Episode Transcript
[00:00:01] Speaker A: Welcome to Obesity a Disease, the official Obesity Medicine association podcast exploring the many facets of the disease of Obesity A Disease podcast is brought to you by the Obesity Medicine Association. A clinical leader in obesity medicine, A
[00:00:28] Speaker B: 33 year old female with class 1 obesity and lipedema has been focused on lifestyle changes with limited results.
Her medical coverage is through Medicaid and in North Carolina they just approved coverage for obesity medications for patients with Medicaid. So she was started on a GLP1 receptor agonist and proceeded to lose £20 over the next six months with marked improvement in her lipedema sustainability symptoms.
Then coverage was discontinued.
Despite continued dietary and physical activity efforts, she began regaining weight and the pain and heaviness in her legs that had improved now returned, significantly impacting her quality of life.
Such is the frustration that patients and providers experience with the fluctuating landscape of obesity medicine coverage. Hi, I'm Dr. Nick Pennings, professor of Family Medicine at the Campbell University School of Osteopathic Medicine and Director of Clinical Education for the Obesity Medicine Associ.
And today I'm joined by Alicia Shelley, MD, and Tracy Norfleet, MD, co chairs of the OMA Advocacy Committee.
Tell us more about yourselves. And let's begin with Alicia.
[00:01:38] Speaker C: Hi, I'm Alicia Shelley. I'm a board certified internal medicine physician as well as a diplomat of the American Board of Obesity. I practice outpatient in Douglasville, Georgia in with WellStar Medical Center.
[00:01:55] Speaker B: All right, thank you. And Tracy.
[00:01:57] Speaker D: Hi, I am Tracy Norfleet. As you know, I am a Chairman co chairman of the advocacy committee for the Obesity Medicine Association.
I have been practicing medicine for over 20 years. I'm certified in obesity and lifestyle medicine and an advocate for the equitable treatment of patients with obesity and also a lived person. I have experience with obesity because I've lived with obesity for the majority of my life.
[00:02:26] Speaker B: Well, thank you, thank you for sharing your insights and welcome to the podcast.
This is a very difficult topic. It's such challenges that healthcare providers face in trying to provide obesity care. And the scenario I provided I think is sort of a typical example of some of the challenges that we're facing. So how are payer policies across the Medicare, Medicaid and commercial insurance evolving in 2026 and what's driving the recent shifts in coverage for anti obesity medications?
[00:03:04] Speaker D: Yeah, I would say the first thing to note, which many of us know now, but some may not, is with Medicare, we now have the Medicare Bridge GLP1 program, which is a demonstration program that's expanding the coverage of GLP1 medications for patients with Medicare Part D who meet the qualifications.
We're excited about this program because it is new and it is increasing access. And although it is not perfect, it is a first step.
As far as Medicaid goes, we have some states that cover, and even with coverage, there are limitations there and barriers that are still there.
And then among commercial payers, majority do not cover obesity management medications. So we have a ways to go when it comes to increasing the equitable access of high quality obesity care.
[00:03:59] Speaker B: Yeah. And Shelly, do you see that these guidelines are actually moving the needle of coverage in coverage decisions?
[00:04:09] Speaker C: So I would say we've definitely come a long way because now we've gone from, you know, understanding that obesity is a chronic disease, that it needs to be treated, that access to care is important to what does that look like in today's society? And so sometimes I do feel that with the guidelines that are there, that especially with some of the commercial payers and even with Medicare, they may not necessarily be allowing access to the way the guidelines are. For example, when we talk about having medications for persons with a BMI of 27 plus a weight related comorbidity or a BMI of 30 and above, sometimes what I'm seeing in my practice is that these commercial pairs would be like, no, you have to have a BMI of 30 with a comorbidity or BMI of 35 and above without a comorbidity for us to cover.
So they're taking some of the guidelines, but not completely all of the guidelines, which is actually having more barriers to patients who really do need it.
[00:05:17] Speaker B: Yeah, it's frustrating when, you know, each insurance company kind of makes up its own rules which are not evidence based. Right.
Yeah. So with this improvement, are we actually reaching the patients that need it the most or are we seeing new disparities developing between different populations?
Tracey, you want to answer that?
[00:05:40] Speaker D: Yeah. I would say we are reaching more patients, but we have not yet gotten to the place where we're reaching all patients who need it the most. There's still health care disparities. We know there are higher rates of obesity in black and Hispanic patients.
And then there's also the cost consideration. So while we do have increased coverage, in particular when we discuss the bridge program, $50 may not seem like a lot to most, but it is a lot to many patients, including Medicare patients. For example, I had a patient in the office with me and after just talking to, learned that after paying her bills, she only had $7 a month left of expense. So even though we have this bridge program where the cost is $50 out of pocket that still is in affordable for her.
[00:06:34] Speaker C: And you know, to add to that too as well, there was an observational study last year in, in Jama Kim et al who looked at EPIC records for over 39 million eligible adult EPIC. And out of that $39 million adult, 30 million eligible adults who had obesity, 2.3% of them actually received a prescription for semaglutide or even tirzepatide even though they were eligible. And you know, and it's not just the doctors not being aware or prescribing it, but it's the access issue where they, even though we may have tried to give you a prescription, but were you able to pick it up from the pharmacy, were you able to continue it over several months?
That is one of the difficulties as well. And they also noted that Hispanic and non Hispanic Asians and non Hispanic black patients were less likely to receive a prescription than non Hispanic white patients. So we are definitely seeing a disparities. It's kind of the haves and the have nots.
[00:07:38] Speaker B: So you see inequitable. Part of the inequitable access is just a lack of prescribing for populations that may need it but. And are eligible for it, but not receiving that.
[00:07:50] Speaker D: Correct, Correct. And I think, you know, as a prescribing clinician physician, in speaking to clinicians, I think that there's still a lot of weight bias and weight stigma out there when it comes to the treatment of obesity. Yes, we recognize it is a chronic disease, but are we yet at the state where we're treating it like we treat other chronic conditions? In other words, not waiting for the patient to bring up treatment, but yet recommending it as a physician for prevention and also for treatment, Weight bias exists in providers, clinicians and even patients themselves. And that's a big barrier that we must continue to drive, to decrease, eliminate so that patients can receive the care that they deserve.
[00:08:38] Speaker B: Yeah, certainly that's frustrating to see providers, you know, not treating obesity having biases towards obesity. But you also mentioned patients too, which I think is very interesting. And do you see that within different patient populations and how should providers address that?
[00:08:56] Speaker D: Yeah, so definitely patients have weight bias and it's not all their fault. You know, there's biases that exist just from growing up and watching cartoons and seeing how patients living in larger bodies are portrayed, are just hearing from unfortunately family members how they feel about people living in larger sized bodies. So we do cover carry a lot of weight bias and then the. Unfortunately, if you present to a medical care provider who also has bias, that can perpetuate that as well.
So it's very hard for patients. I have many patients who will come to me and not even recognize that they actually qualify. I think some of that is due to us comparing ourselves to each other. Unfortunately, over 3% of us live with obesity, and over 75% of us with overweight are obesity. So many of us compare our body sizes to others, but unfortunately, many of us are not at our most healthful state. And because of that, patients with obesity may not ask about medications just thinking that they do not qualify.
[00:10:06] Speaker B: Do you want to add to that, Alicia?
[00:10:09] Speaker C: Oh, I agree 100 fold. Sometimes it's just encouraging patients to, you know, to talk about. Just bring it up so that we can actually have the conversation on how medications can be helpful in what they're doing. And I agree this. Our society that we live in has promoted a lot of weight bias. And. And we've been managing it. And so sometimes for patients, it's just trying to break through. I think the best part of my job is just sharing with a patient that, guess what? There's more than just willpower. It's not your fault. And seeing just them understanding that and just opening up, sometimes they're in tears because there's somebody who understands that this is more than just willpower. I see what you're doing, but there is biology going on that I can't, that maybe willpower is not able to manage as far as to help with managing your will. So it definitely is in our society. But we have a beautiful opportunity to just open the lights for our patients and just share with them. And sometimes just telling them that they're not a failure and that it's not their fault is huge.
[00:11:13] Speaker B: I think that's a very important role for the healthcare provider to be able to shed some of the patient biases that exist out there. One of the biases I sometimes see is family members just being very negative towards people who are losing weight. Right. That they're. That they're very critical of. Of individuals losing weight, whether it be if it's through medication or just weight loss in general. And do you see that? Does that vary among different races or cultures?
Alicia, you want to respond to that?
[00:11:44] Speaker C: Yeah, I would say in my practice, it is something that we see throughout all cultures and ethnicities where you may have a family member who is like, who looks at all the negative, and they're like, oh, don't. Don't take this medic because this is gonna happen. And I've had patients where we've waited years. They could have been eligible to get started on a medication, but because of their children being concerned about it or their family members sharing their concerns, they have stopped, they have held off on the medication. Like, I'll just do it naturally. One year, two years, they still have not have lost a significant amount of weight. And then finally they're like, I just can't listen to them. I had a patient, it took me two years before I convinced her to start a GOP one, and she was finally able to do that. And we got her diabetes controlled because it was, it was more than just weight loss for her. It was like, we need to get your blood sugars controlled. So I don't think it's necessarily based on cultures. I think it's more of that family dynamic because I see it throughout all different races and ethnicities in my practice.
[00:12:52] Speaker B: Yeah. And that's been my experience as well.
And I didn't, you know, wanted to get your insights to see if there was any variation there. But I do think it is a cross cultural concern that we have.
So within Medicaid coverage, are we seeing state to state variation or how wide is that state to state variation for coverage of obesity medications? Tracy, you want to answer that?
[00:13:19] Speaker D: Yeah. So right now there is state to state variation. I believe we have 13 states that are covering Medicaid.
Excuse me, obesity medications in some way are formed, but there's variations. Some only cover severe obesity.
Some require that there's a comorbidity associated with it and specify what that comorbidity is. And then some states will allow for coverage until a person reaches their normal weight and then won't continue coverage. So there's much variation. We're thankful that there is some coverage, but we have a ways to go.
And also recognizing that some state coverage may cover certain medications, where we advocate for the coverage of all medications when it comes to the treatment of this disease. So we've made some progress, but we have a ways to go in treating obesity as equitably as we do for other chronic conditions.
[00:14:19] Speaker B: Yeah. Alicia, did you want to add to that at all?
[00:14:22] Speaker C: Yeah, the one thing I wanted to add was that with the Balance program, it will give an option for Medicaid to opt in for at the state level. But it's also, we're. We're hitting a little bit of weight bias as well, because not all Medicaid programs will opt in. They had until June 30th to say whether they're going to be opting into balance or not. So we haven't gotten the list of states who have decided to do it or to cover it or not. And so that's also a barrier that we're seeing. And I think because it's more individual to the state, that's why we're seeing it varied where some states may cover GOP ones, like you said, just for their FDA indication, their medical condition indication, where others may cover it for weight.
I live in Georgia, so our sister Alabama now covers it for their Medicaid. For GOP1s, however, there was a little bit of politics there because they now have an Eli Lilly plant that is actually being built in the state. So they have a little initiative. I don't know exactly what happened, but they have some incentive to do that. But that may not be the case in other states. And so you may not have that push. And so still more work needs to be done and more advocacy needs to be done at the state level.
[00:15:45] Speaker B: I see the same thing in North Carolina. There's a Novo plant. And interestingly, semaglutide is the drug of choice or you need to fail on it before you can go to other agents. So, yes, politics always plays a role.
So for patients that are on Medicare and Medicaid, is Medicaid covering that $50 additional copay or not?
[00:16:12] Speaker C: No, you have to have either part Medicare Part D or an Eligible Advantage plan. So they're not covering it if you're Medicaid, or at least not in the state of Georgia. Just because we have to go by their State of Georgia's Medicaid guidelines for the prescription.
[00:16:30] Speaker D: Yeah. So if you have dual coverage, it's going to depend on which state you're in.
Typically, if you have the Medicare Part D and have those comorbidities along with the BMI thresholds, you would technically qualify for the program, the GLP1 bridge program.
But it's hard to definitely know if one is covered or not.
It almost feels like a trial and error process at this moment.
So, yeah, yeah.
[00:17:05] Speaker B: Unfortunately, much of the approval process based on formularies is a trial and error process. I always find it very frustrating when you submit something and they say, no, it's not covered. And it's like, well, but what is covered? Well, you have to submit something else to see if it's covered or not. Like, talk about a terribly inefficient system. And it just adds a lot of work on both the healthcare providers, the offices, and even the insurance companies. It's not very efficient on their end either.
But yeah, that's the world we live in.
So how can we make these health care systems, employers and policymakers play a more important role in advancing the treatment of obesity, especially those that are most burdened by obesity related diseases?
[00:17:54] Speaker D: Yeah, I think it really begins with, number one, recognizing obesity as a chronic condition.
Recognizing that it's not just costs that we're speaking of, but we're speaking about health. Not just health for your employees, but health for all, health for the nation. And treating obesity is not just about treating weight, but it's about treating a chronic progressive disease that's related to over 200 other conditions.
So there are downstream costs to avoiding our deciding not to treat obesity, including disability, including patients, not patients, but employees not coming to work. There's so many other costs that are associated with not treating obesity. And at the end of the day, what are you telling your employee when you decide, hey, we're not going to cover your health?
So I think keeping all of those in mind are important for our policymakers. In my experience, Alicia and I both have had the opportunity of visiting Capitol Hill and speaking with representatives. And what I've recognized and learned is that there's a great opportunity for education.
There's a lot of language about costs, but not a lot of language about education and explaining how important it is that we're treating people and showing them and giving them examples of how we can change someone's life and therefore change the lives of their family members and everyone associated with them as a community.
If we just approach this as a disease that deserves a treatment that is equitable to any other chronic condition.
[00:19:37] Speaker B: Yeah. And I think just the ability to exclude obesity treatment from coverage is an example of bias in and of itself.
Yeah. So, Alicia, did you want to add to that?
[00:19:50] Speaker C: Yeah, I just wanted to add to, especially to the policymakers, because the bridge is just a trial and there's no guarantee that on January 1, 2028, when the bridge expires, that the balance that your Medicare insurer will actually opt into the balance plan.
And so therefore, it is important and imperative that we pass the Treat and Reduce Obesity Act. I know we keep talking about this, but it is so imperative so that it's actually in law. And it's actually something that's not optional that you don't have to opt in, but something that these insurers, these Medicare insurers need to actually be required to cover. Because as Medicare goes, so does the other, the commercial insurers go. And so I think as Medicare, they can actually do this and actually it be required, then maybe some of these commercial insurers will also have it as part of their required coverage for people.
[00:20:50] Speaker B: And maybe we should all be sending our local representatives letters about how patients on Medicare that have been able to lose weight and improve their underlying health conditions have benefited from this program in order to keep it going. I think that would be an advocacy strategy that might be helpful to make it not just a bridge, but really a permanent policy.
[00:21:18] Speaker D: Sending those letters are good, but even just picking up the phone and making a phone call just out to your representative and saying, hey, if you have any questions about obesity and why it's important to treat it, I am here for you. Just, just offering that to them so that they have a resource when they're making these big decisions about whether there's coverage and how much coverage and the eligibility and all the things that they actually have a reliable resource to give them the information they need so that they can make a good choice.
[00:21:51] Speaker B: Yeah. And so, Alicia, are there any specific documentation strategies that you use to help get coverage for medications?
[00:21:58] Speaker C: Absolutely. And it first starts off with your progress note. I always have to make sure that I document the failed lifestyle interventions that they've done when they come in. I'm asking, what diet have you done? What do you do for exercise? What weight programs have you been a part of? So making sure that you document that because I've had insurance insurers come back and say, well, have they been on a six month weight loss? This lady has been battling with her weight for all her life. She's been on more than a six month. This is not just her first rodeo. And so it's important that we document what they say and then so that it's in the chart also documenting their medical conditions too, that show that there is a need. Do they have obstructive sleep apnea, do they have heart failure or, you know, kidney, chronic kidney disease? It's important that they see that this is a person who is sick and would benefit from weight loss.
And then also too, because like we were talking about the PA burden, like if you do one drug, they don't tell you whether the other drugs are covered. So you have to do another pa. That's time on your staff, that's time. And if you're the physician that's doing the pas, that's, that's at time for you that you're not compensated for. And so sometimes what we've done in our office is we actually have A list. So we've kept a list of the type of insurers, what they cover. So if I have a question, does this insurer cover this?
She can go back and say, oh, no, they didn't cover it. So at least we can be able to let the patient know we have a plan B in case it doesn't get covered. But finding ways to really improve, improve that workflow is important as well.
[00:23:40] Speaker B: That's great.
Anything to add to that, Tracy?
[00:23:43] Speaker D: Yeah, in addition to that, I typically document their beginning weight. So I create a chart, and it has like a sequential weight, sequential height, and sequential BMI so that whoever's reviewing the chart will be able to see that beginning weight, particularly when you're trying to continue coverage and the patient now has achieved a BMI that's under the threshold that would initially allow you to start the medication.
I think it's important, as Alicia said, to document those comorbidities associated with it. Not just document them, but also document if they're improving or resolving on treatment to show the benefit of taking these medications beyond just weight reduction.
And then finally also documenting when they have to get off of the medication. So if their insurance company is no longer covering it, documenting how perhaps their cardiometabolic parameters may be worsening now that they're off of medication. Because again, we're trying to document and show the benefit of these medications beyond weight, especially for programs like the Medicare GLP 1 bridge program, demonstrate that these medications are important in addition to lifestyle management for not just weight loss, but improvement of obesity and continuing weight management.
[00:25:06] Speaker B: Yeah, I think that those health benefits really are key, and it's what we do it for, right?
[00:25:12] Speaker D: Yeah.
[00:25:14] Speaker B: So we talked a little bit about some of these. But what do each of you see as the most meaningful steps that obesity medicine providers can take at the clinician clinical level to advocate for patients. Patients when coverage is a barrier to treatment.
Let's begin with you, Tracy.
[00:25:32] Speaker D: Yeah. The first thing I do is I just make sure my patients understand that, number one, obesity is not solely their fault. It's not about willpower. So first having that conversation with them about, you know, you deserve treatment for this disease, such as any other condition. And then when we come into barriers, whether it's from their employer, their family members just speaking up, you know, making sure they realize that they're worth.
They're worth the treatment. Just, you know, they have value amongst themselves. As far as coverage amongst employers, I encourage them to reach out to their human resource representatives so that they can hear that their Employees are interested in coverage, and the more they hear about it, the more they'll report it.
I also encourage them to look at other sources as well.
Reach out and join the Obesity Action Coalition to help them with resources as well. So those are some of the things that I'll speak to patients about when it comes to coverage and advocating for themselves.
[00:26:42] Speaker B: And, Alicia, to add to that.
[00:26:44] Speaker C: Yeah, I would say definitely leverage those appeals process, because sometimes they just have, like, an instant denial, like when you send the page, but when you send the appeal with, here is a letter that documents, you know, in their progress. Note that that's documenting their comorbidities and why they need this. Sometimes they will reverse it. So it's definitely important to do the appeals. It can be a little frustrating.
I had one appeal the other day where we. He definitely has moderate obstructive sleep apnea. He definitely needs it. But then they were like, I did the appeal. And they're like, oh, well, he's not part of a comprehensive weight management program. I was like. Like, that's who I am.
So, you know, you just have to keep going, keep going.
So I'm gonna wait a few months, and then I'm gonna restart the process again and see if we can get it covered. But, you know, these are just the hoops we have to go to. But it's worth it, even if it's just for that one patient, you know, what you can do to change their lifestyle. And not only that, we have to look at it. You have this one person, but there's probably many people who are depending on this person. Like, they are a father, they are a son, they're a mother, they're a wife, they're a grandmother. So if we can improve the health of this one person, we may be able to prove the health of the family surrounding it. And although it is a. It is a lot, I'm not going to sit here and lie to you. You know, making sure you have that dedicated staff to help or dedicated staff time so that they can work on these prior authorizations and work on the appeals will be beneficial.
[00:28:14] Speaker D: Yeah.
[00:28:15] Speaker B: I do think the more we appeal, the more likely things will change.
Did you want to add something else?
[00:28:22] Speaker D: Yeah. I would say for patients, as a person living with obesity, sometimes you just have to push back. Right. If you know that you qualify for the medication and your provider perhaps is not listening to you, have that conversation with them or try to have that conversation with them about why you are eligible for treatment.
I've had family members and friends who I know qualify for the medication, who come back and tell me that their providers say they don't, and I have to talk to them about how to advocate for themselves so that they can be considered for treatment. So just because you're told no doesn't mean the answer is no. And sometimes that may mean reaching out beyond your primary care provider to an obesity specialist. You can find them within the Obesity Medicine association. And if that doesn't work and your provider's not listening to you, sometimes you have to consider switching providers.
[00:29:20] Speaker B: Yeah, it is a frustration that I see patients express when they come to see me, that they've tried in the past and not been able to succeed. Well, this has been a great conversation. I'd like to thank you, Dr. Norfleet, Dr. Shelley, for being with us today.
[00:29:39] Speaker C: Thank you. Thank you so much for having us.
[00:29:43] Speaker B: If you like this podcast, please share it with a friend or colleague and help the OMA as we strive to advance clinician understanding of the disease of obesity.
Take care and thank you.
[00:29:54] Speaker A: Thank you for listening to this episode of Obesity a Disease. For more information about obesity medicine, podcasts and other valuable resources from the clinical leaders in obesity Medicine, please visit www. Obesitymedicine.org podcasts. If you enjoyed this episode and want to listen regularly, head out over to itunes where you can subscribe, rate and leave us a much appreciated review. The views expressed in this episode are those of the host and guest and do not necessarily represent the opinions, beliefs or policies of the Obesity Medicine association or its members.
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