Latest / Off the Chart: A Business of Medicine Podcast / S1 Ep163: What physicians need to know about Medicare's new obesity drug coverage, with Tracy Zvenyach, Ph.D., M.S., RN, of the Obesity Action Coalition
Transcript
- Keith A. Reynolds 0:00 Our life's work is helping you protect yours. Copic medical liability insurance delivers more than just a standard policy. Our physician-led leadership team supports and protects physicians, APPs, and medical facilities with expertise developed from decades of experience, CME accredited education, and 24/7 hotline support from a physician. copic.com we're Copic here for the humans of healthcare, here for you. Speaker 1 0:26 What we're seeing in this space is a direct result of the system failure, and the way that our healthcare delivery system and our insurance coverage is not built in a way that's supporting our community. Austin Littrell 0:53 Welcome to Off the Chart, a business of medicine podcast, featuring lively and informative conversations with healthcare experts, opinion leaders, and practicing physicians about the challenges facing doctors and medical practices. My name is Austin Latrell. I'm the associate editor of Medical Economics, and I'd like to thank you for joining us today. In today's episode, Medical Economics senior editor Richard Perchin sat down with Dr. Tracy Zenich, Vice President for Advocacy and Research at the Obesity Action Coalition, to talk about the federal push to expand coverage of GLP-1 drugs and what it means for primary care. They get into the new Medicare and Medicaid programs, opening access to these medications, the persistent problem of drug pricing, and the weight bias and stigma that still shapes how patients are treated. Dr. Spanish, thank you for joining us. And with that, let's get into the episode. Richard Payerchin 1:42 I'm Richard Payurchin, reporting for Medical Economics. With me today is Dr. Tracy Zvinich, Vice President for Advocacy and Research for the Obesity Action Coalition. Thank you for joining us today. Speaker 1 1:56 Thank you for having me. Richard Payerchin 1:57 I think a lot of our audience are hopefully familiar with the coalition, for those who may be new, can you introduce yourself and the organization? Speaker 1 2:06 Sure, so the Obesity Action Coalition, we are a national nonprofit. We are dedicated to serving the community of people living with the disease of obesity, and we support our mission through education, advocacy, and a supportive community environment, and we really focus a lot of our work on improving access to evidence-based care, as well as ways to eliminate and reduce weight bias and stigma, as we see it inherent across society and culture. So education also to help people be informed for all the possible decisions about their health care and working with the their clinical community, the Richard Payerchin 2:50 coalition has long advocated for obesity to be recognized and treated as a chronic disease. From a policy standpoint, how far has that come, and maybe what are some still some still some challenges out there. Speaker 1 3:04 Yeah, OAC, we have as an organization, we've been around for over 20 years, 21 years to be precise, and in advocating on these issues, we've been advocating along the way, but specifically on some of the policy barriers that are are familiar to many today. We've been working for the last about 15 years on those issues. We have seen and made some meaningful progress. We do recognize that obesity is increasingly seen as a chronic disease. We see that obviously in the development of many medical guidelines, and then we also see it in our conversations with policymakers, when we go and speak with whether that's regulators or lawmakers, we do, we do recognize there's broader understanding that obesity is much more complex than kind of the old understanding of people, people making choices, or or the the need for people to move more, eat less, kind of that, that old, that old adage is is is fading away, which is good, because that means that the science and the evidence is becoming more mainstream. Richard Payerchin 4:19 What do you hear from primary care physicians around both the policy and the latest clinical developments around obesity as a chronic condition or disease. Speaker 1 4:28 Yeah, we, when we talk to the primary care clinical community, you know, we, we hear different, different perspectives. So some providers are very comfortable, very comfortable with working with patients that live with the disease of obesity, and kind of understanding that complexity from a holistic point of view, and understanding how obesity is associated with so many of those other chronic conditions and complications, like, like you mentioned, and then we have other. In the clinical community, who are kind of testing the waters, or want to want to learn more, want to understand more about obesity medicine, and how to help the patient population. And then we have some, some clinicians in the primary care community that aren't really quite sure yet, and a little bit more resistant to the new obesity medicine treatments and using them in their daily practice. Now I'll say, say that there is this spectrum kind of perspectives that we hear that is then overlaid by many of the the policy and coverage barriers that we see in this space as well, which make it very difficult from an administrative point of view for clinicians, primary care or specialty to to help patients get access to the treatments that they need, and this goes for the full spectrum of obesity care, which includes everything from nutrition counseling to behavioral therapies to, yes, the the pharmacotherapy options, as well as surgical interventions, so it's it's a mix of I think clinician level of comfort and expertise in obesity medicine as a as a discipline, and then also just the the health system barriers and coverage and access to care hurdles that are in place for the clinical community in general, and yeah, of course, you know there are administrative barriers and time constraints across the board, you know, in healthcare in general, but you know we definitely see that for clinicians working with patients in the obesity community Richard Payerchin 6:46 balance is short for better approaches to lifestyle and nutrition for comprehensive health. What exactly would that program do? Speaker 1 6:56 So the balance model is an effort out of the administration to address obesity care in a more comprehensive way. It is structured to offer a the access to the GLP one medications as well as a lifestyle lifestyle support program. The administration has also been able to negotiate a lower price point for the GLP one medications, and, and that is at the level of $245 so that is much lower than the current, you know, retail list prices, and also lower than the the cash pay programs that are available today, so that's that, that's a positive of of this program. Now the administration has recently come out with some updates to the balance model, where balance initially was going to be offered to both the Medicare program for older Americans and the Medicaid program for for states to offer to their, to their Medicaid beneficiaries. Recently, Medicare CMS announced that the Medicare piece of balance side of balance is not going to move forward in 2027 Only balance for Medicaid state state Medicaid programs will be moving forward, so what they have done there, there's a second arm to the programs that CMS are putting forward, called the Medicare GLP one bridge program, so there's bridge and there's balance, and now they're separated, so Medicare will now have access to the GLP one medications through the Bridge program, and state Medicaid plans will have the opportunity to participate in the Balance program. So that's a recent update from from the administration, Richard Payerchin 8:59 but between the Balance model and the GLP one bridge, is that a distinction without a difference, or are there significant policy differences between those two that are going to have, I guess, significant effects going forward? Speaker 1 9:16 They are still similarly structured programs, so for example, they both offer access to the GLP one medications at the same negotiated price, and they also have a set of clinical criteria that a patient has to meet eligibility to participate in the programs, and the clinical eligibility is essentially the same between between the two with a with a couple with a couple of nuances, so they're similar, but now they are split by the eligible population, so bridges for Medicare and balances for Medicaid through the 2027 year, the Medicare for GLP. One bridge program will start on july 1 and run through december 31 2027 The Balance Model program for state Medicaid plans is technically went live on may 1 of 2026 and is open for applications through july 31 of 2026 It's voluntary for state Medicaid programs to participate in the balanced model, and we are eagerly waiting to hear which states choose to participate Richard Payerchin 10:32 under these programs. Will this mean that GLP one drugs will be available on demand for beneficiaries? It sounds like clearly there will still be just like you said, clinical eligibility and physician involvement and prescriptions. Speaker 1 10:48 Yes, yes, absolutely. So, the on the clinician side, there will be provider attestation that will have to take place, saying that yes, this is a patient that meets the clinical criteria to participate in these programs, so the clinician community definitely has a very important role to play here, and you know, an opportunity to be, you know, working with your patient panels and your patient communities to identify who might be good candidates for these programs, and then as far as the clinical criteria goes, it is, it is BM, BMI based, so it's BMI based on and then whether or not someone has additional complications based on their obesity, so the BMI parameters are 27 and above with a list of certain complications of obesity, then it's BMI of 30 and above with a list of other related complications, and then it's a BMI of 35 and above that is, that is not, does not have to be in that, does not have to be with other complications related to obesity, so it's 2730 and 35 and that, and the details of that are publicly available. It's a long list, that's why I'm not going to run through them right now, but those are easily accessible for for clinicians to look into, so hey Keith A. Reynolds 12:30 there, Keith Reynolds here, and welcome to the p2 management minute. In just 60 seconds, we deliver proven real-world tactics you can plug into your practice today, whether that means speeding up check-in, lifting staff morale or nudging patient satisfaction north, no theory, no fluff, just the kind of guidance that fits between appointments and moves the needle before lunch. But the best ideas don't all come from our newsroom, they come from you. Got a clever workflow hack, an employee engagement win, or a lesson learned the hard way? I want to be true. Shoot me an email at K reynolds@mjlifesciences.com with your topic, a quick outline, or even a smartphone clip. We'll handle the rest and get your insights in front of your peers nationwide. Let's make every minute count together. Thanks for watching, and I'll see you in the next p2 Management Minute Richard Payerchin 13:21 with the GLP one bridge program running only for, call it about a year and a half through the end of 2027 do you think that there's going to be enough time there to develop real usable evidence about the maybe the benefits or drawbacks of the program? Speaker 1 13:37 Yeah, so the intent is to from what CMS reports, they now plan to run the Medicare GLP one bridge program through December 2027 but then hope to transition it into the balance back into the balance model in 2028 and that, and they have that amount of time to your point to gather evidence and analyze it and evaluate it based on the health outcomes that they're seeing, or the cost offsets and the cost savings that they're seeing, you know, across the patient population, and that's going to be really important data to demonstrate the value of comprehensive of obesity care, right. And then what needs to happen, though, for bridge to transition into balance is for the Medicare Part D and Medicare Advantage health insurance plans to opt in to participating in the balance program to then carry it forward through the duration of that demonstration program timeline, which would then be December 2031 Richard Payerchin 14:50 Obviously, one of the main issues that I think patients have run into that our physician audience has run into when they start talking with patients about GLP one drugs is the price. Yes, and I know that there has been some national discussion and debate about federal health programs, Medicare and Medicaid, whether those programs should pay for GLP one drugs for CMS to be able to, you know, launch these programs. How would you describe that in terms of, is that a significant, significant shift in policy, would you say Speaker 1 15:23 it is? It does represent a shift in the way that the government is thinking about cover coverage for obesity treatment and obesity management. To date, previous administrations have interpreted statute to essentially say that they did not have the authority to provide coverage for obesity medications, in particular under Medicare Part D, because the way that the statute was written, there's a prohibition uncovering what they, the language states as weight loss drugs, and with the modern innovative treatments, which we consider to be obesity treatments, not weight loss drugs. Weight loss is an outcome, but that's not the disease that we're treating. We have for years, we've advocated and encouraged CMS to reinterpret that part of the statute, and, and in reinterpretation to offer coverage, the last administration, the Biden administration put forward a proposed rule that would have changed the interpretation of of the coverage, they they use the rulemaking process to put forward a proposed rule under for the part D and Medicare Advantage year plan, and when the new and, but it was not finalized, so when the current administration came into office, they decided to take this, these different approaches using the CMMI demonstration model as one one approach, and then the bridge model is actually using a different administrative authority, and so this, the current administration is using just different, different approaches, but the what we're really encouraged by is that these are signs and direct efforts to recognize obesity as a complex chronic disease, and to put forward a pathway for coverage, and that's something that is long overdue and greatly needed Richard Payerchin 17:31 regarding drug pricing. The coalition has issued a statement on drug pricing for anti-obesity medications. How would you summarize that position? Speaker 1 17:41 Yeah, OAC, we've been very forward about the need to bring down the cost of treatments in general, and particularly the medicines for the patient community, given that there's very limited and variable coverage per se for most patients, coverage for obesity medications is not part of the standard benefit, not part of their standard insurance benefit, right. So, when you, when it's not included in your insurance, when you have to look outside, then you're looking at potentially that higher cost options, whether that's, you know, the retail price, or and because the retail price has has been high for quite some time, but we've seen a lot of changes in the drug pricing landscape for this category in the last 12 to 18 months, so even since we have put out our statement on drug pricing, we have seen prices come down, and we have also seen alternative approaches and alternative programs come out that have further reduced the cost of these medications. So, those are positive steps. However, I will say that for those that don't have affordable coverage in their insurance policy, which are most when we do turn to what the alternative programs offer. Most people still can, cannot afford them. They are there, they still cost a lot. So, there's still work to do there. We've, so we've seen progress, but there is still work to do in regards to affordability, and we're also looking at options like how do we address the prior authorization process to make it easier for the clinician community and the patient community to access to these medications, can we develop patient assistance programs, things like that. This is a fast moving part of this space in general, so we're, we're, you know, we're very engaged, and we monitor it very closely, but there's still progress, but more work to be done Richard Payerchin 19:47 as patients are searching for lower-cost alternatives. Compounded semaglutide and other GLP-1 drugs have become a workaround for some patients. Has OAC taken a position on. Compounding GOP one drugs and other anti-obesity medications. Speaker 1 20:05 Yeah, this is another area we follow very closely, because it, it impacts our community so, so, so greatly, you know. And what we're seeing in this space is a direct result of the system failure and the the the way that our healthcare delivery system and our insurance coverage is not built in a way that's supporting our community, because the the affordable coverage is not part of a standard benefit design, that's why we, you know, we're seeing all these alternative options pop up, and yes, there were some years of shortage, which, which kind of catalyzed this, this new market market dynamic, and it has flourished because there's still so much need in the system, so we definitely, we recognize that there are systems failures, we have expressed concern that that there's a different safety and risk profile for patients to consider when they're choosing whether or not to use a compounded or an FDA-approved product, so we do want to ensure that people are aware of aware of those in their decision-making process, but we understand that because of these these gaps in the system that people are put in impossible positions to have to make these these decisions for their, for their health, and that's why we're working so hard to address the policy and systems barriers, so so people don't have to be put in that position. Richard Payerchin 21:34 There still is surgical treatment for obesity, and some patients opt for that they've had some very successful outcomes as well, and could you talk a little bit about the coalition, the OAC, and the approach to potential surgical treatments for patients? Speaker 1 21:53 Yes, I absolutely, and that's such a great point. So, from an OAC perspective, we advocate for access to the full continued continuum of care for for people that need to treat their disease, and at whatever point they are in their journey. So, again, comprehensive obesity care does include a surgical intervention, absolutely, and some, some patients that is the most appropriate intervention for them, for some patients that have had metabolic and bariatric surgery might need to use a medication down the road, right. So, wherever a patient is on their journey, there someone might need to use multiple interventions over time, or even multiple interventions at the same time, right. So, we definitely advocate and support for access to metabolic and bariatric surgery. There are also newer procedures as well in the endoscopic space that are that have strong evidence behind them, and they're growing in access and coverage as well. So absolutely, we are, we strongly support the evidence-based interventions being available for, for you know, clinicians to be able to deliver, prescribe counsel to, to you know, their patients at whatever point they are in their, in their health journey. Richard Payerchin 23:15 What did I not ask about, or what would you like to emphasize, especially for primary care? Speaker 1 23:20 One of the topics that is really threads through our entire discussion and is kind of the root of a lot of barriers and the the hurdles that we see is is weight bias and stigma and weight bias and stigma is inherent in our society, it's inherent in cult in our culture, and what, how it expresses itself in, in healthcare, and in policy, are in policy, in policy, we see a lot of the exclusionary terms, or a lot of the limitations and restrictions that are put in place, where someone has to do these six things before they can get to the next thing, and in healthcare, we see we see bias and stigma in healthcare systems across our healthcare practitioner community. It's inherent, right? So, in how we talk to the patients, in how is the office setting set up by equipment and gowns and the and the exam tables and the scales. How are we, how are we engaging with the patient community living with obesity, so that it's welcoming, it's respectful, it's compassionate, and that is a part of shared decision making, and what's what, what's the best treatment for the for the right patient, and in a setting that's just set up in the right way for for this patient community, and we definitely see a lot of great, great office environments, and then we see some that that are not, so we see a wide variation in that space, and so weight bias in. Stigma is, is definitely an area that I would love to raise. Part of that, it is around the way that we talk about obesity, and one thing that I always like to share with audiences is people-first language, and what that looks like is talking, referring to people living with the disease of obesity, or a patient living with the disease of obesity, not an obese patient, that's that's a very simple way to, simple way to think about it, and then also images, imagery in this is more on the reporting and the media side, is respectful images of people in all body sizes doing normal things that people do every day, and in respectful ways, where we see sometimes in media and in journalism it might be very unflattering or disrespectful or kind of sloppy images of people in larger bodies, and so a lot of times we talk about language and images as well, so those are those are two things that I like to like to add to the conversation, because the weight bias and stigma threads through, and then the words and the images really send the message about this topic. Austin Littrell 26:21 Once again, that was Dr. Tracy Spanish, Vice President for Advocacy and Research at the Obesity Action Coalition, speaking with Medical Economics senior editor Richard Parishen on behalf of the whole Medical Economics and Physicians Practice teams. I'd like to thank you for listening to the show, and ask that you please subscribe, so you don't miss the next episode. As always, be sure to check back on Monday and Thursday mornings for the latest conversations with experts, sharing strategies, stories, and solutions for your practice, you can find us by searching Off the Chart wherever you get your podcasts. And if you'd like the best stories that Medical Economics and Physicians Practice published, delivered straight to your email six days of the week, subscribe to our newsletters@medicaleconomics.com and physicianspractice.com Off the Chart, a Business and Medicine podcast is executive produced by Chris Mazzolini and Keith Reynolds, and produced by Austin Latrell. Medical economics and physicians practice are both members of the MJH Life Sciences family. Thank you. Transcribed by https://otter.ai