By Zeev E. Neuwirth, MD
While Eli Lilly, Zepbound, has raised valid concerns, we must balance those cautions with the reality that in-person access to weight-loss centers and primary providers cannot meet the needs of those who can potentially benefit from these medications. From a pharmaceutical industry marketing perspective, this is a watershed move that will have impact for years to come.
On January 4, Eli Lilly announced a new direct-to-consumer prescribing channel through their “LillyDirect website. This move coincided with the launch of their blockbuster GLP-1 obesity medication, Zepbound. Since that date, there has been a mix of caution and support expressed by experts.
It’s important to understand what this move represents … and what it doesn’t. First, Eli Lilly is not directly prescribing medications, and they are not employing physicians to do so either. So, the “direct-to-consumer” nomenclature is not exactly accurate. Through the LillyDirect website, consumers can access telehealth companies employing physicians who specialize in weight loss, diabetes, and migraine headaches. These telehealth providers can prescribe Zepbound, but the list is not exclusive to Eli Lilly products. As licensed clinicians, they are obliged to follow standard guidelines and only prescribe if patients meet the appropriate clinical criteria. The platform also directs consumers to local physicians who can prescribe these medications in-person.
The telehealth companies on LillyDirect include Form Health for obesity and 9AM Health for diabetes. The CEO of Form Health, Evan Richardson, has publicly stated that in addition to prescribing Eli Lilly’s GLP-1 and weight loss/diabetes medications, they also prescribe those same categories of medications from other manufacturers. The CEO of Eli Lilly, Dave Ricks, indicated that neither the telehealth companies nor the providers they employ are being incentivized to prescribe Zepbound. Sounds reassuring, but:
(1) We have no further details as to the contractual arrangement between Eli Lilly and these telehealth companies;
(2) We don’t know what business or health data is being shared between them;
(3) Form Health and 9AM health providers will know that the surge in their customers is coming from Eli Lilly. As newer, smaller companies, it’s hard to imagine that this boom will not influence their prescribing decisions.
Other significant concerns have been leveled by weight-loss experts:
(1) One compelling concern has to do with the quality and safety of the clinical care being delivered. Again, these are independent telehealth companies that specialize in weight loss and diabetes care – and they, like any other provider, must follow appropriate clinical care. However, they are limited to a short list of medications. The point being that there are medications not on these lists that are suitable alternatives, and some that are potentially better, for a given individual.
A related concern is disruption of existing provider-patient relationships. The cautions here are two-fold. First, primary physicians have knowledge that could be important in making optimal prescribing decisions. Second, if primary physicians are not aware that their patients are on a GLP-1, this could potentially lead to medical errors and patient harm.
While these telehealth services are not a substitute for primary or specialty care providers, let’s not forget that it’s ultimately the patient’s choice whether or not to keep their primary care physician abreast of any medication changes. Also, let’s not ignore the fact that 50% of adults don’t have a primary care physician and many people already seek care at alternative venues such as urgent care, telehealth, and retail-based care venues.
(2) Telehealth prescribing vs. in-person is another concern that’s been raised.
For example, how will these telehealth companies know with certainty if the weight patients submit is correct since there will be no in-person weigh in? Patients can game the system with false information, even though these medications might not be indicated or right for them.
Additionally, how will these telehealth providers gain access to patients’ medication lists, laboratory tests, and medical history? All of this information might provide some contraindication to receiving GLP-1 medications. Relying on patients to accurately relay their current and past medical status is a concern that’s been raised.
(3) In addition to medications, in-person weight-loss centers also provide nutritional guidance and behavior change programs. If we move to a telehealth system, won’t we lose these other valuable aspects of weight management care? First, these telehealth companies do offer these services. Second, it’s not a given that patients who see in-person providers receive nutritional guidance and behavior change services. Third, numerous telehealth-based weight-loss companies already exist. WW (previously Weight Watchers) has partnered with a telehealth provider group and is offering GLP-1 medications. Ro and Noom are two other companies that offer telehealth-based GLP-1 prescriptions and weight management services.
These cautions are valid and need to be monitored and studied over time. But, we must recognize that we’re not dealing with these concerns in isolation. They have to be balanced against the reality that there are simply not enough in-person weight loss centers or primary care providers to attend to all of the people who can benefit from these GLP-1 agonist medications.
From a broader perspective, the long-term impact and efficacy of these medications has yet to be determined. Numerous questions remain – from a clinical, public health, and healthcare economic perspective. But, in the short-term, these medications have been shown to significantly reduce cardiovascular events as well as mortality in those with obesity and diabetes.
In addition to the clinical care issues, Eli Lilly’s prescribing channel raises numerous questions about whether this is a new industry trend and the potential impact of that.
Industry pundits have remarked that the actual dollar impact of Eli Lilly’s move is relatively small and will not upend the market. But, the bigger question is what happens if and when other pharmaceutical manufacturers begin to follow suit. Keep in mind that these GLP-1 agonists are slated to be the largest blockbuster medications in history. It’s hard to imagine that other pharmaceutical companies won’t imitate and try to better the LillyDirect playbook.
This is a watershed moment in pharmaceutical DTC marketing. Eli Lilly has opened a floodgate, and it is highly likely we’re going to see significant ripple effects for years to come. There is no question that this move was meant to increase consumption of these medications, and it almost certainly will. The more important question to consider is whether or not it will increase inappropriate prescribing and cause more harm than good.
Dr. Zeev Neuwirth (www.reframehealthcare.org) is a healthcare executive, author and nationally-recognized thought leader. His second book, Beyond The Walls: Megatrends, Movements, and Market Disruptors Transforming American Healthcare was published in September 2023. He has over 15 years of experience in leading enterprise-wide programs and developing innovative, forward-thinking strategies. Dr. Neuwirth produces and hosts the popular podcast series Creating a New Healthcare.
He speaks and consults to healthcare systems, boards, medical societies and national associations.