Want ROI on GLP-1s and SGLT2i's? Start with finding the 1 in 4 employees with Stage B heart failure.

GLP-1s have become the $100B headline in healthcare. Employers are struggling to sustain and control the cost of covering them, pharmacy spend is spiking, and debates over ROI dominate boardrooms. Here is the inconvenient truth. Without finding the 1 in 4 employees with silent, Stage B heart failure, or the millions with early chronic kidney disease, those GLP-1 and SGLT2i dollars are only a small part of the story. We medicate the visible problems, weight and diabetes, while ignoring the hidden precursors that drive $30,000 to $50,000 heart failure hospitalizations, dialysis costs above $90,000 a year, and billions in lost productivity.

The hidden threat employers miss

Heart failure does not start in the ICU. It starts quietly, with structural heart changes that most employees and even physicians never see. The AHA calls this Stage B HF, or Pre-HF. It is asymptomatic but measurable disease, often shown as left atrial enlargement, left ventricular hypertrophy, and increased cardiac filling pressures. These are commonly linked to obesity, hypertension, type 2 diabetes, and CKD. CKD often evolves in parallel, progressing silently until late-stage decline forces dialysis or transplant.

• A 2024 report from the CDC's National Center for Health Statistics showed that nearly half of U.S. adults (47.7%) have hypertension, yet only 20.7% achieve adequate control despite treatment.
• Roughly 1 in 4 high-risk adults screened show Stage B HF changes.
• Up to 40% of adults with diabetes have CKD, many undiagnosed until late stages.
• 60% of CKD patients have at least one structural or functional cardiac abnormality, such as LVH or diastolic dysfunction, even when asymptomatic.
• Hospitalizations cost $30,000 to $50,000 each for heart failure, and dialysis can exceed $90,000 annually.
• Progression is predictable. Up to half of Stage B patients develop symptomatic HF within five years, and CKD follows similar trajectories.

You can only manage what you have measured, yet early detection is abysmal. Primary care misses 50% to 70% of early HF and CKD cases for lack of systematic screening. Earlier this year I nominated echocardiography screening to prevent heart failure to the USPSTF. Their January 2025 response was to decline, not because the evidence is weak, but because their agenda is full. In practice that means no Medicare, Medicare Advantage, or ACA-mandated coverage, no zero cost-sharing, and no systemic push to act early.

Employers do not have to wait. Fully insured groups, 40% to 50% of the U.S. commercial market, have the flexibility to cover tests, integrate protocols into wellness programs, and pull prevention forward.

Do not over-index on a single lab

BNP and NT-proBNP are valuable signals but poor stand-alone decision makers. Cut-offs vary, results fall into grey zones, and clinical response is inconsistent and too often random acts of kindness, also known as variability in care.

The ROI is not in ordering one test. It is in structured pathways.

• Biomarkers. NT-proBNP for heart failure stress, UACR and eGFR for CKD.
• Handheld screening echocardiography to confirm structural disease.
• Non-invasive cardiac pressure testing to surface elevated filling pressures earlier, including the non-invasive assessment offered by Ventric Health.
• Risk scores that layer diabetes, obesity, hypertension, and family history.
• Treatment initiation protocols that tie GLP-1 and SGLT2i access directly to risk documentation, bypassing prior-auth bottlenecks.

Employers should not just subsidize tests. They should subsidize consistency, protocolized approaches that turn a low-cost urine test, a biomarker, and a screening echo into a multimillion dollar savings play.

Inverting the utilization management question

GLP-1s and SGLT2is are not just diabetes or weight-loss drugs. They are cardio-renal prevention tools. The evidence:

• SGLT2i's cut heart failure progression and hospitalizations by 20% to 30%, with Class I guideline support.
• GLP-1s in obesity reduce cardiovascular events and HF symptoms, per the SELECT trial.
• Combination therapy may cut HF risk by 40% to 50%.
• This does not even account for the added benefit of GLP-1s in reducing metabolic-associated fatty liver disease, an independent risk factor for both heart failure and death.

Yet only 10% to 15% of eligible patients receive them. Why? Sticker shock of $500 to $1,300 a month, prior auths, and narrow coverage. Employers can flip the script by tying access to early detection. Invert the question. If a patient has evidence of Stage B HF, why are they not on an SGLT2i, and if they are obese, diabetic, or show evidence of MAFLD, why not also a GLP-1?

Why employers are the pivotal players

Fully insured groups face 7% to 8% premium hikes and pharmacy spend consuming 25% to 30% of budgets. GLP-1s already accounted for 10.5% of claims in 2024, up from 6.9% in 2022. Coverage is expanding, but unevenly. 36% of employers cover GLP-1s for both diabetes and obesity, and only 20% cover weight management broadly.

Here is the lever. Do not just say yes or no to GLP-1 and SGLT2i coverage. Say yes when cardio-renal disease or Stage B HF is detected, diagnosed, and a care plan for intervention is defined.

• Wellness integration. Leverage non-invasive cardiac pressure testing in screening, and consider natriuretic peptide testing or a handheld echo alongside health risk assessments, then auto-approve GLP-1 or SGLT2i for positive screens.
• Value-based PBM contracts. Demand rebates tied to fewer heart failure admissions.
• Targeted pilots. Focus on type 2 diabetes, CKD, obesity, and hypertension cohorts where Stage B HF prevalence is highest.
• Equity lens. Use telehealth and subsidies to close gaps for underserved employees, where utilization lags 20% to 40%.

A call to action

Employers are pouring millions into GLP-1 coverage. The smarter play is to spend a fraction of that on diagnostics that surface the hidden disease driving the biggest claims. This is prevention that pays. Lower claims, healthier employees, and a bending long-term cost curve. The USPSTF may lag, but employers do not have to. Make prevention the default.

A question for readers. If you are covering GLP-1s and SGLT2is today and struggling to control cost, what is stopping you from tying access to Stage B detection? That is where the real ROI lies.

All views, analyses, and services presented here reflect my independent professional perspective, informed by more than two decades of real-world experience, and do not represent the views or positions of any current or former employer or affiliated organization. I serve on the advisory board of Ventric Health, referenced above.