Markets by Grant | Wegovy: A Patient Journey

Hello and welcome back to markets by Grant. This is part two of my series on the rise GLP-1 weight loss drugs and resulting trends for startups. This is another piece sponsored by AV — and you can read the originally published version here. To get up to speed on the series, give our initial thesis a quick read.

For this one, I thought I’d take a different approach. I thought, “God forbid, but at some point in the future, perhaps my (~15) devoted readers might grow tired of my writing style. In a parallel universe, perhaps they’d find another voice a refreshing relief.” So, in an effort to satisfy stakeholders across the multiverse and time continuum, I’ve interviewed Ron Levin, Managing Partner at Alumni Ventures, to dive into an actual patient journey.

Together, we hope to extract some lessons for startups operating in this space and others through this deeper look.

We’ve added one new piece to the standard Q&A format here: an “Insights” section (AKA, my glorified commentary section). After each question and answer, we’ll spend a bit of time exploring some ideas and implications, especially as they relate to startups and innovation. Let’s dive in.

Grant Demeter:

Describe your journey to date with weight management.

Ron Levin:

I’ve basically been somewhat overweight since childhood. I don’t know the cause or reasons except for perhaps enjoying food a little too much.

It’s always been a journey for me, and I’ve always wanted to do something about it. I’ve exercised and dieted. These things have worked for a bit, but I always seemed to revert after a while.

I weighed in at an all-time high a little over a year ago. I realized that it wouldn’t get any better unless I did something, so I got really excited once I heard that something new on the horizon might actually help.

Self-diagnosis is the start of every patient or customer’s journey.

It’s not the final, “official” diagnosis, but the recognition of a pain point or desire you’re interested in solving for yourself. Ron’s should be a relatable story to all our readers. Studies show that 80% of people revert to their average weight within a few years of dieting.

Finding and addressing pain points and desires is arguably the most important capability of a startup. As we continue, we’ll identify pain points and desires in Ron’s journey and ideate on strategies startups can use to address them.

Grant:

How did you first hear about GLP-1 drugs?

Ron:

The curse of the VC. I tend to read a lot about technology and innovation in healthcare, and I like to know what’s happening. I remember beginning to hear about these GLP-1 drugs, and Wegovy was the first name that stuck out to me. Once they hit the market, I kept hearing that these drugs were in short supply, and that it was very hard to get a prescription.

As time progressed, I learned about some startup companies, such as Calibrate and Form Health, prescribing the drug. Funny enough, I actually ended up looking at these companies as investments. I got an inside view into the profound results that their patients were seeing — which validated for me some of the hype I was hearing on the news. It dawned on me that there must be some way of getting prescribed and that I might as well give it a try.

Discovery is one of the most important steps in a patient’s journey.

Hearing about a product is a precondition to choosing to use it, but how you hear about a product is predictive of whether you end up using it. Did you hear it in the news? Was it good news or bad news? From a friend? A friend you respect? From advertisers? In what context? From your doctor?

For startups playing in any space, channels are important. The rule of thumb is first to target the highest authority and highest trust channels — in this case, doctors. This is why big pharma spends hundreds of millions of dollars marketing to channel partners. Meanwhile, doctors benefit financially from prescribing these drugs. As VCs, we like startups that have “doctors” as channel partners: respected opinion leaders with shared incentives and skin in the game.

However, in crowded markets, “doctors” may be expensive to reach and less rewarding, given all the options they have to recommend. In these markets, we like startups that go after “underappreciated friends” — overlooked channel partners that are cheaper to reach, a bit less credible, but much more eager to spread the word on your behalf. In a literal example, businesses like Mindset Health have had great success using nutritionists as their channel partners rather than doctors.

Grant:

After hearing about these drugs, how did you explore a prescription?

Ron:

I didn’t know where to go at first. Should I try my PCP? Can they prescribe the drug, or would they send me to a specialist? Would I have to meet with an endocrinologist? A nutritionist? I was unsure.

So I just Googled “weight clinic” and found there was one almost within walking distance from my house. I didn’t know if I could get the drug, but I figured I’d make an appointment, talk to them about it, and see what options I might have.

Exploration is the next step.

After you hear about something, you need a way of efficiently learning more. A lot of people get overwhelmed navigating the complexity of “user onboarding” — in this case, to the medical system.

Selling to consumers is like trying to get birds to eat out of your hand. Startups need to be incredibly careful not to startle or overwhelm them, while holding the birdseed as close as possible to them. Once startups nail the balance, the entire flock will come (this metaphor sounded a lot better when I first wrote it). Pharma has historically done a good job with this, with their nondescript TV commercials and the very simple call to action of “ask your doctor”. Startups need to do the same, with as few “clicks” as possible.

Grant:

You knew about the startups–why did you decide to go the traditional route instead?

Ron:

Convenience. My clinic is very close to my house. Maybe I’m a bit old-fashioned, but I like to meet with a practitioner in person, build more rapport, and really take the time to explain my situation.

I didn’t actively decide against using digital services or a startup, but I felt there was a very low barrier for me to swing by my local clinic.

Determination is the next step.

Rather than a character quality, this describes the act of determining which path to date. It’s not a final decision of who to give your money to, but it’s an initial idea of the type of solution you’d like. The startups had a chance here, and they failed. Instead, Ron chose the familiar path.

Relatively mature markets don’t just have solutions; they have groups of solutions. Before a consumer picks a solution, they have to pick a group. In a way, this means that startups have to compete with each other (against incumbents) before competing against each other. This tends to happen naturally as best practices are picked up quickly in highly innovative environments.

To win Ron’s attention, startups might not need to go brick-and-mortar. But they will need to show that they provide all the same levels of personal support and relationship-building as in-person clinics while beating them in areas like speed and simplicity.

Grant:

What was the process like to get a prescription?

Ron:

The first thing they do is weigh you…unsurprisingly.

Then, they get to know your weight journey and goals. Obviously, I came right out and asked about Wegovy and Ozempic. They are particularly interested in comorbidities to understand your risk factors. If you have more risk factors, like being diabetic or prediabetic, it may improve your chances of getting prescribed a GLP-1 drug. They did a quick blood test at the end of the appointment to make sure there were no preexisting conditions that might risk a negative drug interaction.

The whole thing felt like a standard process for such a new drug. My provider is a nurse practitioner who specializes in weight management, and she took the time to talk through my options, the risks and potential side effects, and the drug administration process. Once the blood test was clear, they went ahead and prescribed me the drug immediately, without another visit. Obviously, my provider has closely monitored my condition, and we’ve met many times since.

Decision is the point at which a person transforms from a prospect to a patient.

Here, Ron, with the help of a broker, decided which product to “buy.” Of course, at this point, he’d already given the broker (his provider) his money to help him get there.

Complex markets tend to have brokers to help customers navigate the realm of offerings in the space. Some startups use brokers as channel partners, others try to disintermediate them, and others become them. In this case, Ron’s broker was very value-additive for the services she provided and may make just as much money for her services as the pharma company selling the product. The “broker” strategy is one we’re excited about for this market. How can startups emerge to help guide customers through their journey?

Grant:

Which GLP-1 drug did you and your provider choose?

Ron:

In short, we took what we could get.

When I was there, they said that insurance didn’t cover Ozempic unless you had diabetes. If you wanted to get on that drug, you’d have to pay out of pocket. At the time, I heard that it was around $1,000 a month.

My provider said that Wegovy was basically the same drug as Ozempic but approved for weight management reimbursement, provided you also had one comorbidity. But, due to supply constraints, Wegovy wasn’t an option either at the time. The only drug my provider could prescribe was Saxenda. This one is a bit different from the others in that it’s a daily injection instead of weekly.

Decision dynamics: Some decisions are easier than others.

This one was easy for hard reasons — supply shortages. More mature markets will have a greater number of reliable options. In nascent markets, you take what you can get. In this case, Ron went for the daily injection drug, even though it’s more of a burdensome solution, simply because it was his only choice.

This is why it’s great to be the first startup in a new space. The bar for quality is lower, and you can snatch up eager customers with little incremental effort. Of course, this can’t last forever, as we’re already seeing in this market. After the benefits of getting there first have worn off, sustainable competitive advantage is what wins.

Future innovations in this space will be ingestible rather than injectable drugs. Provided the same level of efficacy and safety, daily injections won’t stand a chance.

Grant:

Who is paying for the drug and how much?

Ron:

I have no idea, and I’m happy I don’t.

I’m insured, and the vast majority of the payment is covered. I’m unsure how much I pay out of pocket, but it’s super low. Less than the cost of the sandwich that I’m no longer interested in eating.

In my opinion, it makes sense for insurers to reimburse this. If I keep the weight off, it’s been proven that I have a much lower risk of heart disease, as well as other major health conditions that might burden the medical system. Funding GLP-1s could be a huge money-saver for insurers in the end.

Payment is the next step after the decision.

You always decide to pay before you pay, even when you pay upfront. There’s a lot of complexity in payment itself. Are you paying one time or many times? Up front or in arrears? Are you paying per unit or via a subscription for a service? Are you paying using cash or a financial instrument, like a credit card or insurance? If you’re paying with a credit card or insurance, you may not realize it, but you’re paying multiple parties multiple times for one product or service — making it hard to tell how much you’ve paid for any given thing.

In cases like this, how much you feel like you’re paying is much more important than the actual amount. As VCs, we love startups that sandwich their monetization in preexisting cash flows rather than creating new ones. Pharma nailed this by getting insurers to pay for their product, as Ron doesn’t have to shell out via a new cash flow. We also love startups that make a bit of money for their customers in addition to taking their money. For example, imagine a software startup enabling Ron’s weight clinic to collect revenue faster.

Grant:

Tell us about the process of being on the drug. How is the “user experience”?

Ron:

You start at a low dose and work your way up.

These are all self-administered injections, which took some getting used to but are pretty easy now that I’ve gotten the hang of it. For Saxenda, you have to dose it yourself on a daily basis. For Wegovy, it’s an elegant, single-use injector. Both methods are pretty painless.

I felt the effects immediately, and I lost a lot of weight in the first couple of weeks. I didn’t feel much like eating, and in some cases, I had to really push myself to eat. They do advise eating three meals a day and getting plenty of protein, as one of the risks of the drug is losing muscle mass.

I ended up staying on Saxenda for eight or nine months until the supply of Saxenda began running low. Luckily, there was a better supply of Wegovy at that time, so I transitioned to that. I had made a lot of progress but hadn’t hit my targets yet. I found that once you’re on the drug for a while, your body starts to get used to it, and you don’t lose weight quite as fast. On the other hand, the side effects get better as well.

Side effects have been the same for Wegovy and Saxenda. I hear it differs for each person, but for me, it’s been a bit of nausea here and there. I’ve found that it tends to get triggered by certain things — oddly, like coffee. I also found that when I get motion sickness, it’s much more acute. Overall, the side effects are pretty light, and I feel quite comfortable on the drug.

Return on Investment is what you get out of what you pay.

Every product, not just a drug, has therapeutic effects and side effects. We’re hard-pressed to think of a product that is pure joy. Even the Twinkie has a pesky plastic wrapper, which can be tough to open (not to mention the overwhelming feeling of guilt after you’ve eaten it).

The obvious key here is for a startup to minimize side effects and maximize therapeutic effects. And just like with payment, how your customer feels about therapeutic effects is more important than the effects themselves.

For side effects that startups can’t sufficiently minimize, they should monetize. If Ron’s nausea was negatively affecting his view of his treatment journey, pharma or his provider might offer him an anti-nausea medication. If Ron loses muscle mass, they (or another startup) might upsell him on personal training or a protein supplement. They make more money on the upsell while winning more customer trust with Ron, which reflects back positively on their primary product experience. A win-win-win.

Grant:

Where do you stand today? How are things different than you thought they’d be?

Ron:

I’ve been on the drug for 13 months. I’ve lost about 50 pounds. As I mentioned, I’ve found getting full takes longer these days. Given that I’ve plateaued, we’re going to increase my dosage a little bit.

As part of this treatment journey, I’ve been trying to instill good eating habits in myself so I can hopefully keep the weight off after I come off the drug. I’m trying to eat less sugar, carbs, and processed foods while increasing protein.

Before starting my journey, I thought, “I’m going to set my goal, hit my goal, and come off the drug.” My provider quickly dispelled this idea. Instead, we’ve been very gradual, thoughtfully testing at each stage. As I started, we increased the dosage, observed therapeutic and side effects, and decided whether to increase it. Once I hit my goal, we’ll start tapering dosage using the same process: gradually reduce and see how well I maintain my weight at each step.

Can I keep my good habits? I hope so.

Some Final Thoughts:

With Ron, I chose to highlight a patient journey that isn’t yet over because 1) I know Ron and work with him, and more importantly, 2) there’s no clear endpoint for any patient journey. Ron may taper off the medication and successfully manage his weight in other ways. Or, he may regain some weight and choose to restart medication.

For a chronic health concern such as weight management, many startups in the space will “hope to see you again” — and even bank on it. Others will promise to “cure once and for all” in hopes of beating out incumbents for business. In many cases (this one included), telling the difference between them can be tough.

In general, we believe these innovative tensions are good for the patient and good for new businesses. We’re inspired by the leaps and bounds we’ve already seen in this space and are excited to partner with the innovators to come.