About the series
The Business Case for Advanced Primary Care is a podcast series co-presented by Marathon Health and BenefitsPRO.
Speakers
Introduction
"If we don't have the right patient on the right drug at the right time, it leads to bad outcomes, both health outcomes as well as financial outcomes."
Hello and welcome to The Business Case for Advanced Primary Care, a podcast series sponsored by Marathon Health and hosted on BenefitsPRO. I'm your host, BenefitsPRO contributor Michael Krieger. In this third episode—From Scripts to Support, Advanced Primary Care's role in your pharmacy strategy—I'll be talking once again with Dr. Jeff Wells, the CEO of Marathon Health.
Pharmacy spend, especially around GLP-1s, is climbing fast. It's no surprise that the Business Group on Health reports that 90 percent of employers worry about patient and plan affordability of higher cost drugs. Without clinical oversight, lifestyle support, and holistic care coordination, even the most effective medications can fall short. Today, we'll explore how advanced primary care serves as a health home for managing the responsible and effective use of prescriptions. Dr. Wells, welcome back and thanks for joining us.
Thank you, Michael. It's a great pleasure to be here.
What's driving pharmacy trend—and what should employers expect?
So on this final part of our series, let's talk about advanced primary care and how it affects benefits advisors and employees when it comes to prescription medication. First of all, pharmacy trend is outpacing overall medical trend and often hitting double digits. What's driving these increases and what should employers expect heading into 2026?
Employer pharmacy trends and the growth in cost isn't just underlying inflation. It's really a representation of the complexity that impacts human health and ultimately the cost of care. And I know as we talk to employers across the industry in 2026, this is really the number one pain point that we're hearing. Employers forecast 12 percent pharmacy trend next year. And this is on the heels of multiple years in a row with double digit increases, whereas overall medical trend is probably closer to a 7 or 9 percent increase. And we'll touch on some of these, I know, but as you mentioned, the growth and GLP-1s, other categories like autoimmune or biologics and some emerging gene and cell therapies. I mean, there's really exciting innovation coming to market, but when not paired with the right patient at the right time, this can create real pain for the employers that we work with.
Medications aren't always the best answer or the first choice. You really want to look at holistic lifestyle choices, but in total, you just can't understate the impact of medication and pharmacy spend for employers. Estimated at over $528 billion. So I really look forward to digging in and thinking through where there's opportunities to really help these employers that are finding challenges better manage their employer pharmacy strategy so that ultimately their employees and families are getting the right treatment at the right time and supported in a way that drives not only better health, but dramatically lower total cost.
How advanced primary care improves medication adherence
So one of the biggest drivers of avoidable cost in chronic disease is poor medication adherence. How does advanced primary care's continuous relationship model improve adherence? And what impact are you seeing on outcomes and costs?
Yeah, so medication adherence—it's not just a text reminder problem. It's not just as simple as ordering a pill pack. This is really a relationship problem. And you can't segregate the importance of medications for certain conditions away from a holistic view of that individual patient.
And so I think about conditions like anxiety or depression, high blood pressure, high cholesterol, diabetes, where at times medication therapy is critically important to reduce bad outcomes for those individuals. And the adherence of those chronic medications has a direct correlation to health outcomes and avoiding downstream cost. It's really hard for a patient on their own to navigate this without a really healthy relationship working with, in our case, a primary care provider.
And I can't understate the power or the impact of these chronic conditions. 64 percent of employers highlight that chronic conditions are really what's driving their total trend, both medical and pharmacy. And over 80 percent of total healthcare costs have been attributed to one of about 14 chronic conditions.
So where I think advanced primary care comes in is really the ability to support this continuous relationship with a very holistic view, thinking about everything from lifestyle, nutrition, fitness, building resiliency and stress management techniques or better sleep—with a thoughtful plan around medications where they're appropriate. And we're seeing great results. Over the 80th percentile for quality outcomes for common chronic conditions like diabetes or high blood pressure, as an example. And even when you translate that to the economics, we recently did an actuarially validated study on a large percentage of our patient base and saw 31 percent lower spend on diabetes and about 24 percent lower spend on cardiovascular disease for those patients that were engaged in this model.
Navigating specialty drugs and emerging therapies
That's great. There's a lot of buzz around emerging gene therapies, autoimmune therapies, and specialty drugs broadly. How does advanced primary care help patients navigate this complexity, connect to the right specialists, and receive the right treatment?
Specialty drugs are incredible. I mean, really, I went to medical school over 20 years ago. And just to see over that period of time—and even especially in the last five years—the exciting innovation that's coming to market. We really do have these new therapies available that can truly save lives, can truly transform lives and enable people to have a quality of life and an extension of high quality life that was unimaginable, candidly, just a decade ago.
But the challenge is, as those new therapies come to market and an uneducated consumer thinks that it might be a good fit—and certainly the industry is heavily promoting this through marketing campaigns—if we don't have the right patient on the right drug at the right time, it leads to bad outcomes, both health outcomes as well as financial outcomes.
And so we can't shy away from a really intentional focus on how to properly manage the right use of specialty drugs, considering that 50 percent of total pharmacy spend is being driven by this category at this point. Some of these advanced therapies—we're talking about $1,000,000 a year in cost for a single patient. GLP-1s as a category is the number one area of focus for employers; over 77 percent reference it as their number one area of focus.
And so where I think advanced primary care can come in is really serving as that quarterback—to build a deep, trusted relationship with a patient, to understand holistically that individual's risks, needs, goals, values, and preferences, to use the best science and couple it with a very holistic regimen of lifestyle. Oftentimes we can focus on getting people well and better and off of certain medications. But at times, there's a really important need. And so it's just using that level of personalization to get the right plan for that individual patient.
Managing GLP-1s responsibly
So, speaking of GLP-1s, GLP-1 medications for obesity have captured everybody's attention—employers, clinicians, and members alike. I know they can deliver impressive results, but they also pose major cost challenges. How can advanced primary care help ensure that GLP-1 use is clinically appropriate and sustainable for employers?
One of our clinical leaders often says the most expensive GLP-1 is the one prescribed without a plan. I don't think that could be more true.
For years, we've seen really great results for GLP-1s to manage diabetes in a certain set of patients dealing with diabetes. But the newer shift in indication for obesity management really opened a wide door of individuals seeking treatment for that—understandably—but also for employers to really struggle with this decision of: how do I enable the folks that really could benefit from these amazing therapies to get access to them, but it's going to break the bank and then we won't be able to provide the right kind of benefits to anyone if we over-rotate?
And so in response to that feedback and that challenge from our customers, at Marathon Health we really wanted to design a best practice model for managing the right kind of GLP-1 use, especially among those with obesity, built on the foundation of advanced primary care.
The components of that would be: to really target the high-risk, high-need members using prescriptive clinical criteria—so we know, based on the evidence, who's most likely to benefit; then to structure a prescribing and, over time, even a deprescribing pathway, so that we're really minimizing those that start a drug, get off of it, and never get on the right dose; and then coupled with lifestyle management and support, behavior modification, really enabling that individual to shift lifestyle behaviors sustainably. And over time, for most, we believe you can get individuals off of these expensive medications, which certainly do have some side effects as well.
And so the concept of really coupling this primary care model with the right kind of employer pharmacy management is leveraging this health home. Just in the last six months, we've seen amazing results:
- 95 percent of the patients engaged have adhered to the lifestyle program elements
- Almost 60 percent have improved their BMI, or body mass index
- 80 percent with an improved A1C—think blood sugar control—which is really important, not only in diabetes control for those dealing with that, but also as a signal around cardiovascular risk; controlling that helps reduce heart attack, stroke, and kidney disease down the road
- 65 percent with improved blood pressure control
Really, really great early results.
Disruption in the PBM model
As pressure grows for transparency and measurable value around the PBM model, do you see disruption coming and what role could advanced primary care play in driving change?
I mean, if there's one segment of the healthcare supply chain that's been under scrutiny probably more than any other, it would be pharmacy benefit managers. You can barely pick up a newspaper or read an article in the healthcare press that isn't somewhat critical of the role that these middlemen are playing between the pharmaceutical manufacturers and those that ultimately distribute and use the medications.
And I think there are a number of flawed incentives that exist within pharmacy and really within healthcare writ large. And so where I think advanced primary care is coming in is: we partner directly with employers with this health home, with this really holistic, integrated model of care, where we're trying to shift away from a reactive sick care model that's more transactional in nature and move towards one that's very proactive, much more focused on prevention, and being accountable to drive overall health and financial outcomes for those patients and ultimately for those employers that we're serving.
The pharmacy ecosystem really continues to be very complex and opaque. But what we can do with the employers that we work with is to make medications available and easy. So in most of our health centers, we have the ability to dispense simple acute medications or even maintenance medications—the more common medications that patients would use. We also have some mail delivery capabilities, both ourselves and through some partners, or even leveraging the employer's network. And then finally, as I mentioned, a lot of these really intentional clinical programs for specialty medications like the GLP-1s that we referenced.
Closing takeaways
So Jeff, as we wrap up this episode and the series, what are some takeaways that you'd like to leave our audience with about advanced primary care?
Again, the ability to meet an individual patient where he or she is and provide connection to this trusted, ultimate healthcare home—where you've got a party who's totally focused on being accountable to drive the right kind of experience and outcomes for that patient. It's going to be taking ownership of really driving the outcomes that that individual cares about: feeling more rested, having more energy, less pain, more confidence to manage a chronic condition, healthier relationships. And when we do that and do it right, it actually ends up dramatically lowering cost for those individual patients and their families, as well as the employers that we're in partnership with, or labor organizations, who we also work very closely with.
At the end of the day, if an employer or a labor organization wants to optimize their employer pharmacy strategy, what they need to do is look holistically at that—as well as the medical—in an integrated model. Understand that really it's chronic disease underneath this that's driving a burden for the individuals. It's driving a lot of this unnecessary healthcare cost. And if you get those patients connected to this healthcare home, there's just a dramatically different outcome.
And with that, Dr. Wells, thank you again for speaking to us and your insights on this topic. Michael, it's been my great pleasure. Thank you.
