---
status: seed
type: musing
stage: developing
created: 2026-03-12
last_updated: 2026-03-12
tags: [glp-1, value-based-care, medicare-advantage, drug-economics, prevention-economics, research-session]
---

# Research Session: GLP-1 Agonists and Value-Based Care Economics

## Research Question

**How are GLP-1 agonists interacting with value-based care economics — do cardiovascular and organ-protective benefits create net savings under capitation, or is the chronic use model inflationary even when plans bear full risk?**

## Why This Question

**Priority justification:** This follows the gap flagged in the March 10 session ("GLP-1 interaction with MA economics") and directly tests the attractor state thesis. If the most important new drug class is inflationary even under capitated models, the "prevention-first system that profits from health" faces a serious complication.

**Connections to existing KB:**
- Existing claim rates GLP-1 net cost impact as "inflationary through 2035" — but this was written from a system-wide perspective, not from the capitated plan perspective where downstream savings accrue to the same entity bearing drug costs
- MA economics research from March 10 showed MA is VBC in form but misaligned in practice — how does GLP-1 prescribing behavior differ under genuine full risk vs. coding-arbitrage MA?
- The attractor state thesis depends on prevention being economically viable under aligned payment — GLP-1s are the largest test case

**What would change my mind:**
- If capitated plans are actively embracing GLP-1s AND showing improved MLR, that strengthens the attractor state thesis
- If even capitated plans are restricting GLP-1 access due to cost, that complicates the "aligned incentives → better outcomes" story
- If cardiovascular/organ-protective benefits are large enough to offset drug costs within 3-5 years under capitation, the "inflationary through 2035" claim needs updating

## What I Found

### The Core Finding: GLP-1 Economics Are Payment-Model-Dependent

The existing KB claim ("inflationary through 2035") is correct at system level but misleading at payer level. The answer to whether GLP-1s are inflationary depends on WHO is paying and OVER WHAT TIME HORIZON:

**System-level:** Inflationary. CBO projects $35B additional federal spending over 2026-2034. Volume growth outpaces price compression. This is what the existing claim captures.

**Risk-bearing payer level:** Potentially cost-saving. Value in Health modeling shows Medicare net savings of $715M over 10 years when multi-indication benefits are counted. Aon employer data shows medical cost growth reverses after 12 months of sustained use. The SELECT trial exploratory analysis shows 10% reduction in ALL-CAUSE hospitalizations — the single largest cost driver.

**The temporal dimension is key:** Aon data shows costs go UP 23% in year 1 (drug costs dominate), then grow only 2% vs. 6% for non-users after 12 months. Short-term payers see only costs; long-term risk-bearers capture savings. This directly maps to the VBC payment model question.

### Five Key Tracks

**Track 1: Multi-Organ Protection (Beyond Weight Loss)**

GLP-1s are no longer just weight loss drugs. Three major organ-protection trials:
- SELECT: 20% CV event reduction, 10% fewer all-cause hospitalizations, 11% fewer hospital days
- FLOW: 24% reduction in major kidney events, 29% reduction in CV death, slowed eGFR decline by 1.16 mL/min/year (delays dialysis at $90K+/year)
- MASH Phase 3: 62.9% resolution of steatohepatitis vs. 34.3% placebo

Plus unexpected signals: Aon reports 50% lower ovarian cancer incidence and 14% lower breast cancer in female users (preliminary but striking).

The multi-organ protection reframes GLP-1s from "weight management drug" to "metabolic disease prevention platform." The cost-benefit calculation changes dramatically when you add kidney protection ($2,074/subject avoided CKD), liver protection ($28M MASH savings in Medicare), and cancer risk reduction on top of CV benefits.

CLAIM CANDIDATE: GLP-1 agonists protect at least three major organ systems (cardiovascular, renal, hepatic) through mechanisms partially independent of weight loss, making them the first drug class to address metabolic syndrome as a unified disease rather than treating its components separately.

**Track 2: Adherence — The Binding Constraint**

The economics only work if patients STAY ON the drug. They mostly don't:
- Non-diabetic obesity: 32.3% persistent at 1 year, ~15% at 2 years
- Diabetic: 53.5% at 1 year, ~30% at 2 years
- Weight regain after stopping: average 9.69 kg, all weight lost reversed after 1.7 years

This creates a paradox: chronic use makes GLP-1s expensive, but discontinuation eliminates the downstream savings that justify the cost. The economics only work if adherence is sustained AND the payer captures downstream savings.

At $245/month (Medicare deal), 12 months of GLP-1 therapy costs $2,940 per patient. If 64.8% discontinue and regain weight (eliminating downstream benefits), the plan loses $2,940 × 0.648 = ~$1,905 per enrolled patient on non-responders. The adherent 35.2% must generate enough savings to cover both their own drug costs AND the sunk costs of non-completers.

CLAIM CANDIDATE: GLP-1 cost-effectiveness under capitation requires solving the adherence paradox — the drugs are only cost-saving for sustained users, but two-thirds of patients discontinue within a year, creating sunk drug costs with no downstream benefit offset.

**Track 3: MA Plans Are Restricting, Not Embracing**

Near-universal prior authorization for GLP-1s under MA (up from <5% in 2020-2023 to ~100% by 2025). This is MA plans actively managing short-term costs, NOT embracing prevention.

This directly contradicts the simple version of the attractor state thesis: "align incentives and prevention follows." MA plans ARE theoretically incentivized to prevent costly downstream events. But they still restrict GLP-1 access because:
1. Short-term budget pressure overrides long-term savings expectations
2. Adherence uncertainty means most patients won't generate savings
3. Member turnover means plans may not capture downstream benefits
4. The VBC is in form only — coding arbitrage dominates actual strategy (March 10 finding)

CLAIM CANDIDATE: Medicare Advantage plans' near-universal prior authorization for GLP-1s demonstrates that capitation alone does not align incentives for prevention — short-term cost management, adherence uncertainty, and member turnover create structural resistance to preventive drug coverage even under full risk.

**Track 4: Policy Is Moving Faster Than Expected**

Three converging policy developments are reshaping the landscape:
1. **Trump/Novo/Lilly deals:** $245/month for Medicare ($50 OOP), $350 general (TrumpRx). ~82% below list price.
2. **CMS BALANCE Model:** First federal payment model explicitly designed to test GLP-1 + VBC interaction. Requires lifestyle interventions alongside medication. Adjusts capitation rates for obesity. Launches May 2026 (Medicaid), January 2027 (Part D).
3. **International generics:** Canada patents expired January 2026. China has 17+ generics in Phase 3. Prices could reach $40-50/month internationally by 2028.

The price trajectory is the single most important variable. At $245/month, cost-effectiveness depends on adherence and downstream savings. At $50/month (international generic prices), GLP-1s are unambiguously cost-effective under ANY payment model. The question is how fast prices converge.

**Track 5: Counter-Evidence — Sarcopenia Risk**

The strongest safety argument against broad GLP-1 deployment in the Medicare population:
- 15-40% of weight lost is lean body mass (muscle, not fat)
- Elderly adults already lose 12-16% of muscle mass with aging
- Weight cycling (start GLP-1 → lose muscle → stop → regain fat but NOT muscle → worse body composition) is the most common outcome given 64.8% discontinuation
- Sarcopenic obesity (high fat + low muscle) affects 10-20% of older adults and increases falls, fractures, disability

This is genuinely concerning: the same drug that prevents CV events may cause sarcopenic disability. For the Medicare population specifically, the net health effect is ambiguous until the sarcopenia risk is better quantified.

### Population-Level Signal

US obesity prevalence declined from 39.9% (2022) to 37.0% (2025) — first population-level decline in recent years. If causally attributable to GLP-1s, this is the largest pharmaceutical impact on a population health metric since vaccines. But the equity concern is real: GLP-1 access skews wealthy/insured.

## Key Surprises

1. **CBO vs. ASPE divergence is enormous.** CBO says $35B additional cost; ASPE says $715M net savings. Both are technically correct but answer different questions. Budget scoring structurally disadvantages prevention.

2. **Diabetes prevention is the largest economic lever, not cardiovascular.** Per-subject savings from avoided T2D ($14,431) dwarf avoided CV events ($1,512), even in a CV outcomes trial.

3. **MA plans are restricting, not embracing.** Near-universal PA for GLP-1s means capitation alone doesn't create prevention incentives. This challenges the simple attractor state thesis.

4. **The temporal cost curve is the key insight.** Costs up 23% in year 1, then slow to 2% growth vs. 6% for non-users. Payment model structure determines whether you see the costs or the savings.

5. **50% ovarian cancer reduction in female GLP-1 users.** If confirmed, this is an entirely new dimension of benefit not captured in any current analysis.

6. **The BALANCE model combines medication + lifestyle.** CMS is explicitly testing whether the combination solves the adherence problem. This is a more sophisticated intervention than simple drug coverage.

## Belief Updates

**Belief 3 (structural misalignment): COMPLICATED.** The GLP-1 + VBC interaction reveals a subtler misalignment than I'd assumed. Capitation creates the THEORETICAL incentive for prevention, but short-term budget pressure, adherence uncertainty, and member turnover create PRACTICAL barriers. The attractor state may require not just payment alignment but also adherence solutions and long-term risk pools.

**Belief 4 (atoms-to-bits boundary): REINFORCED.** The GLP-1 story is partly an atoms-to-bits story — continuous monitoring (CGMs, wearables) could identify the right patients and track adherence, turning GLP-1 prescribing from population-level gambling into targeted, monitored intervention. The BALANCE model's lifestyle component could be delivered through the sensor stack + AI middleware.

**Existing GLP-1 claim needs scope qualification.** "Inflationary through 2035" is correct at system level but incomplete. The claim should be scoped: system-level inflationary, but potentially cost-saving under risk-bearing payment models for targeted high-risk populations with sustained adherence. The price trajectory (declining toward $50-100/month by 2030) may also move the inflection point earlier.

## Follow-up Directions

### Active Threads (continue next session)
- **GLP-1 adherence interventions under capitation:** What works to improve persistence? Does care coordination, lifestyle coaching, or CGM monitoring improve adherence rates? This is the bottleneck for the entire VBC cost-savings thesis. Look for: BALANCE model early results, Devoted Health or other purpose-built MA plans' GLP-1 protocols, digital health adherence interventions.
- **Sarcopenia quantification in Medicare GLP-1 users:** The muscle loss risk is theoretical but plausible. Look for: real-world outcomes data on fracture/fall rates in GLP-1 users >65, next-gen compounds claiming muscle preservation, any population-level sarcopenia signal in the Aon or FLOW datasets.
- **CBO scoring methodology and prevention bias:** The $35B vs. $715M divergence is a structural problem beyond GLP-1s. Look for: analyses of how CBO scoring systematically undervalues prevention, comparisons with other preventive interventions facing the same bias, proposals to reform scoring methodology.

### Dead Ends (don't re-run these)
- **Tweet monitoring this session:** All feeds empty. No content from @EricTopol, @KFF, @CDCgov, @WHO, @ABORAMADAN_MD, @StatNews. Don't rely on tweet feeds as primary source material.
- **Compounded semaglutide landscape:** Looked briefly — the compounding market is a legal/regulatory mess but doesn't connect meaningfully to the VBC economics question. Not worth pursuing further unless policy changes significantly.

### Branching Points (one finding opened multiple directions)
- **Aon cancer signal (50% ovarian cancer reduction):** Two directions: (A) pursue as a novel GLP-1 benefit claim that changes the multi-indication economics, or (B) wait for independent replication before building on observational data from an industry consultant. **Recommendation: B.** The signal is too preliminary and the observational design too prone to confounding (healthier/wealthier women may both use GLP-1s and have lower cancer rates). Flag for monitoring but don't extract claims yet.
- **BALANCE model as attractor state test:** Two directions: (A) analyze the model design now and extract claims about its structure, or (B) wait for early results (post-May 2026 Medicaid launch) to evaluate whether the combined medication + lifestyle approach actually works. **Recommendation: A for structure, B for outcomes.** The design itself (medication + lifestyle + payment adjustment) is an extractable claim. The outcomes data needs to wait.

SOURCE: 12 archives created across 5 tracks
