Abby Burns (00:09):
From Advisory Board, we are bringing you A Radio Advisory, your weekly download on how to untangle healthcare's most pressing challenges. I'm Abby Burns.

(00:18):
For a lot of people, obesity treatment is synonymous with GLP-1s. But while the spotlight on drugs like Wegovy can help bring attention and even demand to weight loss services, we don't want it to blind leaders to the other services that go into providing comprehensive obesity care. These drugs can't and shouldn't work in a vacuum.

(00:39):
To help us think through the questions leaders should be asking when it comes to how to design and deliver obesity care and what it looks like in practice, I've invited Advisory Board experts, Chloe Bakst, Atticus Raasch, and Payton Grimes. I'll start my conversation with Chloe. Chloe, welcome back to Radio Advisory.

Chloe Bakst (00:59):
Thanks, Abby. Good to be here.

Abby Burns (01:04):
Chloe, regular Radio Advisory listeners will almost certainly recognize your voice as one of our go-to experts on all things drugs and obesity care. So I wanted to get your take on some of the questions I've been hearing a lot around weight management and specifically around GLP-1s. I feel like the spotlight on this class of medications hasn't really gotten dimmer at all at least since the last time you were on this podcast, talking about them for the first time back in spring of 2023.

Chloe Bakst (01:35):
Yes, I definitely agree. I feel like that spotlight has gotten a lot brighter, and we're seeing that in a lot of different ways. There's new drugs on the market. So when we first started having this conversation, it was just Wegovy was approved, and we were kind of waiting to see what would happen with Lilly's drug. That's now on the market. It's Zepbound. We've seen new indications for Wegovy come into light.

Abby Burns (01:57):
Tons of new indications.

Chloe Bakst (01:58):
Yeah, and there's a bunch more in the works. I think what has sustained a lot of the attention here has been the sustained demand-

Abby Burns (02:08):
Right.

Chloe Bakst (02:08):
From consumers for these products. That's not going away anytime soon.

Abby Burns (02:13):
Exactly. As someone who's focused on this space day in and day out, I wanted to pose to you the two questions that I hear the most frequently. First, from an executive standpoint, what the heck should I do as an employer about covering GLP-1s for my employees? And then the second one is from a provider strategy and planning lens., What are GLP-1s doing to my other obesity services, and specifically are they going to doom my bariatric surgery book of business?

Chloe Bakst (02:48):
First of all, I think that employer question of how is this going to impact employer costs, how should we structure our benefits ... I get those questions all the time. I feel like that's a Radio Advisory episode in and of itself. So I'll probably put a pin in that for now because we are actually doing research related to this topic on how we're seeing employers, payers, drug purchasers start to incorporate ways to align drug spend to value, and I feel like GLP-1s are going to definitely fit in there. So come back to me in three months, and I'll have more to say on that.

Abby Burns (03:20):
Okay, excellent. We'll put the employee coverage question on ice for now. We'll have you back. What about the other questions? How GLP-1s are going to affect other clinical services? Is this fear around drugs displacing bariatric volumes, for example, well-founded?

Chloe Bakst (03:37):
It's such an interesting question because again, I get it a lot. This idea of, okay, GLP-1s and bariatric surgery are kind of in competition with each other, they're adversaries, they're going to steal volumes away from one another, which might be true in some cases. I remember hearing from a colleague who went to our June summit this past summer who was at a table with two different health systems, one who reported, "We're seeing our bariatric surgery volumes plummet since the rise in popularity of GLP-1s." Person next to them said, "Wow, that's so interesting. We've seen demand for bariatric surgery boom because people are more interested in weight management solutions. We actually had to hire two new bariatric surgeons."

Abby Burns (04:19):
Wow. Those are two very different reactions.

Chloe Bakst (04:22):
Two very different reactions, and we're seeing this continue to play out in the market as different health systems are starting to consider closing down their bariatric surgery departments because they're afraid they're going to lose volumes from GLP-1s.

(04:34):
So I think the conversation around will GLP-1s pull volumes away from bariatric surgery is missing the forest for the trees because what we should be thinking about is how can we build or consider obesity services, weight management services, as a holistic service line approach or programmatic approach that incorporates both of these elements. Because GLP-1s are really powerful drugs, but they can't operate in a silo, and they're not the silver bullet for the obesity epidemic, as we've said on this podcast earlier. So I think that one push I have for folks who have that real fear is to think more broadly about ways that you can make these two approaches to weight management complement one another.

Abby Burns (05:23):
Sounds like you're saying it's how you deploy the services, how you design and deploy the services more so than the services themselves.

Chloe Bakst (05:31):
Absolutely.

Abby Burns (05:32):
This is where I want to bring in our colleagues, Payton Grimes and Atticus Raasch from Advisory Board's custom research team because they've actually studied what comprehensive weight management programs, which is the programmatic approach you're talking about, actually look like in practice. Payton, Atticus, welcome to Radio Advisory.

Payton Grimes (05:51):
Thanks, Abby. We're happy to be here.

Atticus Raasch (05:52):
Happy to be here.

Abby Burns (05:55):
You two recently did some research around what different comprehensive weight management programs look like. Before we talk about what you found, I'm wondering if you can explain kind of the rationale behind why we need to be talking about programs. That's the language push that Chloe just made for us. Why isn't it enough to just talk about the range of obesity services?

Payton Grimes (06:19):
Yeah, Abby, I think that's a great question, and it's a question that so many leaders are grappling with right now. I think that was the impetus behind the work that Atticus and I did. I actually think it's easiest to describe why it's so important by comparing it to the status quo for obesity care in a lot of places.

Abby Burns (06:36):
Okay.

Payton Grimes (06:36):
So if you imagine a patient is getting connected to obesity care, that usually happens through a PCP.

Abby Burns (06:42):
Primary care physician.

Payton Grimes (06:44):
Exactly. That's often the first point of contact or the way that patients are funneled into a more weight management specific specialty. Because of what we were talking about about bariatric surgery traditionally being the major form of care for weight management care, say a patient sees their PCP, they're referred to a surgery specialist, they have to jump through all the different hoops that are involved between the PCP's visit and then eventually the surgery visit. There's a lot of steps involved in that process, and it can take a lot of time, and there is a potential case that the patient is then seen by the surgery specialist and realize they're not a great fit for surgery. In that case, since they're directly referred to a surgeon, rather than having all the other options for comprehensive obesity care kind of presented within a unified holistic program, they then miss out on all the other options that they could have been a better fit for.

Abby Burns (07:35):
So it's essentially surgery or bust in that case. You all did a market scan of some of these comprehensive weight management programs. What can you tell us about what these programs look like?

Atticus Raasch (07:48):
The challenge here with the market scan than we did, and something I really want to emphasize, is that no two programs look the same. I know that's not always the most exciting thing to say, but it's absolutely true. When we did the research and we talked to a lot of these programs, what we found is that they'll often include some mixture of a few key elements, some of which Payton just touched on.

(08:08):
So those might look like things like lifestyle and behavioral support, so physician counseling or maybe diet and nutrition support. They'll include pharmacotherapy. So this would include GLP-1s, maybe even GLP-1 specific nutrition or exercise classes. They might include different surgical interventions as needed like bariatric surgery or different types of support for patients that are preparing for bariatric surgery. And they might also provide services for common comorbid conditions. So that might look like giving referral pathways to specialists for some of those common conditions or tailored support to those patients who need extra support.

(08:47):
But at the end of the day, sort of regardless of the mix of services and there's really so many, sometimes it feels like too many to count that are offered across country, what we found is that they have a couple of really key things in common.

Abby Burns (09:00):
What are some of those?

Atticus Raasch (09:02):
The first is that they take into account a complete picture of the patient's health. They might include a range of social support or economic support, things that really take into account the complete picture of a patient's health journey.

(09:16):
The second one, and what we feel is one of the real big assets of these comprehensive programs is how they are centralized. So they're able to take all of these different range of services that might be siloed or might be fragmented across the system, and they're able to bring them together to create a really positive experience for the patient. This is something that when organizations can do it effectively, it can be good not just for patients, but also for clinicians and for the system as a whole.

Abby Burns (09:46):
Okay. I definitely want to dig into what you mean by that. Anytime I hear a win-win-win, my radar goes off. But first, all the services that you listed, I agree, those are a lot of services to have in place, and yet they sound more or less straightforward. It's a lot of things that I would expect to hear in a lot of different population health management programs. But I'm guessing if this was easy to create, then having a comprehensive weight management program would be more or less standard practice for how organizations deliver obesity care, which Payton just told me is not the case. Why is this hard to do?

Chloe Bakst (10:24):
Well, I think first of all, it's hard to put a lot of money and resources and energy into a program that you're not sure what the ROI is.

Abby Burns (10:32):
Is that the case with comprehensive weight management programs?

Chloe Bakst (10:34):
Yes, because insurance coverage is so variable in this space. A lot of commercial providers don't cover certain weight management drugs. There's a lot of hoops that jump through to get bariatric surgery covered. We know that Medicare doesn't cover weight management drugs, so there's a fear from a lot of health systems that I speak with of putting a lot of eggs in this basket when they're not sure if they're going to be able to get reimbursement for a lot of these services.

Abby Burns (11:01):
That feels like a pretty big one.

Payton Grimes (11:04):
Yeah, I think going off that point, Chloe, there's the financial piece of ROI, but there's also the clinical piece of ROI. Return on investment isn't just a money thing anymore, especially in the age of payment transformation. So much of that is based on clinical outcomes.

(11:22):
For obesity specifically, it's a disease state that takes a long time to see if the services and the care that's going in is actually making a difference. So provider organizations aren't seeing a very quick immediate return on investment in terms of care, investment being the outcomes for their patients. So it creates a cycle where then if they don't have the outcomes to back up the care that they're providing, then it's even harder to justify reimbursement when negotiating with payers.

(11:51):
Abby, shifting gears a little bit, but another thing that makes comprehensive weight management care so challenging is that treating obesity as a disease state is tricky to do. Part of the holistic treatment is the fact that there are so many external factors that are outside of the control of the clinician that they're not able to kind of inflect within the walls of a doctor's office. Even the factors that are involved in clinical care within the walls of the doctor's office live all over a health system or a hospital. They're not all in one place.

Abby Burns (12:21):
Oh. I think that makes a lot of sense when we're thinking about a lot of times obesity is not the only clinical condition that someone has. They also have hypertension, they might also have diabetes.

Atticus Raasch (12:32):
Think about it this way, Abby. One organization that we talked to told us that they have nearly 50 different weight management related programs that were spread out across their system.

Abby Burns (12:41):
50? 5-0?

Atticus Raasch (12:43):
5-0. These different programs weren't talking to each other. They were rather siloed, and ultimately they coalesced all of these down to three major departments. So they went from 50 to three in order to bring that centralization that really acts as the lever for these comprehensive programs.

Abby Burns (14:19):
Atticus, I'm glad that you brought us back to the centralization piece because it does seem like there are a lot of headwinds to creating and implementing a comprehensive weight management program. But I have stuck in my head that you told me that if organizations do this right, and I'm putting right in air quotes because I know there's no one right answer, if they do it right, it can serve patients, clinicians, and systems. So to overcome those headwinds, the benefits need to be pretty substantial. I'm always optimistic, but admittedly skeptical of win-win-win situations. Paint the picture for me.

Atticus Raasch (14:57):
Yeah, absolutely. So let's start with patients. I think that in my mind, this is perhaps the most obvious win. Patients are able to get a wide variety of different types of care that they need, often in the same place or with a lot easier patient navigation so they're able to get the help that they need easier.

(15:16):
For clinicians, we know doctors, they want to help their patient. In the story that Payton told earlier, oftentimes a patient might not be clinically eligible or just not the right fit for either bariatric surgery or even GLP-1s, and so with these comprehensive programs, doctors are able to get care to their patients that they might not have been able to offer otherwise.

Abby Burns (15:40):
It sounds like it takes the onus off of, for example, the primary care provider, to know everything, to know whether a patient is most appropriate for GLP-1s or bariatric surgery and essentially gives them a team to work with.

Chloe Bakst (15:54):
Abby, I'm really glad that you framed it like that because we know from our research that 44% of providers don't know how to approach obesity as a topic with their patients, and they feel really uncomfortable and they avoid it. So I think one really powerful benefit to a clinician here is that if you know that somewhere in your health system is a comprehensive obesity program that you can refer your patients to and you know that there's clear patient navigation and that there's communication between that hub and you as a separate physician, that creates such a clear pathway and almost a relief to a provider who has probably been saying to patients for years, "You have to lose weight. Please lose weight," and knows that A, that can be stigmatizing and B, that it's not at all effective. So the idea that you can refer patients to a comprehensive obesity program, I think is a huge benefit for providers.

Abby Burns (16:51):
Yeah, I have to imagine that it would alleviate some of the burnout, maybe even the moral injury of, "I want to provide care for my patients, but I can't because of factors outside my control," to revert back to the differences in coverage that you all mentioned earlier. I think that makes a lot of sense from the patient and the clinician angle, but you also said it could help the organization as a whole and holding that right next to the unclear ROI, I'm curious for the case that you'd make that comprehensive weight management programs ultimately can benefit the health systems.

Atticus Raasch (17:22):
Yeah, it's a great question. Something that we saw is that designing comprehensive programs can actually increase referral uptake for a lot of these services that were siloed before and maybe not getting the appropriate utilization.

Abby Burns (17:35):
That reminds me of the story that Chloe told earlier about the system that had to hire an additional bariatric surgeon in response to GLP-1 demand.

Atticus Raasch (17:44):
Absolutely, and one of the things that we know is that more patients are coming in the door because of the demand in GLP-1s, and now kind of like we were talking about earlier, when a primary care provider is faced with a patient who would like weight management support, instead of it being as we said before, bariatrics, meaning GLP-1s or bust, now they can sort of put them into the centralized process to get them the help they need, whether that's through a sleep clinic or nutrition and exercise classes or anything like that. It's almost like a central highway to get patients the help they need as opposed to just maybe some black or white options.

Abby Burns (18:23):
Yeah. I think that's so important, Atticus, because one stat that has always stuck out in my mind is that only 1% of people who are clinically eligible for bariatric surgery actually get it. So then it's always curious to me when I hear the question about is this going to tank my bariatric surgery volumes? Where my mind goes is, it's kind of the idea of all press is good press. If you can get more patients in the door, maybe they see a billboard for Wegovy and they go, "Hey, maybe I have actually more options available to me," maybe that ends up the right clinical avenue if you can get them there is bariatric surgery, so I'm so glad that you brought that up.

Chloe Bakst (19:02):
Yeah, the metaphor we've been using a lot, Abby, is a rising tide lifts all boats.

Abby Burns (19:06):
Yes, exactly. Exactly. Exactly. That actually also makes me think about, Payton, you were talking about the challenge of clinical ROI, and we were talking about how a lot of times patients don't only have obesity, they have obesity and another comorbidity. I also have to imagine that supporting patients' obesity care has positive impacts on their other comorbidities.

Chloe Bakst (19:29):
It's so funny that you say that Abby, I was thinking about, I recently met with a health system who was doing a lot of intensive planning around how they can de-silo their existing weight management offerings and create this comprehensive program, and I was looking at the list of attendees who were at this meeting and looking at all the different service lines that are present, and I counted at least nine, and I could have missed some.

Abby Burns (19:55):
Wow.

Chloe Bakst (19:55):
And so that's everything from pediatrics to nephrology. So when I think about the clinical sequelae of what could happen from a really strong comprehensive obesity program that brings in ... I mean, Atticus mentioned sleep services, he mentioned nutrition ... I mean, the ROI might be difficult to calculate from a clinical perspective, but its potential certainly feels profound.

Abby Burns (20:21):
Yeah. I think where my mind goes with that is I think about 90% of people with type 2 diabetes, for example, are either overweight or living with obesity, and we know that diabetes is one of the most common clinical conditions in the country. So I think the opportunity for impact is not just really big at the individual level, but at the population level.

Payton Grimes (20:41):
So we got just a little bit bigger. We went from patients to clinicians to system, and now we're helping all populations.

Abby Burns (20:48):
On that note, I want to wind down our time with some actionable advice. There is clearly so much value we can unlock with comprehensive weight management at all those different levels. That value evaporates if programs aren't built in a way to compound the value of each individual service rather than pit them against each other. What is it that systems need to do in order to put themselves in a position to unlock that value?

Payton Grimes (21:15):
Yeah. I think there's a couple of different recommendations we can give here. But starting with scale what works. Build on the existing obesity services that already exist within your system or expand into related services. Abby, you were just talking about how diabetes support is really integral to holistic care in this space and include obesity care, more holistic comprehensive obesity care, within your diabetes services. I think by leveraging existing capabilities and prioritizing what your system is already good at, you can look for opportunities to build out in those areas. As you continue to grow, you'll have more opportunities to partner or invest in order to expand those capabilities over time.

Atticus Raasch (21:57):
Building off that, we'd also say keep the patients in the system. We've been spending some time talking about sort of new patient capture as a result of perhaps buzz from things like GLP-1s, but if you're a program who has some of these fragmented services, you have lots and lots of patients already within your system that could really benefit from this kind of comprehensive approach. If your options are hard to navigate and not comprehensive, then there's really not much of a reason why those patients would stay. So that's why we'd recommend to work to keep patients in the system.

Payton Grimes (22:30):
There's lots of tools nowadays to help health systems do that, and without taking the lid off of the whole AI jar, I would just point to the fact that there's so many ways to survey existing systems and find patients within your own systems who are ripe for an intervention.

Chloe Bakst (22:46):
I totally agree with both Payton and Atticus. The last two things I would add to this. One is we've been talking a lot about comprehensive obesity care services, and that's obviously the end goal of what we're working towards, but this will take time and it's okay to start small.

Abby Burns (23:03):
Yes. Important point.

Chloe Bakst (23:05):
Yeah. I don't want health system strategy leaders to leave this podcast episode and feel really overwhelmed or too stressed to take on this idea or this concept. I think a way to make this feel more tangible is to just really understand the market that you're in and the care that your specific patient population needs. I've spoken with health systems who are exploring compounding their own versions of GLP-1 because in their area the biggest issue is access to medications because of shortages. I've spoken to others who know that wellness is a huge priority for their patient population, and so they're exploring ways to create out-of-pocket programs, subscription models where patients can interact with different providers on their wellness journey that incorporates weight loss but is not necessarily focused on it.

Abby Burns (23:58):
Yeah. It really comes down to understand the patients that you're serving and what they need and will engage with. Well, Atticus, Payton, Chloe, thank you for coming on Radio Advisory.

Payton Grimes (24:10):
Thanks for having us.

Atticus Raasch (24:11):
Thanks for having us.

Abby Burns (24:18):
What I take from this conversation is that the question shouldn't be what are GLP-1s going to do to my surgical volumes, but how can I harness the attention from GLP-1s and structure my obesity care services to work together? If this is a question you're grappling with, we have resources you can turn to, and as we continue to learn more about obesity management, we'll continue to share. Because remember, as always, we're here to help.

(25:06):
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 Advice Board. This episode was produced by me, Abby Burns, as well as 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 Carson Sisk, Leanne Elston, and Erin Collins. Special thanks to Kara Marlatt. We'll see you next week.