THOUGHT LEADERSHIP
Why rising specialty drug costs are pushing plans toward more coordinated, outcome-driven care
Health plans continue to expand access to new, transformative, evidence-based therapies. This is an important step forward, but access alone does not always translate into better outcomes, improved patient experience or lower costs.
The rise of costs related to specialty drugs, especially GLP-1 medications used to treat obesity and diabetes, is bringing into focus the gap between access, affordability and measurable results. These therapies offer meaningful clinical promise, but they are also driving higher costs and increased use, including, in some cases, off-label use, while creating new challenges with coordinating and managing care over time.
This is not just a health plan issue, but one that spans the broader healthcare system.
We spoke with Chris Regal, Director of Clinical Innovation at AHIP, to get his perspective on what’s changing and what it means for health plans.
The specialty drug market has long exhibited challenges with high launch prices and continued growth in spending, factors that play a key role in driving up costs throughout the system. What is different now is the scale.
GLP-1s are high-cost therapies being used by a large and rapidly growing share of the population, with about 1 in 8 U.S. adults reporting having used one, compared to traditional specialty drugs that have typically been limited to smaller patient groups. This creates new affordability pressure across employers, health plans and public programs.
These medications can be used successfully—but not always. Even when used appropriately, results with GLP-1 therapies do not always match clinical trials, and patients may start treatment without consistent follow-up.
Many treatment journeys also occur outside coordinated care models, making it harder for plans to track patient progress, manage outcomes and control total cost.
Innovation in pharmaceuticals is critical, but it comes at a cost. Drug pricing remains a major driver of healthcare costs and premiums, and in some cases, prices are significantly lower outside the United States.
Health plans prioritize innovation in the way care is delivered so patients can achieve meaningful results. Medication alone is not enough; without appropriate care coordination and management, higher drug spending may not translate to value. Plans strive to manage what is best for individuals with what is best for the populations they serve and to promote affordability.
This is why affordability becomes such a central issue.
Managing cost requires more than utilization controls alone; we need structural changes. This is where value-based models may be able to play a role. By linking payment more directly to outcomes, these approaches aim to ensure that higher drug spending translates to real-world results.
Chronic disease is one of the biggest challenges facing the healthcare system today. Three out of every four U.S. adults have at least one chronic condition, and more than half have multiple. These diseases drive nearly 90 percent of total healthcare spending.
Health plans are focused on reducing this burden through prevention and early intervention.
GLP-1s can be part of the solution when used appropriately and where they can truly deliver value. Weight reduction can be valuable in protecting against chronic conditions. For some patients who already have chronic conditions, weight loss may reduce the need for other medications, such as insulin or treatments for high blood pressure.
But GLP-1s are not a standalone solution, and their impact depends on how they are integrated into broader care.
Lasting impact comes when they are part of a coordinated approach to managing chronic disease across conditions and over time. Without ongoing support, outcomes may not be sustained. Studies show patients who discontinue GLP-1 therapies can regain more than five percent of body weight on average and may also see declines in related health measures such as blood sugar and cardiometabolic health.
Affordability is a top priority for policymakers, patients and employers.
High drug prices are under increased scrutiny, along with greater attention on how GLP-1s may be covered in Medicare and Medicare Advantage. CMS recently expanded coverage on a temporary basis through the Bridge Model and is exploring expanded coverage, while recognizing the potential for significant cost impacts on the federal government and taxpayers.
At the same time, strong demand for these therapies has fueled the rise of direct-to-consumer prescribing. While this expands access, it can also contribute to more fragmented care, making outcomes and costs harder to manage at scale.
Across the system, policymakers and purchasers are placing greater emphasis on accountability, particularly for how drug spending translates into patient outcomes. Drug manufacturers, payers, providers and patients must align on expectations and the measurable results to be achieved with these medications.
Health plans are adapting their strategies to manage high-cost therapies more effectively. Tools like prior authorization remain important, helping ensure patients receive appropriate care within the right clinical context.
This adaptation reflects a broader shift in how plans manage care, as they move beyond approval decisions alone to actively managing outcomes over time, an example of how health plans are evolving care delivery to keep pace with more complex therapies and patient circumstances.
This shift is increasingly important as more people face higher out-of-pocket costs. About 40 percent of commercially insured individuals are enrolled in high-deductible health plans, meaning the cost of these medications is more directly felt by patients. This heightens the need to ensure treatment delivers value.
As a result, health plan leaders should focus on:
Plans must also rethink how care is delivered, not just what is covered.
Specialty drugs are reshaping healthcare.
They highlight the gap between access and outcomes, the burden of chronic disease and growing affordability pressure.
Closing that gap requires more than expanding access to more medications.
It requires a coordinated approach that connects care over time. Sustained outcomes depend on ongoing engagement, support and effective treatment management. A Teladoc Health analysis of patients receiving GLP-1s through external providers suggests that many do not consistently reach optimal dosing levels, which can further limit outcomes.
Virtual care can help improve access, support patients between visits and bring greater coordination to complex care journeys.
As GLP-1s and other specialty drug markets continue to grow, success will depend on the ability to deliver consistent, measurable outcomes.
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