This is a brilliant, highly compelling concept. I have some nagging concerns that long-term GLP-1 usage might have some negative side effects and impacts that we have not yet been able to see in the trials or general usage. If we would go whole-hog into mass usage ... and then see a mass negative impact to the population down the road ... that is a scary thought. But, I know the side effects seen thus far have been fairly minor, and these concerns may be unwarranted.
Thank you. I share your concerns. Implementation is everything. Any large-scale programme requires careful monitoring both for effectiveness and unintended effects. What I was trying to do here was to get us to think of these drugs not just as a cost but as investments that could earn their place in the public portfolio.
A thought-provoking piece on the enormous untapped potential of a national GLP-1 strategy in Canada — turning a public health challenge into a once-in-a-generation opportunity
Sharp analysis and bold vision systems-level thinking by @PeterASinger
.... as always
This is the kind of policy imagination healthcare desperately needs. 🇨🇦📊💊
Thank you. Common side effects (nausea, vomiting, etc) would show up in the model through adherence. Domestic manufacturing and industrial policy are indeed closely linked; the biggest bang for the buck is innovation. Exhibit 1: Denmark and Novo Nordisk.
Is the basic argument underlying with these drugs that the benefits to the patient, both direct (less heart disease) and indirect (higher economic productivity, lower system healthcare costs) outweigh the potential downstream side-effects/consequences, to the degree that we can reasonably forecast them?
Thank you. The patient perspective is key. What this analysis does is show that the fiscal gains to government from increased labour productivity and decreased health care costs from a well tailored GLP-1 programme outweigh the costs and return money to treasuries over a long term horizon. In plain speak, the drugs pay for themselves and make money for taxpayers. I compare the returns to other public investments.
Thanks for the reply. Maybe I should re-phrase the question - outside of the scope of this analysis on the financial upside, which was very clear, I'm curious about patient impacts and the risk-return profile of actually taking the GLP-1. And how that consideration would potentially effect this proposal, which I found economically compelling, but medically unclear (due to my own lack of knowledge on the topic).
In other words, my inquiry is not about what you wrote in the article, but from a pure medical/pharmaceutical perspective - the basic argument of prescribing this class of medications, as I understand them (the direct benefits) is the consequent lower risk of heart disease and other co-morbidities associated with obesity. I also take your point that there are indirect health benefits associated - a person not dealing with obesity is, all else considered equal, likely to be more productive, which is associated with a higher income, which then associates to a higher quality of life. Not always the case, but generically speaking.
So if we're thinking about it as a risk-reward tradeoff from a systemic perspective, are those medical upsides "worth" the risks associated with this class of drugs? What metrics could we use to define that? Does a patient's life expectancy go up when they are prescribed to GLP-1s compared to not? I don't know if we have that kind of data (yet?) but that's what I'm curious about. I'm not fully versed, but the fact that we don't know what the long-term effects are, for example, would be one risk. The chance that it doesn't work for specific groups - that any short-term observed benefits are erased in the long-term, or the drug is increasingly ineffective after X years of usage. And so on.
Thanks for the clarification. Yes i would say the risk-benefit from the patient perspective is in favour of benefits — although of course every person would make their own decision under the doctrine of informed consent. For example, the SELECT trial in people with BMI > (gt or equal to) 27 and one cardiovascular comorbidity showed a 19% reduction in OVERALL mortality (and a 20% reductions in Major Adverse Cardiac Events). That is very large, although specific to the trial population and not for widespread primary prevention. There are other indications too. We modelled the lives saved globally and it came out to 2.1-3.1 m people per year (on about 60-65 m total global deaths). On the risk side, you have side effects that are common and not serious, which can often be handled through dose adjustment, like nausea, vomiting, diarrhea. Then you have side effects that are rare (like 1 in 10,000, or slightly higher in more recent estimates) but very serious like NAION, a form of sudden blindness. This risk - benefit ratio is comparable or better to many other things physicians would recommend to patients. I hope this helps and thanks again.
Very interesting! This seems to align well with Dr. Wendy Norman's research on healthcare system savings following the implementation of universal prescription contraception coverage. Her analysis finds that once contraception uptake reaches a steady state in year four (ie after the initial rush at the beginning of the program, especially for more expensive and reliable long acting reversible contraception options), BC will be looking at annual health system savings of $27 million (https://mcusercontent.com/353019c4e982ae7eb8ea53150/files/ad6a308e-fc79-b35c-935a-1d83e4e460d3/Contraception_Cost_Effectiveness_UBC_CART_Analysis_2023_11_26.pdf).
It would be much harder to calculate, but I wonder what back-of-a-napkin math would look like for comprehensive pharmacare, instead of being limited to one or two drug categories. My instinct is that health system cost savings would continue to scale.
This is very interesting! We need more of this sort of rigorous evidence-based analysis of public policy.
I was discussing additional effective public health opportunities in Canada with Claude a while back. Two other options that came up were in the areas of smoking cessation and opioid use disorder. Any thoughts on that?
This is a brilliant, highly compelling concept. I have some nagging concerns that long-term GLP-1 usage might have some negative side effects and impacts that we have not yet been able to see in the trials or general usage. If we would go whole-hog into mass usage ... and then see a mass negative impact to the population down the road ... that is a scary thought. But, I know the side effects seen thus far have been fairly minor, and these concerns may be unwarranted.
Thank you. I share your concerns. Implementation is everything. Any large-scale programme requires careful monitoring both for effectiveness and unintended effects. What I was trying to do here was to get us to think of these drugs not just as a cost but as investments that could earn their place in the public portfolio.
And well done! Thank you!
A thought-provoking piece on the enormous untapped potential of a national GLP-1 strategy in Canada — turning a public health challenge into a once-in-a-generation opportunity
Sharp analysis and bold vision systems-level thinking by @PeterASinger
.... as always
This is the kind of policy imagination healthcare desperately needs. 🇨🇦📊💊
#GLP1 #PublicHealth #HealthPolicy #ObesityCare #HealthcareInnovation
1.Anywhere in this modeling is there consideration for the nagative economic consequences of this drug's side effects?
2. If the govt commits to supplying this stuff let's manufacture it here. Let's make the needles here.
Thank you. Common side effects (nausea, vomiting, etc) would show up in the model through adherence. Domestic manufacturing and industrial policy are indeed closely linked; the biggest bang for the buck is innovation. Exhibit 1: Denmark and Novo Nordisk.
Is the basic argument underlying with these drugs that the benefits to the patient, both direct (less heart disease) and indirect (higher economic productivity, lower system healthcare costs) outweigh the potential downstream side-effects/consequences, to the degree that we can reasonably forecast them?
Fascinating analysis.
Thank you. The patient perspective is key. What this analysis does is show that the fiscal gains to government from increased labour productivity and decreased health care costs from a well tailored GLP-1 programme outweigh the costs and return money to treasuries over a long term horizon. In plain speak, the drugs pay for themselves and make money for taxpayers. I compare the returns to other public investments.
Thanks for the reply. Maybe I should re-phrase the question - outside of the scope of this analysis on the financial upside, which was very clear, I'm curious about patient impacts and the risk-return profile of actually taking the GLP-1. And how that consideration would potentially effect this proposal, which I found economically compelling, but medically unclear (due to my own lack of knowledge on the topic).
In other words, my inquiry is not about what you wrote in the article, but from a pure medical/pharmaceutical perspective - the basic argument of prescribing this class of medications, as I understand them (the direct benefits) is the consequent lower risk of heart disease and other co-morbidities associated with obesity. I also take your point that there are indirect health benefits associated - a person not dealing with obesity is, all else considered equal, likely to be more productive, which is associated with a higher income, which then associates to a higher quality of life. Not always the case, but generically speaking.
So if we're thinking about it as a risk-reward tradeoff from a systemic perspective, are those medical upsides "worth" the risks associated with this class of drugs? What metrics could we use to define that? Does a patient's life expectancy go up when they are prescribed to GLP-1s compared to not? I don't know if we have that kind of data (yet?) but that's what I'm curious about. I'm not fully versed, but the fact that we don't know what the long-term effects are, for example, would be one risk. The chance that it doesn't work for specific groups - that any short-term observed benefits are erased in the long-term, or the drug is increasingly ineffective after X years of usage. And so on.
Thanks for the clarification. Yes i would say the risk-benefit from the patient perspective is in favour of benefits — although of course every person would make their own decision under the doctrine of informed consent. For example, the SELECT trial in people with BMI > (gt or equal to) 27 and one cardiovascular comorbidity showed a 19% reduction in OVERALL mortality (and a 20% reductions in Major Adverse Cardiac Events). That is very large, although specific to the trial population and not for widespread primary prevention. There are other indications too. We modelled the lives saved globally and it came out to 2.1-3.1 m people per year (on about 60-65 m total global deaths). On the risk side, you have side effects that are common and not serious, which can often be handled through dose adjustment, like nausea, vomiting, diarrhea. Then you have side effects that are rare (like 1 in 10,000, or slightly higher in more recent estimates) but very serious like NAION, a form of sudden blindness. This risk - benefit ratio is comparable or better to many other things physicians would recommend to patients. I hope this helps and thanks again.
Very interesting! This seems to align well with Dr. Wendy Norman's research on healthcare system savings following the implementation of universal prescription contraception coverage. Her analysis finds that once contraception uptake reaches a steady state in year four (ie after the initial rush at the beginning of the program, especially for more expensive and reliable long acting reversible contraception options), BC will be looking at annual health system savings of $27 million (https://mcusercontent.com/353019c4e982ae7eb8ea53150/files/ad6a308e-fc79-b35c-935a-1d83e4e460d3/Contraception_Cost_Effectiveness_UBC_CART_Analysis_2023_11_26.pdf).
It would be much harder to calculate, but I wonder what back-of-a-napkin math would look like for comprehensive pharmacare, instead of being limited to one or two drug categories. My instinct is that health system cost savings would continue to scale.
Surely there are more reputable sources than the Tony Blair Institute?
This is a parody right? I laughed and laughed. So good.
This is very interesting! We need more of this sort of rigorous evidence-based analysis of public policy.
I was discussing additional effective public health opportunities in Canada with Claude a while back. Two other options that came up were in the areas of smoking cessation and opioid use disorder. Any thoughts on that?
Thank you. They are both improved by GLP-1s. But more importantly, tobacco harm reduction technologies are probably underused. I covered those in this conversation https://singerp.substack.com/p/tobacco-harm-reduction-with-derek?r=1ytch0&utm_medium=ios
I was wondering if GLP1s might have some utility with those areas I mentioned. That would only further buttress your case.