| Domain | Key Finding | Evidence Level |
| Coverage and physiology | Randomized Medicaid coverage produced no detectable change in blood pressure, cholesterol, or HbA1c at 2 years. It did nearly eliminate catastrophic out-of-pocket spending and cut positive depression screens by 9.15 points. | Randomized (Oregon HIE, 12,229 adults) |
| Coverage and mortality | ACA Medicaid expansion was associated with a 0.132 percentage point drop in annual mortality among low-income near-elderly adults, a 9.4% relative reduction, driven by disease-related deaths. | Quasi-experimental, linked death records |
| Cost of the intermediary | Administration consumed 34.2% of U.S. national health expenditure in 2017 at $2,497 per capita, versus 17.0% and $551 in Canada. Insurer overhead alone: $844 versus $146 per capita. | Cross-national accounting analysis |
| The intermediary in clinic | Physicians average 40 prior authorizations per week consuming 13 hours of practice time. 95% report delayed care, 79% report patients abandoning treatment, 26% report a serious adverse event. | National survey, 1,000 physicians |
| Why patients stop incretins | Real-world discontinuation reaches 46.5% in type 2 diabetes and 64.8% in obesity without diabetes, attributed primarily to cost and gastrointestinal effects. | Retrospective cohort |
| Cash versus coverage | LillyDirect tirzepatide vials run $299 to $449 per month against a $1,086 list pen. Medicare's GLP-1 Bridge pays $50 for the KwikPen and explicitly excludes the cheaper vials. | Manufacturer and CMS program documents |
| What to do Monday | Price the cash channel before you price the benefit. For a meaningful share of patients the direct price is now lower than the coinsurance on the covered product. | Practice recommendation |