussion to go into a value generation. Rob MacNaughton (16:39): And to that point, these GLP-I drugs have a pervasive impact as obesity is probably the center pin for at least 40 other chronic conditions. And I think this is going to touch on something earlier you said, there's a component about value creation, in the sense that these therapies particularly done in concert with lifestyle intervention and coaching, can, and I believe, will reduce the total cost of care. That's the value creation side of things. The next question that I think you were aiming at is who captures that value? Particularly from an employer standpoint. And I will tell you, that there's probably been a gravitational pull, in terms of our go-to market, in terms of those employers that have longer employee retention periods, whether that be their unions or trusts or federal employees, because there's greater confidence and conviction, that if the value creation comes to the fore, which I believe the folks that are jumping in now, those decision makers do believe there's that likelihood that they will be the ones that have the best chance to capture it. And that's why they're able help. Rae Woods (17:40): Unless you continue pressure on the purchasers to cover these drugs as we get more information in terms of their clinical outcomes, Medicare in particular isn't going to be able to ignore this for much longer. Rob, you said these medications are not a silver bullet. How does the clinical trial data translate to the real world? Where do these drugs fall short? Rob MacNaughton (18:00): Our advantage is that the clinical trial information is still evolving. Rae Woods (18:05): Sure. Rob MacNaughton (18:05): The studies that come out that you had highlighted, they show that the GLP-1s do work, and then when people come off the GLP-1 drugs, they gain the weight back. Rae Woods (18:15): And there's a pretty sizable portion of the population that comes off the drug within the first year, I think 25%. Rob MacNaughton (18:20): That's another element, but I think the rhetoric around the study I just highlighted, is that then the takeaway is, therefore these drugs must be chronic. I don't think that's the takeaway. I think that's a pretty myopic aperture. I think there's going to be more studies that look at the use of GLP-1's done in concert with other elements of lifestyle change, and they can show what the impact is of GLP-1's as a result. For instance, our empirical evidence that calibrate shows that people lose more weight when taking GLP-1 drugs when combined with lifestyle intervention. And for a subset of the population, they can taper and titrate, in some cases off of medications altogether. And I think you're going to see more studies around that. And then more importantly, there's also data out there that shows between 10 to 15% are non-responders, they don't work. And then another material percent have potential side effects, that unless you're working with a clinician, you're more likely to come off. And as a result, to your point two-thirds of people who go on GLP-1 drugs today tend to come off. Rae Woods (19:21): What's the physician perspective here? Spencer Nadolsky (19:22): Yeah. I mean, we want people to also stay on these drugs if it has that cardiovascular benefit. Rae Woods (19:28): In the same way that they would stay on say, a statin? Spencer Nadolsky (19:30): Say, a statin or whatever else. And some people will want to taper off and hopefully, if they want to, you can help them do that. But if you're going to your local medspa and getting bathtub tirzepatide and you're not giving them good guidance, they may have some side effects or whatever. We don't even know what they're putting in their tirzepatide or semaglutide. And then you're not monitoring them, they could come off because they have some reaction and then never show back up to that medspa. So you want to be working with a program, whether it's a Calibrate or any other program, that will actually monitor and titrate the medicine appropriately. And if the patient wants to titrate off, you help them come off or whatever they want to do. So I think the adherence part is very important. And there's some good data to show that, hey, maybe the local anesthesiologist who decided to open up their own medspas, probably not the best person to be getting this from. Rae Woods (20:19): Probably not. Rita Glaze-Rowe (20:19): Well, and also let's talk for a minute about where care is actually being delivered, right? Rae Woods (20:22): Yes. Rita Glaze-Rowe (20:23): So the majority of this is being done at the primary care office. We did an analysis across 49 different clinical trials that are going on, and the end points that are being used are actually not getting into what is happening in the real world practice, where care is actually being delivered in the primary care office. So there's a tremendous amount of education that needs to take place about how all of that clinical trial data actually gets into real world practice, so that we can begin to manage the care appropriately. Rae Woods (20:53): And this is exactly why we need to be talking about GLP-1s, and we need to be talking about comprehensive weight management support. Now, I think it is easy to simply say, "Yeah, we need to focus on physical activity and nutrition," but we all know that the answer is not as simple as eat less and move more. Frankly, if it was that easy, the four of us would not be on this stage at HLTH having this very conversation. Rita Glaze-Rowe (21:17): I'd be walking somewhere. Rae Woods (21:19): So my question is, what's missing from the conversation about comprehensive weight management that would help us actually get to sustainable change? Spencer Nadolsky (21:29): Yeah. So I'm a big shill for lifestyle is medicine, but I'm also a big shill for these medicines themselves. The big thing out there- Rae Woods (21:37): Which by the way, it sounds counterintuitive. Why is that not counterintuitive, that you're a self-described shill for these medications, but you're also a physical activity junkie? Can I say that? Spencer Nadolsky (21:46): Yeah. The thing is, some people respond really well to lifestyle by itself. Some people do. There's always going to be diets and things around, and there's not everybody's going to want to take these medicines. I could see a future where we're all just taking these medicines. But at the time being, there's going to be a portion of the population that never wants to take these medicines and they can respond very favorably to lifestyle. You see it everywhere. 10 to 15% of people that do these trials will have the results of something like a Wegovy or a tirzepatide. The big concern with these are rapid weight loss and people are worried about body composition changes. So not just looking at the scale, but looking at what happens to their body composition. Rae Woods (22:25): Meaning they're losing lean mass or losing bone mass? Spencer Nadolsky (22:26): Yeah, worried about muscle. So if people just get thinner without improving their outcomes, and we do see reductions in heart attacks regardless, but we don't know in the future, what if these people then come off these medicines, regain their weight, do we know the body composition changes when they regain the weight? Are they regaining mostly adipose tissue or fat tissue? And not regaining that muscle that they had lost? And then if they keep cycling back on and off, are we going to end up with more of the sarcopenic obesity? Which is essentially the derogatory term is skinny fat, so I don't like using that term, but that's how people interpret it. Rae Woods (23:02): Yeah. Spencer Nadolsky (23:03): So imagine being just thinner, but not being able to do those activities of daily living, doing all those things, like walking around Disney World and those things. So I think it's really important as a comprehensive program, that we're at least encouraging and nudging people towards that. We can't force people to do it, it's all about behavior change and trying to figure out how to get people to do that. But the drugs will enable it at least. So if you're not talking about it, the patient's not as likely going to be nudged in that way of doing that. So at least some programs, I know Calibrate does it, the programs that I've been associated with do it. (23:37): But putting it out there, where Rita was talking about primary care offices, you have five minutes to talk to a patient, you write them the script, you say, "Get the hell out of my office." Onto the next person. Do they have the time to actually deliver that comprehensive care? So ideally, you would have programs that you have dietitians, you have exercise physiologists, you have behavior change therapists. You have a psychologist to deal with the mental issues that people go through now that they've lost so much weight. Rae Woods (24:02): Yes. Spencer Nadolsky (24:03): I have patients that are having affairs, because they're getting attention from other people now. So I'm like, "I don't know how to deal with that necessarily. I'll talk to you, but..." Rae Woods (24:11): I appreciate the fact that as a physician, you're saying, "Hold on, my knowledge falls short of this. And there is a piece, there is a gap that is missing to actually not just support my patient in their weight loss journey, in their chronic disease journey, but in all the ripple effects that that's going to have on their life." And Rob, I know that one thing that I think Calibrate believes is missing from the conversation about weight management, is behavioral health. Can you talk more about that? Rob MacNaughton (24:33): Well, absolutely. And we have our four pillars of lifestyle intervention. It's diet, nutrition, sleep, exercise, and behavioral health. And that is a new use case that I hadn't heard pop up in ours. But everyone's journey is unique. And that's why we are a firm believer of having it be a physician led lifestyle intervention and coaching platform. Every journey is unique, and we do believe, and I think our empirical results would show, that for a material amount of the population, the lifestyle intervention is completely additive or multiplicative force factor on the drugs themselves. And to Spencer's earlier point, some people respond better to lifestyle intervention and behavior change than others. And as a result, their journey could be different than someone who doesn't. And in terms of the behavioral health, yes, there will be aspects that our coaches will chat about and our doctors will chat about with our members. And it's just part of a more collaborative and comprehensive care plan associated to one's unique journey. Rae Woods (26:38): There's a great question that just came through in the chat. We're talking about comprehensive weight management programs. Who is actually doing that? Who is actually creating, providing, offering comprehensive weight management? Rita, you are smirking. Is anyone doing this well today? Rita Glaze-Rowe (26:53): I think we're seeing fractured solutions. So we always say the first set of innovation comes in the silo. Everybody works in the silo and then it bubbles up. What we're not seeing quite yet, is the connected solutions. And they're all valuable by the way, but we're not seeing fully connected solutions. And I think one of the things that we talk about all the time and getting removed from this, is we talk about people as this journey just started. For most of the people that we speak to about this, their journey has been lifelong. They started to getting judged in seventh grade and now they're in their forties. So for them to look at themselves in the mirror and say, "Diet and lifestyle hasn't worked for me for 35 years? Why would it work now? And so why would you put me through another six months of that," is really where the reality of most of this journey is. And so when we look at, how do you do that comprehensively? It is also a social and societal game too, that we have to start playing. Rae Woods (27:51): Yes. Rita Glaze-Rowe (27:51): And one of the people who came very strongly and said, "It costs us nothing to change how we talk about obesity." Rae Woods (28:00): Yeah. And I'll tell you from the health system perspective, every single business leader that I speak to on the provider side is thinking about, how do we create a comprehensive weight management program? Frankly, a lot of them are thinking about this as a way to create different channels to other parts of their business. And I do even mean changing the pathways for their own surgical volumes. I don't just mean bariatric surgery. Rita Glaze-Rowe (28:20): Because they've invested in those lines of service. They've invested in bariatric care and they've invested in those lines of service. So now they look at it from that community perspective to say, "How do I have this?" And there's a lot of consensus building that needs to take place too. Clinical consensus building around then what those pathways should be. So we have yet to see that. Rob MacNaughton (28:39): And I think this is a microcosm of a bigger issue. At Calibrate, we wish and try to collaborate with PCPs as much as possible. To your point, PCPs are overwhelmed, and as our health system becomes far more specialized, you now have more specialists focusing on certain conditions and certain elements, it's becoming more fractured. And it's making the comprehensive collaborative care effort more difficult. And frankly, as a healthcare sector, that's where I think the hope and intent of technology, interoperability, and speaking as a provider organization, we don't feel the tools are there yet. Rae Woods (29:15): And on that note, I want to channel, there's a cynic in the audience who I love. I love a good cynic, as a self-described cynic myself. I want to ask, why should we actually believe this is possible, right? We know that obesity and chronic disease has grown virtually unchecked over the last several decades. Why should we believe now, that comprehensive weight management is actually possible, given all of the challenges within the current delivery system? Spencer Nadolsky (29:43): Yeah, I mean, we talk about comprehensive delivery system, but these drugs are going to be doing a lot of the heavy lifting. We just have to support them. Rae Woods (29:51): So what's changed, is the drugs themselves? Spencer Nadolsky (29:52): The drugs, it's just ridiculous what's coming down the pipeline. These newer drugs are just going to melt the fat off of people. And I'm worried that some of the wrong people are going to take them and end up basically skeletons walking around, this is how good these things work. So these drugs, they're going to be so abundant five to 10 years, we'll look back at these conversations of compounding and all this stuff and we'll just laugh at how this is like the wild west. These companies, manufacturers are going to come out with newer and newer, better versions of these things. Rob MacNaughton (30:20): And the CDC just released information. Last week, obesity in the U.S. went down for the first time possibly ever. Again, we're not hanging the mission accomplished banner up yet by any stretch of the imagination. But I think the last study was it was at 42.9% and now it's at just over 40%. So it has ticked down and it's certainly been timed with I think the rise of GLP-1s. So we are having an impact. I think the numbers show we're having an impact. Now, much more work to be done, much more evolution in development needed, such that we can touch on your next question of, where do we go from here? Rae Woods (30:59): Yeah. But it does beg the question of in a world where, and I'm going to be blunt here, the traditional healthcare system has failed to deliver comprehensive obesity support to date. We know then, because there are gaps in our system that there are new market entrants that are coming in. There are new drugs, there are new vendors. Rob, I'm looking at you over here. There are new partners that are coming to the table saying, "I can help, not just with the administration of GLP-1s, but with this comprehensive weight management support." Now, the rub is that some of these things maybe should be held sacred to the traditional delivery system. Some should be outsourced. What needs to stay within the traditionals and what should we outsource to the non-traditionals? Spencer Nadolsky (31:44): Yeah, I mean, I think we're going to see healthcare change over the course of this next decade. I think we're seeing innovative ways of delivering healthcare that are just... Do people even need a PCP? I'm a PCP, so... But is it going to start changing to where you just get your care a lot online and you have some in-person doctor for acute care? I think a lot of these innovative ways of delivering healthcare are going to disrupt the system, because academic healthcare systems are where you usually see these comprehensive obesity treatment programs, but they're not scalable. They're only in metropolitan areas. Rae Woods (32:19): Sure. Spencer Nadolsky (32:20): So what about the person in a rural area? They go to a telemedicine place, where they can finally get access to these, because their primary care doctor doesn't have enough time for them or can't even get them in. Rae Woods (32:29): And let's be clear, they're solving actual gaps for those patients, for those users. So then perhaps the question is, how do we prevent fragmentation? I know that the traditional delivery system is not exactly known for being frictionless. So then if we have different partners who are providing different aspects of care, maybe even purposely, right? Spencer, you said, "I don't have time or know necessarily how to do the same thing that a dietician or an exercise physiologist can do." As we have more players that are filling reasonable gaps in the system, how do we prevent fragmentation? Rita Glaze-Rowe (33:00): Can we answer the cynic for a second? Rae Woods (33:01): Yes, please. Spencer Nadolsky (33:02): Yeah, go do it. Rita Glaze-Rowe (33:03): We haven't talked about incentives. We haven't talked about aligning the incentives to get to that comprehensive. Because the more we have, what we will deem to be traditional, along with different doors to enter that system, we also have to make sure that the incentives are aligned to deliver that care in a way that gets us to the health goals, and we don't. Rae Woods (33:28): In the right timing too. Rita Glaze-Rowe (33:29): In the right timing. Rob MacNaughton (33:31): Again, I think it's a microcosm of a bigger issue. As healthcare, we've become more specialized, which is good, because you have a higher degree of expertise and understanding of a given condition. And if done appropriately, you can treat more people. There is scales about specialization and focus. And to your point, it comes down to economies. If someone is underwriting the cost of healthcare, they're going to look for that. And so there may be this internal dissonance or friction as specialization increases and the need for collaborative care increases. But the glue in the system isn't there yet. I am hopeful, optimistic, largely for incentive reasons, that there will be a solve for this. Rae Woods (34:18): Yes. Rob MacNaughton (34:19): I just don't know if an incumbent or a player in one of those specialist areas can make the investment necessary to be the collaborative glue across all sectors. Rae Woods (34:29): To that note, then, do we think that these partnerships between the traditionals, the non-traditionals... And by the way, when I say non-traditionals, I don't just mean vendor partners, I mean folks that we typically just think of as being outside of healthcare, nutrition actually being one of them, physical activity, exercise physiologist being one of them. Is this a temporary stepping stone, these new partnerships? Or do we think we're describing a more permanent way of moving forward and thinking about the very way that we address obesity as a healthcare system? Spencer Nadolsky (35:00): Yeah, I mean, you go to other countries, it's more like this socialized healthcare and everybody has the same EMR and they all talk to each other. You put some note in it, everybody in that country can see it. Ideally, all of our EMRs would all talk to each other. You put a note in whatever EMR you're using, it would be able to transfer to whoever else is using a different EMR. I think that's the concept. I know a lot of people are trying to do that with these health information exchanges. But if we can move forward with that, that would be great. Because I don't want to use Epic necessarily, or someone else doesn't want to use XYZ. How to get there though? I don't know. Rita Glaze-Rowe (35:33): Can we talk about the generational force as well? Rae Woods (35:35): Sure. Rita Glaze-Rowe (35:35): So we've got younger generations who are coming in, who are already living a little bit healthier, and they're also demanding more from our healthcare systems. Rae Woods (35:45): Yes. Rita Glaze-Rowe (35:45): Demanding more. And we're seeing that more and more. So as we see this come together, we're going to see these natural inflection points, where they just won't stand for [inaudible 00:35:56]C Rae Woods (35:56): So maybe you think permanent, maybe you think the traditional healthcare system has failed this new generation, and so we're going to see more folks like calibrate that are saying, "Here are the four pillars that we need to provide to real people in order to create sustainable results." Rita Glaze-Rowe (36:08): Because it becomes about relationships because that's what they're looking for. They're looking for those relationships. And PCPs who have five minutes aren't going to be able to deliver on that relationship around their care. Rae Woods (36:18): Or deliver on their goal, right? Rita Glaze-Rowe (36:19): Or deliver on their goal. Rae Woods (36:20): As we started off with what Spencer said, is their goals. Rita Glaze-Rowe (36:23): And their goals can be individualized, so are we going to get to that personalization? Rob MacNaughton (36:25): Spencer said something that registered with me and it was to the effect that healthcare is going to change over the next decade. And I think it's going to change profoundly. I'm not necessarily certain how. I do feel good about Calibrate's positioning in this space, but the point is, and I think it actually lends to your notion of incentives, is that there are incumbent players today that have revenue and profit pools. And then based on their dynamics, that will essentially determine their appetite for partnership, collaboration and progress. And I can't tell you how that's going to play out, because I think a large number of incumbent players will have very different philosophies and strategy. It will be exciting. I'm not sure I know where that direction goes, but to your point, I'm pretty confident it's going to change a lot in the next decade. Rae Woods (37:13): Let's go there last. Before we wrap up our session, I have two rapid fire questions that I want to ask each of you. We started off this conversation talking about goals and almost naming how patients, healthcare systems and purchasers might have slightly different goals. Let's do this rapid fire. How will we know when we're actually successful as an industry? And maybe you can even predict when that might happen. Spencer Nadolsky (37:36): I think when everybody who needs access gets access. Rae Woods (37:40): To GLP-1s? Spencer Nadolsky (37:42): Or whatever comes down the pipeline. Yes. Rae Woods (37:45): Rita? Rita Glaze-Rowe (37:45): We start to achieve actual population health goals, where we start to see that we maybe can fly a small [inaudible 00:37:52]. Rob MacNaughton (37:54): A line where we see pervasive improved healthcare outcomes and ideally, the total cost of care in this country goes down. To me, that's the win, because then it becomes sustainable. And then you get to have the true population health metric improvement across, not only body weight loss, but the myriad of other metabolic metrics that enhance people's lifestyle or quality of life and just dramatically reduce other chronic conditions materially. Rae Woods (38:23): If that's where we ultimately need to get, what is coming next when it comes to comprehensive weight management, that you want everyone in our audience and everyone listening at home to know, so that they can take action at their organization? Spencer Nadolsky (38:34): These drugs will enable the behavior change, but they won't do the behavior change. You just need to nudge them into that once they have that drug with them. Rita Glaze-Rowe (38:43): We need to continue to have this conversation and make it be meaningful for the people we're trying to treat. Rae Woods (38:49): Yep. Rob MacNaughton (38:49): Absolutely. And these GLP-1 drug therapies, as well as literally hundreds that are probably in the pipeline right now, we believe that they're best utilized in concert with lifestyle intervention and coaching. They don't solve for it, but they certainly enable it. Rae Woods (39:05): Well, thank you so much for joining me at the HLTH stage and on Radio Advisory. (39:16): My biggest takeaway from that conversation, is that I'm not sure that when it comes to weight management, we are all operating towards the same goal. Does everyone need to be on GLP-1s? What are the essential elements of comprehensive weight management? And who really needs to be providing that support? Look, we may be at a moment where there are still more questions than answers, but that doesn't mean that we can afford to wait. There's just too much demand, too much excitement and too much at stake. We have to come together to address comprehensive weight management. And remember, as always, we are here to help. (40:11): New episodes drop every Tuesday. If you like Radio Advisory, please share it with your networks, subscribe wherever you get your podcasts and leave a rating and a review. Radio Advisory is a production of Advisory Board. This episode was produced by me, Rae Woods, as well as Abby Burns, Chloe Bakst and Atticus Raasch. The episode was edited by Katy Anderson. With technical support provided by Dan Tayag, Chris Phelps, and Joe Shrum. Additional support was provided by Leanne Elston and Erin Collins. We'll see you next week. Abby Burns (40:52): Hi, it's Abby Burns co-host of Radio Advisory. This episode is coming to you on election day. As you probably noticed, we didn't do any election coverage or speculation today. But later this month, we'll have two post-election episodes that'll unpack the outcomes and their implications for healthcare. On November 19th, we'll be breaking down what the presidential, congressional and state elections results mean for healthcare leaders. And then on November 26th, we'll do a deeper dive into the healthcare policies that you might need to pay attention to in the upcoming year. In the meantime, you can visit advisory.com to get all of Advisory Board's elections coverage. You can also register for Advisory Board's post-elections webinar on December 17th. The links are in the show notes.