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The Perils of Precert for GLP-1s

43% of larger companies say they will be covering weight-loss drugs in 2024...and most of those will suffer a double-digit increase in total healthspend, as you can see if you scroll down.


Prior authorization (“precert”) won't help in this case, because patients, doctors, or patients and doctors in collusion, can game the system to get precerted via the necessary-but-not-sufficient PBM process, without the actual indication.


GLP-1s are the poster child for gaming the system, mostly because precert alone doesn't work. Unlike, for example, a scan showing a finding that might require an intervention, people can create their own "findings." Wegovy typically requires the FDA standard of a 30 BMI. The average adult BMI is close to that, so people can gain weight before the weigh-in, just like in the days of outcomes-based wellness.


Ozempic is gamable as well. A diabetes diagnosis requires two fasting blood glucoses over 125 mg/dL. Simply don’t fast. You’ll get the diagnosis, and then metformin as a first-line therapy. Often, a single metformin prescription qualifies someone for Ozempic.


There are four other reasons that the traditional precert system will be gamed:

  1. The cosmetic benefit. Imagine how much plastic surgery would be demanded if health benefits covered facelifts or nose jobs…and no surgery or recovery time was needed to achieve the results.

  2. Doctors may believe their Hippocratic Oath requires them to bend the insurance rules to prescribe something that they genuinely believe might help their patients.

  3. Doctors are often graded on patient satisfaction. If a doctor can satisfy a patient by giving them drugs, they might fudge the paperwork a bit.

  4. And if your own doctor won’t? Other doctors will provide prescriptions…even without an office visit. Contrast this to other interventions that are precerted: people don't google for doctors promising to perform a spinal fusion or hysterectomy on you. Not since pain clinics have doctors advertised DTC this heavily. And those ads were, by FDA necessity, much more muted.

 

The impact of gaming on healthspend


Consider these screenshots from Quizzify’s Weight Loss Drug Economics Calculator (WLDEC). WLDEC, available here by subscription, includes all the major inputs needed to calculate the increase in drugspend Wegovy (or Ozempic) coverage will generate. On the left are a few of the inputs. The right shows the raw impact on total healthcare spend at the very top, and then the net spend increase if Quizzify's Curb Their Enthusiasm quiz, described in the net section, is used to moderate usage.


The 0% gaming scenario (lower left corner) yields a gross increase in total healthcare spend of 9%, and a net spend increase of 5%.

Now watch what happens if a realistic 6% game the system: net healthcare spend increases 80%, from 5% to 9%.


 

How to fix it: Two-factor authorization


If someone is completely and utterly committed to cheating, there’s not much that can be done. For everyone else, there is the precert equivalent of two-factor authentication, which we call two-factor authorization. One factor is, of course, the standard PBM check-the-box precert for diabetes or BMI.


The other is Quizzify’s “Curb Their Enthusiasm” quiz curriculum, which can change wavering minds, and educate unwavering ones. People who are demanding GLP-1s inappropriately are likely laser-focused only on the benefits and not the many drawbacks. 12 of those drawbacks, plus 3 other questions, comprise the initital Curb quiz. Then, along the way, there are several other nutrition and lifestyle-oriented quizzes.


Here is an example:

The Curb quiz covers other topics, like the most important risk to know about, the worst potential side effect not listed on the labels (yet), the most avoidable complication, and much more. The ongoing quizzes are more about the biggest culprit of all in diabetes and obesity: hidden added sugars. Even so-called superfoods like cranberries and dark chocolate are full of them. And we are not afraid to name names, if requested. (I'm looking at you, Naked Juice.)


The added benefit: people who do complete these quizzes – and of course satisfy the PBM precert specs – will know much more about the drugs they are taking. This is the first step to a lasting result.

 

The Cost of Adding Quizzify: Decimal Dust


The cost of Curb is about one-half of 1% of the cost of Wegovy. Even getting someone to pause for a month to think things over yields an ROI exceeding 10-to-1. And you’ll do much better than that, guaranteed.


Consider the 1000-life example above: It would likely cost less than $7000 to reduce your spend by $100,000 or more, guaranteed.


Depending on your budget for these drugs, two-faactor authorization can require either a passing score or else just quiz completion. And unlike traditional precert, which everyone hates when they get denied, an employee can’t really complain because their employer is making them learn something about the drugs they want their employer to pay for.


It is also an easy add: just as with two-factor authentication, employees get a six-digit code We submit the same code to the PBM, which then clears them to get the prescription.


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