I am writing in opposition to the plan to change the approval criteria for glp1 weight loss medications.

These changes would limit access to the most effective tool I have to treat my patients, the majority of whom are racial minorities.  It is a documented fact that obesity disproportionately affects racial minorities. According to the CDC, “Combined data for 2015 through 2017 allowed for assessment by major racial/ethnic categories and found that non-Hispanic black adults had the highest prevalence of obesity (38.4%) overall, followed by Hispanic adults (32.6%) and non-Hispanic white adults (28.6%).”

“Adults with obesity often have multiple-organ system complications from the condition and, as a result, are more at risk for heart disease, stroke, type 2 diabetes, and multiple types of cancers.”

Compared to options available to treat other chronic conditions, few anti-obesity medications exist, and the ones that are available are often contraindicated due to comorbidities.

Even if one of the alternative medications is not contraindicated, your requirement that a patient must try and fail one for six months before a glp1 can be prescribed, is not scientifically based and is potentially harmful. For example, consider the young woman with polycystic ovary syndrome and idiopathic intracranial hypertension for whom quick, substantial weight loss could obviate the need for neurosurgical intervention. I respectfully suggest that my years of training and experience equip me to decide that the patient should be prescribed a glp1 at her first visit with me, not six months later.

I support a requirement that patients should be working to implement appropriate lifestyle changes. I’m sure that I speak for all Medical Weight Loss practices when I say that this is one of the reasons that we spend so much time with our patients. The luxury of having every patient counseled by a registered dietician would be nice. However, specifying that this education must be done by a dietician is impractical. There are not enough dieticians in the state to meet the demand and, consultation with a dietician is, ironically, often not covered for the diagnosis of obesity or overweight. My practice has a number of personnel, none of whom is a registered dietician, who successfully provides this counsel. 

I understand your efforts to control costs.

Have the costs of not treating obesity been calculated? What is the cost to the Virginia Department of Medical Assistance Services, in money and resources utilized, of one myocardial infarction –the ambulance ride, ED visit, CCU admission, cath lab, in-hospital medications, and subsequent lifetime care of the patient’s CAD including cardiologist visits, costly medications, cardiac imaging, etc.

Coronary artery disease is just one of the roughly two hundred comorbidities associated with untreated obesity.

In conclusion, I would also like to ask that you consider how the already onerous prior authorization process is leading to physician (and NP/PA) burnout. The extra time I devote to additional conversations with distressed patients, writing letters, and doing peer-to-peer appeals is precious time away from my children, and spouse. I now have one full time employee whose sole job is dealing with prior auths and appealing denials.

The proposed changes are neither evidence based nor will they lead to savings in the long term. Please do not make the very important job of providing the best possible care to our deserving patients, more difficult than it already is.

Respectfully,

Sommer Knittig, M.D.

Obesity Medicine

Internal Medicine