Who governs access? GLP-1 medicines and the new stewardship challenge

Key takeaways:

·         As GLP-1 distribution expands, oversight of access pathways is becoming an increasingly important governance issue.

·         Manufacturers are increasingly shaping the channels through which patients access treatment, raising questions about oversight and responsibility.

·         Weak controls over distribution channels may create regulatory, reputational and litigation risks.

GLP-1 medicines have rapidly become one of the fastest-growing segments in global healthcare, driven by strong clinical outcomes and expanding use in obesity and cardiovascular disease indications. For investors, this has largely been framed as a story of commercial success. From a stewardship perspective, is this increasingly a story about how access is governed?

As healthcare becomes more consumerised, an underlying structural shift is emerging. Many patients can now access treatment through digital platforms, telehealth providers, and direct-to-consumer models rather than through traditional physician-led pathways. Manufacturers are no longer solely supplying medicines into an existing distribution system; they are increasingly shaping how patients access these medicines. Eli Lilly’s* ‘LillyDirect’, for example, combines disease education, access to independent providers[1], and third-party pharmacy fulfilment. Meanwhile Novo Nordisk* has used NovoCare Pharmacy and telehealth partnerships to expand access to Wegovy[2].

This evolution matters because it changes where risk sits. As access pathways become more fragmented and digitally intermediated, responsibility becomes less clearly defined. Companies correctly note that prescribing decisions sit with independent clinicians. However, this does not fully reflect the reality that manufacturers may design, enable, and economically benefit from the channels through which those decisions are made.

The investment stewardship perspective

The stewardship issue, therefore, is about whether companies exercise appropriate oversight over the distribution systems they help create. This includes partner selection, standards for compliant promotion, safeguards around patient screening and contraindications, monitoring of adverse effects, and the ability to intervene or withdraw from partnerships where risks emerge.

Emerging evidence suggests that these risks are not theoretical. A 2024 analysis of a large GLP-1-supported, digital, weight-loss service found prescribing errors in 4.4% of more than 37,000 prescriptions with errors most commonly linked to gaps in safety counselling and inadequate investigation of contraindications[3]. At the same time, U.S. regulators have increased scrutiny of non-approved compounded GLP-1 products and misleading promotion, underscoring that weaknesses in access pathways can translate into regulatory intervention.[4]

From stewardship to financial outcomes

From an investor perspective, the key question is how these governance dynamics translate into financial outcomes through potential revenue or cost impacts or through potential compliance or litigation risks. While broader access can support near-term growth, poorly governed access models can undermine the durability of that growth over time.

First, where medicines reach patients without appropriate safeguards, regulatory scrutiny is likely to intensify. This can constrain distribution channels, increase compliance requirements, and, in some cases, narrow the eligible patient population. Second, adverse outcomes associated with specific access pathways can give rise to litigation and reputational risks, particularly where companies have played a role in enabling those channels. 

Developments in the U.S. obesity market illustrate this dynamic. Novo Nordisk expanded Wegovy access through telehealth partners in 2025, before terminating its collaboration with telehealth company Hims & Hers* over concerns relating to compounded semaglutide and marketing practices. A revised collaboration in 2026 introduced tighter conditions around product use and promotion[5]. For investors, the significance lies in what this demonstrates - channel design and the ability to intervene are central to managing risk in practice.

Access pathways in practice

For stewardship, this points to a clear expectation. Where companies shape or enable new access pathways, we believe oversight should be proportionate to their degree of influence, particularly where that influence may increase exposure to legal and regulatory liability. This includes rigorous partner due diligence, clear standards for appropriate use, visibility over channel performance, and credible mechanisms to monitor and act on emerging risks. 

We are engaging with the intention to understand how companies are designing and overseeing these newer access pathways in practice, including how they monitor partner conduct, assess patient outcomes, and identify emerging risks. This includes the tools and data they use to maintain visibility across potentially highly fragmented channels, as well as the mechanisms available to intervene when issues arise.

In an increasingly consumerised healthcare environment, governance is embedded in how access is delivered and in how effectively companies are able to respond as those delivery models evolve. 

 

Assumptions, opinions, and estimates are provided for illustrative purposes only. There is no guarantee that any forecasts made will come to pass.

*For illustrative purposes only. Reference to a particular security is on a historic basis and does not mean that the security is currently held or will be held within an L&G portfolio. The above information does not constitute a recommendation to buy or sell any security.

 
[1] Lilly Launches End-to-End Digital Healthcare Experience through LillyDirect™ | Eli Lilly and Company
[2] Digital partnerships & solutions
[3] GLP-1 RA Prescribing Errors in a Multidisciplinary Digital Weight-Loss Service: A Retrospective Quantitative Analysis - PMC
[4] FDA Intends to Take Action Against Non-FDA-Approved GLP-1 Drugs | FDA
[5] Hims Inc. - Hims & Hers Announces Strategic Shift for US Weight Loss Business