GLP-1s top drug plan spend reports, but the retrospective data to justify the investment doesn't exist yet, says iA's Frédéric Leblanc
GLP-1 receptor agonists have dominated drug plan conversations for the better part of two years. They sit at the top of utilization and spend reports, and with a generic semaglutide now approved in Canada - the first G7 country to take that step - plan sponsors are starting to ask harder questions about what they're getting for the money.
Still, while the clinical story is strong, the economic story is still being written, underscores Frédéric Leblanc, a pharmacist and Strategic Lead, Products and Drugs Programs at iA.
“I'm pretty convinced that the GLP-1 drugs are improving the health of plan members, when taken appropriately,” he said. “The health outcomes related to it are real, and they were all measured in strong studies. It's basically reproducing a normal pathway mechanism in the body. It's all the interconnection between all these cardiometabolic conditions.”
According to Leblanc, GLP-1 receptor agonists work by mimicking an incretin hormone naturally released in the intestine after eating, slowing gastric emptying and reducing appetite. That mechanism makes them effective for both diabetes management and weight loss and the benefits extend even further.
Studies have demonstrated cardiovascular risk reduction, kidney protection in diabetic populations, improvements in metabolic liver disease, and more recently, obstructive sleep apnea.
GLP-1 cost savings remain unknown
But whether that clinical value translates into cost savings for plan sponsors is a question no one can answer yet, he suggests. The complications that GLP-1s aim to prevent, like cardiovascular events, strokes, peripheral arterial disease, kidney and liver disease, take years to develop, and the drug class simply hasn't been in widespread use long enough to generate the retrospective data needed to measure its economic impact.
"People don't really die directly from diabetes or from obesity. It's a complication of those conditions," he said. He draws a parallel to HIV treatment: expensive drugs that eliminated costly hospitalizations and opportunistic infections, but where the full picture only became clear after years of observation.
Statins history could shape GLP-1s
The closer analogy, he argues, is statins. Leblanc noted how those cholesterol-lowering drugs faced the same scrutiny in the 1990s and early 2000s - high cost, uncertain long-term payoff - and it took well over a decade of real-world data before the downstream benefits were established. He sees GLP-1s on a similar clock and facing the same structural disconnect.
"The cardiovascular event might happen in the 60s and the 70s later on in life, when you will pay the cholesterol medication for twenty years, and the event that's being prevented would have occurred twenty years later,” he said, emphasizing the costs that prevention eliminates don't land on the plan sponsor's bill. Rather, they fall to the public health system, and he believes that mismatch makes the return-on-investment invisible to the payer footing the drug cost, even when the health intervention is sound.
"All of these chronic conditions, they yield significant health outcomes," he added.
Instead, the early signals that do exist come from clinical trials, not real-world plan data, and they're drawn from high-risk populations - members with diabetes or significant excess weight who showed fewer cardiovascular events and hospitalizations.
Leblanc identifies two groups most likely to see short-term benefit: plan members with established cardiovascular disease and those with kidney disease tied to type 2 diabetes. Beyond those cohorts, though, he suggests the picture gets speculative.
"Plan sponsors shouldn't expect that cardiovascular expenses are going to go down or renal medications are going to go down," he said.
Why GLP-1 weight management is a coverage equity issue
A reduction in disability claims is theoretically possible if fewer members suffer cardiac events requiring hospitalization, but no insurer in Canada can currently draw that line, he said, as systems aren't built to connect a prevented event back to a specific drug intervention.
While the weight-loss dimension, amplified by social media attention, is where most plan members focus, Leblanc frames it as a coverage equity issue. The World Health Organization (WHO) classifies obesity and overweight as a chronic disease, and the associated health risks are well documented.
"Why would a plan cover cholesterol lowering when it's not an immediate threat?" he said, adding cholesterol medication prevents a future event, and so does weight management treatment. He emphasized denying one while covering the other raises fairness questions that plan sponsors can't easily dismiss.
"We know clearly that being overweight is a significant risk factor. So if you're able to act on that factor, why would you deny coverage when you cover cholesterol medication, for example?" he said.
He pushes back against the impulse to pit drug spending against other wellbeing investments like nutrition counseling or mental health supports.
"I think what's important is not necessarily to oppose the two," he said, adding drug costs will keep climbing but that increase buys something it didn't before.
"The cost goes up, but you get always more for your money because there's always more and more treatment being" developed, he said, contrasting it with a utility bill that rises without delivering additional value.
Additionally, while generics should provide some relief, Leblanc tempers expectations.
"There's so much activity in that market. There's new drugs that don't have a generic, and there's even more coming in the pipeline," he said, adding the result will be a mix of generic and patented use, not a clean cost reduction.
"I think what's important is really the balance between access to newer therapies that provide greater health outcomes and managing costs at the same time," he said.
