Admittedly, this comes to you from a place of concussion-inducing-head-banging-against-brick-walls-level frustration. For the past year, I have made it a personal mission to get people suffering from obesity on GLP-1 agonists. These drugs are all in the same class, have identical mechanisms, and three are the same generics. (Ozempic, Wegovy, and Rybelsus are all semaglutide.) They are advertised as Wegovy, Ozempic, Rybelsus, Saxenda, Trulicity, and Mounjaro. To say these are life savers is not an exaggeration. In my mini-experiment of about 60 patients on these medications, thousands of pounds have been lost. My patients on these medicines have struggled for life and have finally seen their hard efforts lead to results. They are fitter, happier, and more confident. Most importantly, they are healthier. Their blood pressures, cholesterol panels, and arthritis symptoms are better. Their fasting blood sugars are lower. Their risk of cardiovascular disease is lower. It is bad enough that access to these medications has been difficult, with out-of-pocket costs approaching $1600 per month and supply chain delays. Now, despite covering these medications, some insurers are labeling all patients on these drugs as diabetics. Since several of these medications are FDA approved for diabetes but not for weight loss, insurers have decided that if a patient fills a script for a GLP-1 agonist, they, by definition, must have diabetes and need to be treated as such. So what is the problem? First, doctors have been prescribing off-label medications for years. It is crazy to have unequivocal data about the benefits of a drug and hold off on prescribing it while the gigantic, rusty wheels of the FDA turn. We are still waiting for new labeling indications on some drugs after decades of using them off-label. We will never tell an insurer that a patient has diabetes to get these medications covered because that is fraud. So, we write the scripts. We use the diagnoses of obesity, morbid obesity, and obesity with complications. Months or weeks later, these same patients appear on our rosters of “diabetic patients needing care.” The insurers want all of these patients to have a diabetic eye exam, blood test, and kidney screen. The problem is they are not diabetic. The labeling of these patients as diabetics has many implications. First, no patient without a disease — especially a chronic one like diabetes — should be labeled as having it in their medical record. It can follow them in their quest for life insurance, certain jobs, licenses, etc. For us, because a significant portion of our “diabetic patient population” has not had the appropriate diabetic screenings, we appear not to take good care of our diabetic patients. As a result, our quality scores go down, and with them, our incentive payments. For example, in one of our programs, 36 of our 200 or so “diabetic patients” do not have diabetes. That is a big number. So here is the kicker, for our practice to achieve the highest ratings, we need to either do these tests on all of these patients, whether or not they have diabetes, or we need to convince the insurance companies to take them off our diabetes lists. This is where my concussions have come in. The latter is not happening. So then, do we give in and do a couple of blood tests and an eye exam on patients that don’t need them? Our patients say go for it! They don’t care. They are so so happy to be where they are. But guess what? Those same insurers will not cover those tests unless we add the diagnosis of diabetes to the orders. Of course, we won’t do that because that is fraud. So, we are stuck for those patients who happen to be covered by these specific plans. I come to you all with this because I am a tiny fish in a massive pond. I am told by many people in the insurance industry, from representatives up to medical directors, that the system is unchangeable due to the complexity of the algorithms used, but “they are working on it.” But, maybe if consumers/patients covered by these plans reach out, this may change a little faster. I know one thing for sure. GLP-1 medication use for obesity is here to stay. The meds will improve, as will the patient’s demand for them. Not only do patients on them not have diabetes, they most likely now will not develop diabetes because they will no longer be obese. I will keep beating my drum. We have long conversations with patients who this policy may impact and explain the pros and cons. Not one patient has said, “No thanks. I don’t want to be labeled as a diabetic.” All would opt for the opportunity to change their lives despite this insane hiccup. Sadly, our stellar scores in the diabetic care arena will go down. But if that is the price to pay for doing the right thing for our patients, so be it. If your patient is labeled as “diabetic” because of these meds, call, write a letter, and let your voice be heard. Don’t sit back and allow them to be bullied into a diagnosis they don’t have because of a “difficult algorithm.” The ultimate irony is that this is the very diagnosis we are trying to prevent, For those curious about my consultations, at the moment, we are keeping a waiting list as my schedule is full, but please talk to your doctors. Almost every primary care doctor I know understands these medications’ impact and is willing to prescribe them. Obesity is not the consequence of bad behaviors it is a disease that finally has effective, safe, lasting treatments. Patients with obesity have been marginalized long enough. We, especially health care providers, have got to start taking down barriers for these patients — not adding to them. Source
