Performance guarantees that are worth signing

The structural problem

In a typical employer GLP-1 program, vendor fees are a modest share of total cost and drug spend is the overwhelming majority. Most performance guarantees place a portion of the vendor fee at risk. Even a total forfeiture of fees leaves the dominant cost line entirely untouched.

This is not necessarily bad faith — vendors that do not control the pharmacy benefit genuinely cannot guarantee drug spend. But it means the guarantee is a quality-assurance instrument, not financial protection, and it should be evaluated as such.

What to negotiate instead

Tie guarantees to persistence and clinical response, not weight loss alone. Persistence is what converts spend into outcomes and is the variable the vendor most directly controls.

Get the measurement baseline in writing, with the data source named. Whoever defines the baseline defines the result. This clause is worth more attention than the guarantee percentage.

Secure an independent audit right. You need the contractual ability to have a third party verify the vendor's own reporting. Vendors that resist this are telling you something.

Add a continuation-review obligation with teeth. Require the vendor to conduct and report documented continuation reviews at defined intervals, with a remedy if they do not.

Where risk-bearing vendors change the calculus

A small number of vendors will place a substantial share of fees at risk against clinical targets, and a smaller number will underwrite medication-reduction outcomes directly. Where that structure is available and your population fits, it is materially better than any guarantee you can negotiate onto a fee-for-service model.

The trade is reach. Risk-bearing vendors gate enrollment more tightly, because they have to. Decide whether you are optimizing for population coverage or for financial protection — you will not fully get both.