Integrated Care Needed as Metabolic Disease Prevalence, Costs Climb, Experts Say

Metabolic disease is reshaping care delivery and costs, with experts at the Academy of Managed Care Pharmacy (AMCP) 2026 meeting in Nashville, Tennessee, underscoring the need to rethink it as an interconnected, population-wide crisis rather than a series of isolated conditions.¹

Demographic Drivers, Clinical Burden of the Metabolic Health Crisis

Denise Wolff, PharmD, senior consultant of business strategies for AMCP, began the session, “The Future of Metabolic Health in Managed Care: Population Risk and Financial Impact,” by highlighting the demographic drivers and implications of the metabolic health crisis. She described obesity as the “central hub” driving diabetes, as well as cardiovascular, chronic kidney, and liver diseases.

Wolff argued that this interconnected burden requires a shift from isolated disease management to an integrated metabolic health approach, in which conditions interact, compound, and accelerate. This model would involve prevention, integrated care, and long-term economic impact modeling.

By the numbers, 40.3% of US adults have obesity, 38.5% have metabolic syndrome, and approximately 12.5% have diabetes. She reiterated that metabolic dysfunction is the common driver across conditions, contributing to the cardiac, renal, and metabolic, or CRM, cluster. With multimorbidity rising significantly from 1999 to 2020, this cluster now affects nearly 1 in 4 adults aged 65 or older, with high-cost event risk intensifying at each layer of disease overlap.

Wolff also highlighted the increased obesity prevalence among adults between the ages of 20 and 39, a historically lower-risk population. She added that childhood obesity trends are driving earlier onset of type 2 diabetes, with incidence in youth roughly doubling between 2002 and 2018 and continuing to increase among young adults.² Additionally, Wolff emphasized that earlier obesity onset extends disease trajectories and drives higher cumulative plan spend over a patient’s lifetime.¹

She concluded by emphasizing the urgency of addressing the metabolic health crisis at a population level.

“We have a population-wide situation here with our metabolic health, across all demographics and all ages,” Wolff concluded. “…The more time goes on, the more comorbidities you have. It's not 1 +1 = 2. It's nonlinear. So, it is compounding, and it's very costly, and it's not just the money; it's our health, it's how we feel, [and] it's how our kids feel.”

Understanding Metabolic Disease Cost Growth Through Claims Data

Building on Wolff’s foundation, Ian Smith, FSA, MAAA, FCA, actuarial senior director at Optum, provided the payer perspective on metabolic disease costs. He first explained that the analysis is derived from a claims-based payer disease costing tool, which organizes data into episodes of care across approximately 500 diseases, enabling trend analysis over time by plan and population.

Smith noted that the tool groups related care into condition-specific episodes, with each claim assigned to 1 episode to avoid double-counting. Additional diagnoses may generate separate episodes if related care occurs, while comorbidities within an episode adjust severity and expected costs. By including both medical and pharmacy coverage, he highlighted that payers can see the whole member picture.

For this analysis, Smith focused on a commercial population of 22 million lives, using data from 2022 through 2024. He emphasized that there is no single standard definition of metabolic disease, so Optum developed a list, which includes diabetes, obesity, hypertension, and heart disease.

Based on this definition, he determined that metabolic conditions accounted for 13% of total spending in the 2024 commercial population, up from just under 12% in 2021. Smith attributed this growth to diabetes and rising pharmacy costs associated with glucagon-like peptide-1 (GLP-1) receptor agonists.

Diabetes remains the highest-cost condition in the dataset, as related spending grew approximately 14% annually from 2022 to 2024, driven almost entirely by pharmacy rather than hospital or physician services. Over the same period, diabetes’s share of metabolic spending rose from 37% to 45%, accounting for nearly half of total metabolic expenditures.

Hypertension and heart disease also rank among the top 15 cost drivers. In contrast, Smith noted that obesity is significantly undercoded in claims data, limiting visibility into its true prevalence and cost impact.

Along the same lines, commercial claims see about 5% diabetes prevalence and 10% obesity, which is much lower than epidemiologic data. Smith highlighted that this reflects that conditions are captured only when members are treated for them and coded in claims.

He then explained how plans use these data to make decisions, noting that payer decision-making is trend- and change-driven, as they set a budget and then look to see where reality deviates from expectation. If something is off, they consider why it is changing, whether it is a 1-time spike or a continuing trend, and if an intervention is effective and predictable enough to incorporate into actuarial models.

However, short time horizons complicate these decisions. Since member tenure is about 2.5 years, plans typically seek a return on investment (ROI) within 1 to 2 years. Smith highlighted that many metabolic interventions, particularly for obesity, deliver benefits over longer time periods, making them difficult to justify in short-term forecasts.

“That's one of the things with obesity [interventions] like GLP-1s: they do have an effect, but that immediate effect of weight loss may not have a short-term health impact, but it definitely does have a long-term health impact,” he concluded. “…How do we categorize that? We’re going to see it slowly through time, and that's what's going to get it into payers’ financials.”

Rethinking Metabolic Health Through an Integrated Care Framework

To round out the session, Melissa Durkee, PharmD, BCACP, national pharmacy programs manager at the US Department of Veterans Affairs National Center for Health Promotion and Disease Prevention, reviewed the emerging paradigm of integrated metabolic health management.

She began by outlining 3 key drivers necessitating an integrated framework. The first is a clinical shift from treating single diseases to addressing interconnected metabolic dysfunction. The second is rising consumer expectations, as younger patients with chronic disease increasingly expect personalized, digital, on-demand care. The third is economic reality, with an urgent need for stakeholders to focus on optimizing the total cost of care and avoiding downstream costs.

Durkee emphasized that metabolic health can no longer be treated as a siloed issue, because clinical, consumer, and economic forces require a unified approach. As Wolff previously noted, metabolic dysfunction underlies multiple disease states, including diabetes, cardiovascular disease, chronic kidney disease, and sleep apnea. Because of this, diabetes management now involves all of these.

Similarly, GLP-1s demonstrate benefits beyond weight loss, including reductions in liver fat, improvement in sleep apnea, and delayed progression from prediabetes to diabetes. Durkee noted that although clinical guidelines increasingly endorse obesity treatment as part of cardiometabolic risk reduction, policy and payment have not fully caught up yet.

In addition, she highlighted the importance of lifestyle and behavioral support, which is often underemphasized in practice. Key challenges include delivering meaningful, effective lifestyle support and measuring ROI on it. Similar to other consumer sectors, patients increasingly expect health care to be continuous, personalized, and digitally accessible.

Digital tools can help meet this demand, including apps, home blood pressure cuffs, and body composition scales. These resources enable patient engagement while generating data to inform clinical decision-making. Durkee emphasized that these tools are intended to augment, not replace, clinical care.

As the system evolves, she stressed the need to move from a drug-budget mindset to total cost of care optimization. While clinicians often select therapies based on clinical benefit, they often lack tools to quantify long-term savings over multiyear horizons. Instead, metabolic health strategy must account for total system costs rather than pharmacy and medical silos.

She added that payment models are increasingly adapting to align incentives with downstream value. Value-based contracts tie reimbursement to outcomes, population-based payment models establish fixed budgets that encourage prevention and innovation, and integrated chronic disease programs provide intensive, data-driven support for high-cost populations to reduce long-term expenditures.

Durkee concluded by emphasizing the need for alignment across 3 domains to support population-level metabolic health management.

“I think [there] are 3 areas that we can lean into when we think about a framework leaving here today: the interconnected science of the clinical care piece—we know that that paradigm is shifting; the personalized consumer risk support that our patients expect; and modernized value-based economics, attempting to really quantify total cost of care,” she concluded. “They all need to work together on our cohesive population health strategy moving forward to optimize care and our value composition.”

References

1. Durkee M, Smith I, Wolff D. The future of metabolic health in managed care: population risk and financial impact. Presented at: AMCP 2026; April 13-16, 2026; Nashville, TN.
2. Trends in diabetes among young people. CDC. May 15, 2024. Accessed April 16, 2026. https://www.cdc.gov/diabetes/data-research/research/trends-new-diabetes-cases-young-people.html