GLP-1 Showdown: Inside The High Stakes War over Patients

[00:00:00]Novo Nordisk just sued Eli Liy and the legal war between these two companies is starting to intensify. But just because these two companies are battling over patience doesn't mean they're battling for patients. And while these two major companies are going at it in court, whistleblowers from one of the largest teleaalth companies in the country are alleging that patients were being pushed through their system at breakneck speed, often uh ignoring warnings and potential pitfalls when it comes to access to obesity medicine. And these again always sound like different stories, but really they're part of the same struggle.

[00:00:40]Pharma wants the patients. Teleaalth companies want the patients. Insurance companies want the patients, but they don't want to cover the patients. Right?

[00:00:48]Every corner of the system wants influence over your prescription for your chronic disease. But when the coverage gets difficult, side effects get too difficult to manage, weight loss becomes too aggressive, or you need more than just a refill to hit your goals, that's where I'd really like to know who wants the patient then. And all of this sort of creates a more difficult question about obesity medicine in general. one that we're going to wrestle with on today's podcast because I think the question really becomes how altruistic are we allowed to be when more than 100 million Americans are living with the disease of obesity but only a few thousand clinicians actually have the dedicated expertise in obesity to treat it. In other words, can we demand an ideal level of care for people living with obesity that our health care system simply isn't built to deliver?

[00:01:49]And on the flip side, does accepting faster, more scalable models leave patients more vulnerable to becoming simply just transactions inside of a prescription machine?

[00:02:02]Because right now, obesity medicine is scaling in a massive, massive way. And the question is whether we scale care or scale access and patients are being fought over.

[00:02:18]Today we're going to ask what it would actually mean if patients were being fought for. Welcome back to On the Pen, the weekly dose podcast.

[00:02:30]Welcome to the On the Pen podcast with your host Dave Nap.

[00:02:49]Welcome back to the Weekly Dose podcast.

[00:02:51]I'm your host Dave Napman on the Majaro.

[00:02:53]That's why I'm here. And you are on the pen, the place where we cover obesity medicine stories. uh so you can understand what's happening because if you understand what's happening and what it means for you, you can take that and come up with better questions and better conversations once you get to the doctor's office and as we'll get into sometimes that time is very limited. But before we get into today's story, I want to tell you that today's episode and each episode moving forward is sponsored by our partners at Vafit. Now, that's the company behind my level, the app that we brought you on a podcast episode a few months ago before I was ever partners with Voit.

[00:03:35]I was using their services and became a patient of them. And at in that process of sort of becoming their patient, I I learned the importance of managing to your GLP-1 levels and not your GLP-1 dose. That has meant absolutely everything to me in my journey. I'm down to my lowest weight in 10 years and I'm using a third of the turseptide dose that I was using before I went on my little sabbatical. We're not going to rehash that all today. If you want to check out more, just go to our linkree otplinks.com and you'll see all of the information that we have about my level VOIT and you can get connected there and learn more about what they're doing. Really appreciate their partnership at VOIT.

[00:04:17]Now, let's get into the stories because the biggest story of this week, no doubt, is the story that dropped today that Novo Nordisk and Eli Liy are officially at war in the courtroom because Novo Nordisk had filed a federal lawsuit against Eli Liy and essentially accused Eli Liy of deceptive advertising involving Majar and Zepbound. And Novo claims that Lily is using outdated comparisons that place Lily's highest dose of trespatide against the older lower dose of ozepic and WGOi while failing to adequately account for the fact that Novo's newer highdosese WGOI HD option is available the 7.2 milligram. Lily, for their part, says its advertising is supported by clinical evidence, including the Surmount 5 head-to-head trial, which compared heride directly against semiglutide, and found greater average weight loss with youriteide at the doses studied. That's the story. That's the story that's going around in the news today. But let's talk about what I think about it because the easier way to cover this is to just turn this into some spectacle professional wrestling wrestling match between two pharmaceutical companies. I think it's back to the days of the NWO and Sting and and all of these professional wrestlers kind of coming out staring at the audience as they march down to the the professional wrestling ring, right?

[00:05:40]So, we've got the two heavyweights battling for the title here. But this lawsuit is more than just about corporate pride and being able to say that you're the best. It's about who controls the story that patients are being told right now. And for years, Novo has dominated this discussion. They just they simply have. The cultural language, the zeitgeist around GLP1s was so deeply embedded that ompic sort of became synonymous with all of these drugs and and you even today I mean even today you'll go around and people are saying he's on ompic or she's on ompic. It became synonymous. Novo owned the name of the entire space. But then Lily came along with Majar and Zeppbound and they really started to own the efficacy and the patient lived experience story didn't they? I mean from my perspective they did. Tzepide entered the market. It produced weight loss results in the real world that changed what patients and clinicians expected from obesity medicine. Right? When surmount 5 directly compared trazepatide to semaglletide or semiglutide at the doses studied, tzepide was obviously superior.

[00:06:49]But then in the real world, patients noticed the same thing. Tzepide was simply more tolerable and simply more effective at turning down their food noise. And ultimately what's happening is that Novo's mad that Lily is using the evidence from this surmount five story surmount 5 study to tell their story uh basically about the efficacy of the drug. And I think ultimately obviously this will be decided in court right what what they can and can't say.

[00:07:17]But here's what I think matters to patients because a company can use a real study like Lily did here, but they can also tell an incomplete story. In other words, it can use an accurate number. The surmount 5 numbers are accurate but they can create an impression with patients and the patients of mind that does definitely disc deserve some scrutiny and another look uh at the total picture because it can tell one piece of the story really loudly while while sort of placing the qualifications of what they're saying in those small letters that you essentially have to be a bald eagle uh to to be able to read. That's advertising. That's pharmaceutical advertising landscape in the United States. It's not designed to give you a complete medical education.

[00:08:01]Uh it's designed to move you towards a decision. And that smiling person on the kayak on the very peaceful lake just rowing around around is designed to move you towards something, right? But they don't know your medical history. They don't know that you've taken one drug and failed and maybe have a contraindication. Uh I also think of of, you know, my favorite. It's It's always like somebody's cutting up vegetables in a kitchen that looks like it has never been used to cook anything. I don't know. We got four kids in our house. Our kitchen is rarely if ever spotless clean. Uh even when we have company, it's like it's just crazy. But I digress. Patients are being moved towards medical decisions inside this marketing war. And ultimately, the war right now that's being fought is which medicine causes more weight loss? which one is better, which one won the clinical trial, which drug is strongest.

[00:08:58]And that language sort of makes obesity sound like a contest where everyone should just want the medication with the largest average number.

[00:09:07]But clinical trial averages are not what's borne out in the real world. Have we learned that yet? I I think we have, but the rest of the world has yet to learn this story. And I think that's sort of what's at the heart of what's going on between these two companies right now. Because some patients do respond extraordinarily well to semiglutide. Many respond better to trespathide. Some can tolerate one drug but don't tolerate the other. Uh some maybe don't tolerate either of them.

[00:09:35]Don't don't respond well to either of them. Some of them may require the new generation the amalin drugs the glucagon agonist uh some of the pathways that we went into this week that aren't even incrretin related. Right? Obesity is not one disease from one malfunction. It is many biologic. I think of it more personally this is my personal opinion but I think of it more as a family of diseases with sort of one visible outcome right that is excess adapostity it's overweight but the idea that there's a universal winner just by hitting a higher number has always been overly simplistic when it comes to the idea of obesity as a disease. So in other words, for patients, it's not about whether Lily defeats Nova or Nova def defeats Lily. The patient just needs an honest explanation of the data. What side effects occurred, what what drug has better efficacy with things like sleep apnea or things like heart failure or things that may be more relevant to one patient than another.

[00:10:41]They need the information that applies to their health. And what we see here is pharma battling again over the patient but not necessarily for the patient. And that brings us to a much juicier story from this week. I don't know if you all saw this from Stat News, a very interesting uh publication that they put out a detailed investigation into a company called LifeMD. Now, LifeMD is a publicly traded company with hundreds of thousands of subscribers and they play a significant role in the GLP-1 market.

[00:11:19]Such a significant role that actually they partnered with Nova Nordisk and Nova Nortis listed LifeMD as a place where patients could find legitimate medication uh legitimate sourcing and legitimate patient support. So, LifeMD had built all these integrations intended around connecting patients to pharmacy systems associated with both Eli Lilly and Nova Norris. So this wasn't some anonymous like you know we only and ever sell compounded medications or gray market website. This was one of the polished publicly traded pharmaceutical company connected pathways into obesity treatment. So that sort of lays the groundwork. And they had some whistleblowers come forward to to Stat News, which again I struggle with this because I'm like pretty much any company can have people, you know, as they grow they leave. These people leave with, you know, sort of a vindictive spirit and want to, you know, just spill the tea, right? Um, and I feel like at any point this could happen to any company and any company specifically in this space because there's been so much growth so fast because of access to these medications.

[00:12:22]But I'm getting somewhere with this and and so just hang out with me, right? And by the way, if you're just tuning in or if you're new to the podcast, hit the like button, hit the subscribe button, and there's also a hype button if you're watching on your mobile device, which if you do that, you can do it up to three times by refreshing the video. Uh, that helps other people who haven't seen this content to get connected with it. And there's so many people getting on these medications and I think this is going to be a particularly useful episode for some of those people especially if they're seeing some of these these stories here. But essentially these these former staffers came to Stat News and they just basically said listen what's happening at at LifeMD is a story that that we need you guys to help us tell. Right? So they're saying that essentially LifeMD pushed clinicians and their staff to just increase the number of patients that were moving through its system and sometimes at the expense of careful screening and followup strongly denies these characterizations.

[00:13:23]Uh so that point needs to be attached to everything that you hear from this point on. These are allegations. These are not this isn't come up in court. was whistleblowers to a website that was happy to report on all this stuff. So, they're disputed. They've not all been proven. Uh so, just keep that in mind as we move along here. Uh but some of the details that were outlined here are too important to glide past and I think play to a bigger conversation that we need to have about teleaalth and obesity care in general. So, these these employees told stat that clinicians were expected to complete as many as 20 to 25 tasks in an hour. And LifeMD says that those tasks included more than prescriptions. They could include reviewing lab results or answering messages, uh, performing other clinical work. But two former employees said that providers were sometimes reviewing approximately 25 patient cases per hour. 25 cases per hour. That's a lot of cases to review in an hour.

[00:14:19]That's one every 2 minutes and 24 seconds. Uh if you're trying to do the mental math there. So according to these former workers, the queue could include new patients. It could include refills or dose increases. And clinicians would be reviewing people they had never treated before and sometimes with sparse documentation in the charts. So one former worker described the culture at LifeMD as get patients in, get them out and get them processing as many as we possibly can. and another summarized uh the message the overall message there as prescribe and go. Of course, LifeMD disputes the framing and says it doesn't pressure their clinicians to prescribe anything. The company's live appointments were reportedly reduced to from 20 minutes to 15 minutes and LifeMD that says that that change actually reflected data showing that the average appointment lasted only about seven minutes and that clinicians were not required to rush. So, think about that for a second. Seven minutes may be enough for some uncomplicated follow-up appointments. Um, not every medical encounter requires some sort of, you know, production, right? A documentary film crew or a congressional hearing, right? But some some of these do, right?

[00:15:31]Uh 7 minutes is not a long time to unpack years of obesity, uh current medications that somebody might be on, previous weight loss attempts, uh mental health, eating behaviors, contraindications, uh patients expectations are another huge one uh uh to to get folks to adhere to these medications, have proper framing about what to expect from these medications. But according to these former employees, clinicians could be discouraged from asking questions of patients that might delay the prescribing process. So the investigation offered some examples involving some really common medications. They list omerazol, which is something that's commonly used for reflux. Now, do you simply record that as a routine medication, or do you ask why the patient takes it? Because if the person obviously has a history of things like slowed digestion, these medications can complicate or build on that, right?

[00:16:23]Uh same thing with like levothyroxine.

[00:16:26]Do you assume that there's just an uncomplicated hypothyroidism or do you ask whether the person had thyroid surgery and why they had thyroid surgery? Um could they have a family history of MTC? So those questions can reveal information that would change the treatment and according to these patients this just wasn't happening at an appropriate level. So obviously there's tons of allegations uh that that exist within this article from stat uh life MD basically like I said refutes the allegations and say that says that you know they have a standard process uh to restart patients on the lowest dose when they come back on a medication. Uh and although an an executive reportedly acknowledged that a clinician might sometimes continue at a higher dose when a patient is strongly insists upon it um this was sort of a recurring theme that patients weren't being dosed properly because of these you know shorter visits with the doctors uh with the doctors that were prescribing.

[00:17:23]Now, this kind of brings to the most sort of salacious part of this article, which was about essentially a a former chief operating officer. His name is Brad Roberts and he was documenting his own weight loss experience to Stat uh again former employee and basically said that uh that uh in a lawsuit that he's actually filed uh and medical affidavit that Stat actually uh obtained here that he he received six different GLP-1 medications over the course of his treatment which doesn't necessarily mean he was taking all six simultaneously but six different medications were prescribed and there was an outside endocrinologist who reviewed the records and alleged that uh Roberts was escalated to the highest dose of Mjaro more rapidly than was recommended. Now that same thing happened to me by the way because you couldn't get the middle doses, right? Uh between February and December of 2023, uh his reported weight fell from 286 pounds to 177 pounds. He lost 109 pounds. Talk about a super responder. Maybe was taking all six. Uh which is nearly 40% of this guy's starting body weight in less than a year. And then as uh a result, Robert says there were medical complications.

[00:18:35]He developed uh something called patulus ustation tube dysfunction which is a condition uh which the the tube connecting the middle ear to the back of the throat remains open when it should stay closed. And a specialist reportedly attributed this to a condition uh that is caused by rapid fat loss around the structures that support that tube. And so Roberts described severe and persistent symptoms including ringing in his ears, trouble eating solid foods, falls, fainting, cognitive difficulties, and changes in speech. Now, Life MD, who is overseeing his care, denies any wrongdoing. It's chief executive off officer noted that Roberts had previously appeared in company marketing praising his weight loss experience. The company says Roberts and another former executive brought their claims after being terminated for performance related reasons. Again, this all gets very messy and that's why I hesitated to whether to even bring this story this week, but I think it's it's important in the broader context of the conversation that we need to have here because again, disgruntled employees can say a lot of things and a tellahalth doing huge volume is certainly not going to be doing things perfectly.

[00:19:41]But what I think this begs is this question because we know the typical voices out there who will use this kind of story to their benefit and say this is these largecale teleahalths or pill mills. We're the only ones that are doing it right. But my question back to you is how altruistic can we afford to be about access to these medications when over a hundred million people in this country are living with obesity and we only have a few thousand clinicians that are dedicated to obesity medicine expertise.

[00:20:18]In an ideal system, every patient would receive an extensive appointment, as extensive as they wanted or needed it to be. They'd receive an obesity specialist. Every medical record they have would be reviewed. Every medicine would be checked, their muscle, uh their their their body composition, their protein intake, their hydration, their mood, their gastrointestinal symptoms, their blood pressure, their labs. All of these things would be monitored.

[00:20:48]Every dose escalation would be a carefully thought through conversation between the medical provider and the patient.

[00:20:56]Every concerning message would receive an immediate response to these patients.

[00:21:02]But it's just not the system that we live in. And more than a 100 million Americans are living with obesity. We don't have a 100red million appointment slots with obesity specialists. just we don't have it. We don't have enough endocrinologists. We don't have enough obesity medicine physicians. We don't have enough trained dieticians.

[00:21:22]We simply don't have enough primary care doctors who even begin to understand these drugs appropriately.

[00:21:28]And even if we trained thousands more tomorrow, they wouldn't be evenly dis distributed. They wouldn't all practice in rural communities. They they wouldn't accept every insurance plan. there's so many hurdles and barriers to patients uh who are seeking care. So yes, we can sit here and say that every GLP-1 patient deserves all of these things and we would be right. We wouldn't be wrong to say that they deserve that. But we'd also be describing a situation that will likely never exist.

[00:22:01]And so what is the alternative? It's tellahalth scale.

[00:22:06]But for many, this is an experience that lacks some of the nuance that may be required for that specific patient. So how altruistic can we afford to be about access? Can we ex can we sit here and really insist that every uncomplicated patient should receive this most intensive form of care before accessing medication? We can't allow access to become a magic word that excuses everything. But at the same time, patients are facing real battles and real obstacles to getting these medications. Access cannot become a shield for negligence. But perfection cannot become a form of gatekeeping either. And that's where the answer lies to all this. We need a system that actually understands the difference between an uncomplicated case and a complicated patient. Me, that's me. I'm the complicated patient.

[00:23:01]Healthcare sort of already does this, right? We triage. A person with routine blood pressure does not necessarily need a cardiologist. A patient with uncomplicated reflux doesn't necessarily need a gastroenterenterologist.

[00:23:14]And a sore throat doesn't require an infectious disease specialist to say that a patient has strep throat. So obesity medicine is going to have to operate under this same sort of umbrella. Some patients may be safely treated through a super streamlined, super quick asynchronous telealth health pathway like a younger patient that's got an uncomplicated case. No, you know, major gastrointestinal issues or an eating disorder or no high-risisk medications that might interact or history of thyroid cancer, all all of those things, right? So, a structured questionnaire can collect that important information and filter them. But what about the 78-year-old patient who comes along who doesn't maybe have access to to the medication for one reason or or another and they're on 25 medications, right? Probably a different lane needs to be required for different patients.

[00:24:08]You know, same with patients who get on these medications and lose 40% of their body weight in less than a year, like this Seale executive from Life MD. If you're losing 40% of your body weight in less than a year, you probably need a different level of monitoring than somebody like me who's maybe losing a pound a week when they're really getting after it. We don't need identical care for every patient is the point that I'm making. And that distinction is sort of the conversation that keeps missing here is like how do we solve for this and who's working on solving for this? The problem isn't that life MD wanted to treat a large number of people. That's exactly what we want them to do. The problem is that according to their former employees at least the volume may have become the objective instead of the mechanism and that's something that we can't ignore and I'm curious to hear from you what are your thoughts on this it seems to me that we have got to strike a better balance in the teleaalth space of finding those patients who need that extra level of care and then providing it but even the folks that have the advanced uh issues and advanced complic application. We don't create more barriers to them getting treatment. How do we support them? How do we leverage tools, technology, AI to support that person? Uh because again, there's still too many of those people out there to receive the level of care that they need from simply an obesity specialist or an endocrinologist. We just simply don't have enough. So the answer lies somewhere in between here and we have got to adapt the tools that are out there and available to patients to teleaalth companies um to to improve care and as patients we ought to start demanding better too because we ought to demand that that we um have more options when we go to these telealth companies that we're we're just not getting a prescription we're getting care and there is a distinction between both. Some people need much less care uh and some people need need much more comprehensive care. So, how do we weed those patients uh out from one another and how do we provide the level of care that one patient needs over another? And I think that's the question that hopefully we'll see answered and I know we've been talking to some very interesting companies in the space. I'm eager to uh bring some of them on and introduce them to you. Uh that's what I got for this week though. Really interesting conversation. What are your thoughts? Let me know in the comments of this video. I'm curious to hear from you. Uh thank you for bearing with us and thank you to Pixel Labs again for offering up their space as our space new space gets finished up. Uh you can find them at the description of this video.

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