
有什么是GLP-1類藥物做不到的呢,?糖尿病和肥胖癥被越來越多地認(rèn)為只是冰山一角。美國食品藥品管理局(Food and Drug Administration,,F(xiàn)DA)已批準(zhǔn)Wegovy用于治療心血管疾病,,目前研究人員正在研究GLP-1類藥物治療多種病癥的潛力,包括哮喘,、關(guān)節(jié)炎和牛皮癬,、某些類別的肝臟疾病、抑郁癥,、眼科疾病、阿爾茲海默癥和物質(zhì)使用障礙等,。最近的一項(xiàng)研究甚至發(fā)現(xiàn),,GLP-1類藥物可以降低10種不同癌癥的患病風(fēng)險(xiǎn)。
GLP-1的適應(yīng)癥越來越多,,這可能意味著這種藥物所針對(duì)的是美國最常見和治療成本最高昂的病癥的根本原因(可能是炎癥),。即使目前正在開展的試驗(yàn)中只有一小部分取得成功,GLP-1類藥物就可能會(huì)顛覆我們對(duì)醫(yī)療保健的認(rèn)知,。
但它們并非萬能,。事實(shí)上,GLP-1現(xiàn)象正在更清楚地暴露出我們的醫(yī)療保健體系的各自為政和功能異常,。就像GLP-1可能幫助我們發(fā)現(xiàn)不同疾病的共同點(diǎn)一樣,,它們也讓我們有機(jī)會(huì)一窺醫(yī)療保健體系出現(xiàn)問題的根本原因。
藥品價(jià)格過于昂貴
在美國,,GLP-1藥物的價(jià)格高達(dá)每年15,000美元,,遠(yuǎn)高于其他富裕國家,這已經(jīng)成為醫(yī)療保健成本上漲的最大原因之一,。私人雇主本就面臨著成本難以為繼的趨勢(shì),,而他們的員工需要報(bào)銷藥物費(fèi)用,但他們實(shí)際上可能已經(jīng)無力承擔(dān),,這令他們倍感壓力,。有研究表明,,如果不進(jìn)行成本控制,GLP-1類藥物的廣泛應(yīng)用可能讓醫(yī)療保險(xiǎn)和整個(gè)醫(yī)療保健體系破產(chǎn),。
GLP-1類藥物還揭露出醫(yī)療保健系統(tǒng)的效率低下和不公平,。那些有能力自付費(fèi)用的人正在大量購買GLP-1類藥物(有些人甚至是出于虛榮心),而依賴醫(yī)療保險(xiǎn)或醫(yī)療補(bǔ)助的人群卻難以獲得這些藥物,。后者患肥胖癥和糖尿病的比例更高,。例如,禮來(Eli Lilly)最近大幅降低Zepbound價(jià)格的舉措僅適用于自費(fèi)患者,;而且即使降價(jià)后每個(gè)月的價(jià)格依舊需要數(shù)百美元,,這仍然令許多人負(fù)擔(dān)不起。
GLP-1類藥物揭示了醫(yī)療保健如何迅速變成一場(chǎng)淘金熱
制藥公司,、遠(yuǎn)程醫(yī)療提供商甚至膳食補(bǔ)充劑銷售商直接向消費(fèi)者銷售GLP-1類藥物,,以滿足迅速增長(zhǎng)的需求。有些提供商利用GLP-1類藥物供應(yīng)短缺所留下的漏洞,,為患者開具復(fù)合型仿制藥,,但美國食品藥品管理局警告這些仿制藥可能并不安全。
這是一個(gè)典型的例子,,說明了交易性遠(yuǎn)程醫(yī)療1.0模式的局限性和消費(fèi)主義泛濫的危險(xiǎn),。患者可以輕松買到復(fù)合型GLP-1類藥物,,即使在某些情況下,,改變生活方式或者其他方法可能在臨床上更加合適。但在交易完成之后,,誰來負(fù)責(zé)患者的健康管理,?誰來幫助患者管理副作用以及他們的整體身心健康?
如果患者因?yàn)榉脧?fù)合型GLP-1類藥物患病,,就得去看急診,,賬單則要由他們的雇主和保險(xiǎn)公司承擔(dān)。在這種情況下沒有贏家,。
碎片化的醫(yī)療保健交付
開具GLP-1類藥物處方的醫(yī)生類型快速增多,。最初作為一種糖尿病藥物,幾乎只有內(nèi)分泌科醫(yī)生可以開具GPP-1類藥物處方?,F(xiàn)在,,心臟科醫(yī)生、整形外科醫(yī)生,、內(nèi)科醫(yī)生甚至精神科醫(yī)生都在給患者開處方,,他們的視角或許與內(nèi)分泌科醫(yī)生不同,而且有時(shí)候在沒有全面了解患者健康狀況的情況下開藥,。不同科室開始制定GLP-1藥物的臨床指南,。
考慮到各醫(yī)療保健??聘髯詾檎那闆r,初級(jí)保健醫(yī)生(PCP)可能為患者開GLP-1類藥物,,用于控制體重,,但患者的心臟科醫(yī)生卻毫不知情,反之亦然,。這種情況的可能性越來越高,。誰來負(fù)責(zé)保證患者的整體健康?誰會(huì)從整體上為了患者和整個(gè)醫(yī)療保健體系而關(guān)注臨床結(jié)果和成本,?
我們真正需要的處方
我認(rèn)為GLP-1確實(shí)是一種神奇的藥物,。但目前尚無定論,而且與此同時(shí),,GLP-1類藥物掀起的熱潮,,正在使醫(yī)療保健體系中的利益相關(guān)者(包括患者、雇主,、保險(xiǎn)公司,、醫(yī)療保健服務(wù)提供商等)面臨不可持續(xù)的臨床和財(cái)務(wù)風(fēng)險(xiǎn)。
從積極的一面來看,,不斷增加的風(fēng)險(xiǎn)以及來自消費(fèi)者和整個(gè)行業(yè)前所未有的關(guān)注,,或許最終能夠修復(fù)已經(jīng)破碎不堪的醫(yī)療保健模式。解決GLP-1類藥物相關(guān)問題的方法,,可能正是我們一直以來所需要的:
? 預(yù)防,。美國在預(yù)防和初級(jí)保健方面的投資,遠(yuǎn)低于其他富裕國家,。增加初級(jí)保健和心理健康服務(wù)的普及,包括通過虛擬醫(yī)療保健的途徑,,對(duì)于可持續(xù)地解決我們目前使用GLP-1類藥物治療的疾病的上游原因至關(guān)重要,。
? 綜合保健。綜合保健包括初級(jí)保健醫(yī)生與??漆t(yī)生之間以及導(dǎo)診與患者倡導(dǎo)者之間的縱向保健協(xié)調(diào),。考慮到藥物的高成本和管理糖尿病等慢性疾病的挑戰(zhàn),,這些保健團(tuán)隊(duì)成員提供的全面財(cái)務(wù)和行政支持尤為重要,。
? 基于結(jié)果的支付。最近推動(dòng)將GLP-1類藥物納入醫(yī)療保險(xiǎn)談判是一個(gè)良好的開端,,但這并不是解決醫(yī)療成本趨勢(shì)的靈丹妙藥,。盡管消費(fèi)者對(duì)GLP-1類藥物的需求很高,但研究表明,,多達(dá)三分之二的患者沒有堅(jiān)持使用這些藥物足夠長(zhǎng)的時(shí)間來實(shí)現(xiàn)或維持臨床療效,,這意味著前期成本很高,,但對(duì)患者和醫(yī)療保健購買者幾乎沒有回報(bào)。與重要的臨床和財(cái)務(wù)結(jié)果掛鉤的商業(yè)和支付模式——以及激勵(lì)合理處方和綜合護(hù)理以提高依從性和長(zhǎng)期療效——是減少浪費(fèi)并實(shí)現(xiàn)GLP-1類藥物全部?jī)r(jià)值的關(guān)鍵步驟,。
GLP-1類藥物具備改變醫(yī)學(xué)的潛力,。但如果我們繼續(xù)將它們硬塞進(jìn)我們分散和碎片化的醫(yī)療系統(tǒng),它們的潛力將受到限制,。這再次表明,,我們需要從頭開始重新構(gòu)想醫(yī)療保健體系。(財(cái)富中文網(wǎng))
本文作者歐文·特里普現(xiàn)任Included Health公司聯(lián)合創(chuàng)始人兼CEO,。
譯者:劉進(jìn)龍
審校:汪皓
在9月24日召開的藥品定價(jià)聽證會(huì)上,,美國參議院衛(wèi)生、教育,、勞工與退休金委員會(huì)主席伯尼·桑德斯(弗吉尼亞州獨(dú)立參議員)發(fā)表開場(chǎng)詞,。Chip Somodevilla - Getty Images
有什么是GLP-1類藥物做不到的呢?糖尿病和肥胖癥被越來越多地認(rèn)為只是冰山一角,。美國食品藥品管理局(Food and Drug Administration,,F(xiàn)DA)已批準(zhǔn)Wegovy用于治療心血管疾病,目前研究人員正在研究GLP-1類藥物治療多種病癥的潛力,,包括哮喘,、關(guān)節(jié)炎和牛皮癬、某些類別的肝臟疾病,、抑郁癥,、眼科疾病、阿爾茲海默癥和物質(zhì)使用障礙等,。最近的一項(xiàng)研究甚至發(fā)現(xiàn),,GLP-1類藥物可以降低10種不同癌癥的患病風(fēng)險(xiǎn)。
GLP-1的適應(yīng)癥越來越多,,這可能意味著這種藥物所針對(duì)的是美國最常見和治療成本最高昂的病癥的根本原因(可能是炎癥),。即使目前正在開展的試驗(yàn)中只有一小部分取得成功,GLP-1類藥物就可能會(huì)顛覆我們對(duì)醫(yī)療保健的認(rèn)知,。
但它們并非萬能,。事實(shí)上,GLP-1現(xiàn)象正在更清楚地暴露出我們的醫(yī)療保健體系的各自為政和功能異常,。就像GLP-1可能幫助我們發(fā)現(xiàn)不同疾病的共同點(diǎn)一樣,,它們也讓我們有機(jī)會(huì)一窺醫(yī)療保健體系出現(xiàn)問題的根本原因。
藥品價(jià)格過于昂貴
在美國,,GLP-1藥物的價(jià)格高達(dá)每年15,000美元,,遠(yuǎn)高于其他富裕國家,這已經(jīng)成為醫(yī)療保健成本上漲的最大原因之一,。私人雇主本就面臨著成本難以為繼的趨勢(shì),,而他們的員工需要報(bào)銷藥物費(fèi)用,,但他們實(shí)際上可能已經(jīng)無力承擔(dān),這令他們倍感壓力,。有研究表明,,如果不進(jìn)行成本控制,GLP-1類藥物的廣泛應(yīng)用可能讓醫(yī)療保險(xiǎn)和整個(gè)醫(yī)療保健體系破產(chǎn),。
GLP-1類藥物還揭露出醫(yī)療保健系統(tǒng)的效率低下和不公平,。那些有能力自付費(fèi)用的人正在大量購買GLP-1類藥物(有些人甚至是出于虛榮心),而依賴醫(yī)療保險(xiǎn)或醫(yī)療補(bǔ)助的人群卻難以獲得這些藥物,。后者患肥胖癥和糖尿病的比例更高,。例如,禮來(Eli Lilly)最近大幅降低Zepbound價(jià)格的舉措僅適用于自費(fèi)患者,;而且即使降價(jià)后每個(gè)月的價(jià)格依舊需要數(shù)百美元,,這仍然令許多人負(fù)擔(dān)不起。
GLP-1類藥物揭示了醫(yī)療保健如何迅速變成一場(chǎng)淘金熱
制藥公司,、遠(yuǎn)程醫(yī)療提供商甚至膳食補(bǔ)充劑銷售商直接向消費(fèi)者銷售GLP-1類藥物,,以滿足迅速增長(zhǎng)的需求。有些提供商利用GLP-1類藥物供應(yīng)短缺所留下的漏洞,,為患者開具復(fù)合型仿制藥,,但美國食品藥品管理局警告這些仿制藥可能并不安全。
這是一個(gè)典型的例子,,說明了交易性遠(yuǎn)程醫(yī)療1.0模式的局限性和消費(fèi)主義泛濫的危險(xiǎn),。患者可以輕松買到復(fù)合型GLP-1類藥物,,即使在某些情況下,,改變生活方式或者其他方法可能在臨床上更加合適。但在交易完成之后,,誰來負(fù)責(zé)患者的健康管理,?誰來幫助患者管理副作用以及他們的整體身心健康?
如果患者因?yàn)榉脧?fù)合型GLP-1類藥物患病,,就得去看急診,,賬單則要由他們的雇主和保險(xiǎn)公司承擔(dān),。在這種情況下沒有贏家,。
碎片化的醫(yī)療保健交付
開具GLP-1類藥物處方的醫(yī)生類型快速增多。最初作為一種糖尿病藥物,,幾乎只有內(nèi)分泌科醫(yī)生可以開具GPP-1類藥物處方?,F(xiàn)在,心臟科醫(yī)生,、整形外科醫(yī)生,、內(nèi)科醫(yī)生甚至精神科醫(yī)生都在給患者開處方,,他們的視角或許與內(nèi)分泌科醫(yī)生不同,而且有時(shí)候在沒有全面了解患者健康狀況的情況下開藥,。不同科室開始制定GLP-1藥物的臨床指南,。
考慮到各醫(yī)療保健專科各自為政的情況,,初級(jí)保健醫(yī)生(PCP)可能為患者開GLP-1類藥物,,用于控制體重,但患者的心臟科醫(yī)生卻毫不知情,,反之亦然,。這種情況的可能性越來越高。誰來負(fù)責(zé)保證患者的整體健康,?誰會(huì)從整體上為了患者和整個(gè)醫(yī)療保健體系而關(guān)注臨床結(jié)果和成本,?
我們真正需要的處方
我認(rèn)為GLP-1確實(shí)是一種神奇的藥物。但目前尚無定論,,而且與此同時(shí),,GLP-1類藥物掀起的熱潮,正在使醫(yī)療保健體系中的利益相關(guān)者(包括患者,、雇主,、保險(xiǎn)公司、醫(yī)療保健服務(wù)提供商等)面臨不可持續(xù)的臨床和財(cái)務(wù)風(fēng)險(xiǎn),。
從積極的一面來看,,不斷增加的風(fēng)險(xiǎn)以及來自消費(fèi)者和整個(gè)行業(yè)前所未有的關(guān)注,或許最終能夠修復(fù)已經(jīng)破碎不堪的醫(yī)療保健模式,。解決GLP-1類藥物相關(guān)問題的方法,,可能正是我們一直以來所需要的:
? 預(yù)防。美國在預(yù)防和初級(jí)保健方面的投資,,遠(yuǎn)低于其他富裕國家,。增加初級(jí)保健和心理健康服務(wù)的普及,包括通過虛擬醫(yī)療保健的途徑,,對(duì)于可持續(xù)地解決我們目前使用GLP-1類藥物治療的疾病的上游原因至關(guān)重要,。
? 綜合保健。綜合保健包括初級(jí)保健醫(yī)生與??漆t(yī)生之間以及導(dǎo)診與患者倡導(dǎo)者之間的縱向保健協(xié)調(diào),。考慮到藥物的高成本和管理糖尿病等慢性疾病的挑戰(zhàn),,這些保健團(tuán)隊(duì)成員提供的全面財(cái)務(wù)和行政支持尤為重要,。
? 基于結(jié)果的支付。最近推動(dòng)將GLP-1類藥物納入醫(yī)療保險(xiǎn)談判是一個(gè)良好的開端,但這并不是解決醫(yī)療成本趨勢(shì)的靈丹妙藥,。盡管消費(fèi)者對(duì)GLP-1類藥物的需求很高,,但研究表明,多達(dá)三分之二的患者沒有堅(jiān)持使用這些藥物足夠長(zhǎng)的時(shí)間來實(shí)現(xiàn)或維持臨床療效,,這意味著前期成本很高,,但對(duì)患者和醫(yī)療保健購買者幾乎沒有回報(bào)。與重要的臨床和財(cái)務(wù)結(jié)果掛鉤的商業(yè)和支付模式——以及激勵(lì)合理處方和綜合護(hù)理以提高依從性和長(zhǎng)期療效——是減少浪費(fèi)并實(shí)現(xiàn)GLP-1類藥物全部?jī)r(jià)值的關(guān)鍵步驟,。
GLP-1類藥物具備改變醫(yī)學(xué)的潛力,。但如果我們繼續(xù)將它們硬塞進(jìn)我們分散和碎片化的醫(yī)療系統(tǒng),它們的潛力將受到限制,。這再次表明,,我們需要從頭開始重新構(gòu)想醫(yī)療保健體系。(財(cái)富中文網(wǎng))
本文作者歐文·特里普現(xiàn)任Included Health公司聯(lián)合創(chuàng)始人兼CEO,。
譯者:劉進(jìn)龍
審校:汪皓
Senate Health, Education, Labor, and Pensions Committee Chairman Bernie Sanders (I-VT) delivers opening remarks during a hearing about drug pricing on Sep. 24.
Is there anything GLP-1s can’t do? Diabetes and obesity are increasingly looking like the tip of the semaglutide iceberg. The Food and Drug Administration (FDA) has approved Wegovy for cardiovascular disease, and researchers are now exploring the potential of GLP-1s for a host of conditions, including asthma, arthritis and psoriasis, certain liver diseases, depression, eye disorders, Alzheimer’s, and substance use disorders. A recent study even found GLP-1s may reduce the risk of 10 different cancers.
The growing list of potential GLP-1 indications suggests the drugs may target the root cause (inflammation, probably) of the most prevalent and costly conditions in the U.S. If even a fraction of the trials now underway pan out, GLP-1s have the potential to reshape health care as we know it.
But they can’t solve everything. In fact, the GLP-1 phenomenon is making the fragmentation and dysfunction of our health care system even more apparent. Just as GLP-1s may help us discover the common denominator in seemingly disparate diseases, they are shining a bright light on the root causes of the health care system’s ills.
Drugs are too expensive
The price tag of GLP-1s in the U.S.—up to $15,000 per year, far higher than in other affluent countries—has become one of the single biggest drivers of rising health care costs. Private employers, already facing an unsustainable cost trend, are feeling the pressure from their workforce to cover the drugs, yet they quite literally may not be able to afford it. Some studies suggest widespread GLP-1 adoption, absent cost controls, could bankrupt Medicare and the health care system as a whole.
GLP-1s are also shining a harsh light on the inefficiency and inequity in health care. Those who can afford to pay out of pocket are gobbling up the supply of GLP-1s (in some cases for vanity use), while access remains limited for people on Medicare or Medicaid who are disproportionately burdened by obesity and diabetes. For example, Eli Lilly’s recent move to slash the price of Zepbound only applies to patients paying out of pocket; and at several hundred dollars per month, even the markdown price is out of reach for many.
GLP-1s shows how quickly health care can turn into a gold rush
Pharmaceutical companies, telehealth providers, and even supplement sellers are marketing GLP-1s directly to consumers to meet the runaway demand. Exploiting a loophole resulting from the GLP-1 shortage, some providers are prescribing compounded generic versions of the drugs that the FDA has warned may be unsafe.
This is a prime example of the limitations of the transactional Telehealth 1.0 model and the dangers of consumerism running amok. Patients can easily get compounded GLP-1s, even when lifestyle changes or other approaches are more clinically appropriate. But who is looking after their health once the transaction is complete? Who is helping them manage side effects, as well as their overall physical and mental health?
If patients get sick from compounded GLP-1s, they could end up in the ER—and their employer and insurer foot the bill. In this scenario, no one wins.
Fragmented care delivery
The type of clinicians prescribing GLP-1s has expanded rapidly. In their first act as a diabetes drug, GLP-1s were prescribed almost exclusively by endocrinologists. Now cardiologists, orthopedists, internal medicine physicians, and even psychiatrists are prescribing them—presumably with a different lens than an endocrinologist would, and sometimes without full visibility into the patient’s overall health. Different specialties are starting to establish their own clinical guidelines for GLP-1s.
Given how siloed specialty care is, it’s increasingly likely that a primary care physician (PCP) might prescribe GLP-1s for weight management without the patient’s cardiologist knowing about it—and vice versa. Who’s looking out for the whole person? Who’s looking at clinical outcomes and costs in a holistic way—for that patient, and for the system as a whole?
The prescription we really need
I’m rooting for GLP-1s to be a miracle drug. But the jury is still out, and in the meantime, the GLP-1 frenzy is exposing healthcare stakeholders across the system—patients, employers, insurers, providers—to unsustainable clinical and financial risks.
On the plus side, these mounting risks—and the unprecedented attention from consumers and the industry alike—may finally be what it takes to fix broken health care models. And the solutions to the problems surrounding GLP-1s are the same ones we’ve needed all along:
? Prevention. The U.S. invests far less in preventive and primary care than other affluent nations. Increasing access to primary care and mental health services—including through virtual care—is essential to sustainably address the upstream causes of the conditions we’re now treating with GLP-1s.
? Integrated care. This includes longitudinal care coordination between PCPs and specialists, as well as navigators and patient advocates. The wrap-around financial and administrative support these care team members provide is especially important given the high cost of the drugs and the challenges of managing chronic conditions like diabetes.
? Outcomes-based payment. The recent push to include GLP-1s in Medicare negotiations is a good start, but it’s not a silver bullet for the healthcare cost trend. Despite the consumer demand for GLP-1s, studies have shown that as many as two-thirds of patients don’t stick with the drugs long enough to achieve or sustain the clinical benefits, which means substantial upfront costs with little to no payoff for patients and healthcare purchasers. Business and payment models tied to clinical and financial outcomes that matter—and that incentivize judicious prescribing and the integrated care needed to boost adherence and long-term results—are a critical step toward minimizing waste and realizing the full value of GLP-1s.
GLP-1s have the potential to transform medicine. But if we continue shoehorning them into our siloed and fragmented health care system, their potential will be stunted. It’s yet another indication that we need to reimagine the health care system from the ground up.
Owen Tripp is co-founder and CEO at Included Health.