I am writing to object to any additional barriers to GLP1 Agonist medication for patients suffering from the chronic condition of obesity, especially the vulnerable medicaid population.
I am a bariatric medicine specialist. Most patients come to me after trying lifestyle change and commercial programs for years. They are frustrated and exhausted. Many need the support of medication right away. There is much scientific evidence that GLP1Agonists, at this time, are the most effective treatment. Delaying access when the physician using best practices as the guide deems it necessary leads to more frustration and loss of many patients as well as more morbidity and mortality while waiting for access to the medication that is needed.
Whatever the cost is of covering GLP1 Agonists in this population, it will be less than covering the debilitation of spine and joint damage from obesity which includes but not limited to hip and knee replacements that become necessary as a result of wear and tear , the medical consequences of obstructive sleep apnea which include heart disease and much more, and the damage to the brain from intracranial hypertension to name a few consequences of obesity. For example, a recent patient with a h/o of non alcoholic steatohepatitis and was regaining weight very fast which would have led to cirrhosis , was able to prevent cirrhosis of the liver with the use of a GLP1A. Another example is a patient with medicaid and the diagnosis of prader willi syndrome which causes an uncontrollable appetite as a result of this genetic disorder. The only hope was a GLP1 A. This medication has been very effective and he is now in control and losing weight. he would die within a year or two if he were not getting this medication.
Access to this medication is vital for many patients and placing more barriers in front of access to it will lead to more morbidity and mortality and cost in other ways.
Daphne L. Bryan, MD
I believe that the new guidelines for Wegovy and Saxenda use are too strict. It will be very difficult if not impossible to have each of these individuals assessed by a registered dietitian. Plus, it will also be cost prohibitive. A BMI of greater than 40 is the recommendation used for bariatric surgery. We would like to treat these individuals before they reach that mark. For the betterment of the health of the community, it would be better to lower this BMI to what is deemed obese, which is 30 and up.
I am an obesity medicine specialist and I oppose several of the proposed changes.
For a patient with class I obesity, and CAD or DM II, they should be eligible for saxenda and wegovy. These are two major comorbidities that are significantly improved by GLP-1 RA and weight loss.
Should NOT have to have tried another drug within 6 months. If they didn't tolerate a drug in the past, I would not re-prescribe as that could cause patient harm. The requirement should be that they have tried another drug for weight loss in the past OR other drugs are not indicated due to their medical comorbidities.
Requiring assessment by RD is unnecessary step that will disproportionately effect more remote patient populations as these areas are unlikely to have access to an RD.
Change "member not currently on other GLP1- RA" to "Patient will not be on two GLP-1 RAs at the same time" We often have to switch between GLP-1 RA s for various reasons, which requires both to be active at the same time.
The proposed service authorization changes are not only too strict, they are much too difficult for the average person to comply with. People on Medicaid are already having difficulty with finances. Having to meet with another provider (nutritional counselor), is adding another financial burden. Patients are already being counseled by their weight-loss provider (PCP, bariatrician, etc). Why put an additional roadblock in their way if it's not absolutely necessary?Also, the BMI of 40 is in Bariatric Surgery territory. Thank you.
I am an obesity medicine specialist and writing to reject the proposed changes being made to the prior authorization process for anti-obesity medications for the Virginia Medicaid population. I am concerned with the following proposed changes:
Item 4: This is vague and somewhat antagonizing. Yes, obesity is life threatening over time when not properly treated; otherwise, VA Medicaid would not pay for bariatric surgery.
Item 5: How could a patient try another GLP-1 RA prior to Wegovy or Saxenda if VA medicaid will not cover off label prescribing of GLP-1 RA?
This prior authorization form is tedious, not geared towards the patient's benefit, and full of bias. The decision making process implemented in this form is not in alignment with any scientific information or the treatment recommendations from any medical society.
Do not change the requirements to obtain obesity medications. Obesity is a disease affecting our nation, worsening our health, and driving up health care costs by virtue of the health consequences! It is important to get on top of this illness before it gets extreme. Our state and country could do this one thing to lower health care costs by investing in a disease that is killing our people. Please do not make the requirements any more stringent than they already are.
I am an internal medicine physician who has practiced obesity medicine for the past 10 years. During this time, the single biggest advance in the treatment of obesity has been FDA approval of GLP1 agonists. I have been able to help so many more people become successful and regain their lives. None of the other anti-obesity medicines work nearly as well. I have seen patients who have failed weight loss surgery become successful again. GLP1 agonists have helped people get their lifesaving transplant surgeries and life altering joint replacements. I have also had patients no longer need their joint replacements.
I work at an urban academic medical center and treat a large number of Medicaid patients. The ability to use GLP1 agonists has been transformative. I understand these medications are expensive, but so is treating the downstream cost of obesity not only for the patient but for society as a whole.
The proposed changes are not in line with society guidelines for treating obesity nor the FDA indications for use of these medications. I think it is reasonable to try another medication for 6 months if there are no contraindications, but use of anti-obesity medications is indicated in patients with a BMI of 30 or more or 27 or more with 1 weight related comorbidity. Additionally, in my 30 years of medical practice, I have never had a single patient see a dietitian and lose weight. We do all of our own nutritional counseling and have been very successful.
I am asking that you please reconsider the barriers the are being proposed because they will leave some of our most vulnerable patients without access to this very effective treatment.
I am a nurse practitioner and worked in the area of weight management, childhood obesity (classes) and cardiac rehabilitation from 2005 until 2018. I currently work as a primary care provider at a Free Clinic with most patients covered by Medicaid. GLP1 agonists have been embraced by my patient panel and many have seen successful weight loss for the first time in their lives. They have already been educated by their primary care and community health workers on nutrition, portion control and healthier choices. Given the state of our economy, many are unable to access nutritious and inexpensive foods as they live in a food desert. The cheapest foods are often higher in calories and high in sugar. So, requiring a nutritional visit by a registered dietician (RD) is yet another barrier to accessing much-needed GLP-1 medication. Most plans will not cover a dietician consult and RD’s are difficult to find. Money is tight when rent is going up as well as gas and food. They have been given many educational booklets, provided 1:1 nutritional teaching and are aware of healthier food choices. However, once they start seeing results with a GLP-1, they become additionally motivated to make better choices. Increasing the BMI requirement does not make sense when a BMI of 40 places them at morbidly obese and eligible for bariatric surgery. Why don’t we use evidence-based medications to promote weight loss prior to surgical options? Once patients have experienced a myocardial infarction and/or stent or bypass, they are very motivated to lose weight and make lifestyle changes. Don’t make them wait to be eligible for a GLP1 or have them meet additional requirements prior to obtaining these medications. Many weight loss drugs are contraindicated for those with a history of hypertension, heart disease or cardiac arrythmias. I will not prescribe these higher risk medications for weight loss as this would not be appropriate. Primary care providers, caring for this vulnerable and marginalized population, have been so excited to track significant weight loss with our Medicaid patients whose BMI is 30-40. They now can take lower doses of antihypertensives, decrease the dose of their diabetes medication and feel better about themselves. The positive results to mental health and depression from weight loss have been life-altering for my patients. Self-esteem is restored. They continue to visit the gym and meal-plan, but they now can see that it works with the addition of a GLP-1. Listen to those of us who work with Medicaid patients every single day. Please do not limit access to this medication for the Medicaid population. They deserve something positive in their lives.
Do not change the requirements to obtain the obesity medicine. Obesity is a major disease that affects the overall body which comes at a major expense.
I would like to take this time to stress the concerns that I have about the proposed changes to criteria for weight management for medicaid recipients in the state of Virginia. I have been prescribing the class of medication including Wegovy for few years now. It not only helps people to lose weight but allows people to lower their blood pressures, lower cholesterol levels, improve insulin levels/glucose levels and most importantly offering a reduction in cardiovascular events with the latest data showing heart failure protection. In my opinion the benefit is far beyond that of weight loss. This class of medication has been life changing for many people of Southwest Virginia. I have been working in Southwest Virginia for the past 9 years, in my hometown. Lee County is significantly underserved for multiple medal reasons including lack of medical services beyond primary care and emergency room care, we have a lack of specialists that can provide the essential care patients of Lee County need without a significant drive which is difficult for many citizens of the county. Obesity is a growing concern for the county and there is high population of individuals with significantly elevated BMIs, including that of children. With the proposed changes for the medication, patients will be far advanced in illness levels before being offered the medication that could potentially cost the state of Virginia millions of dollars in healthcare costs related to treatments of cardiovascular disease and/or heart failure, if this medication is still allowed at current criteria it could save the state millions of dollars over time. This will be a major setback for the patients of Lee County as on the proposed recommendations is an evaluation by dietician which there is only 1 in Lee, Scott and Wise counties to the best of my knowledge, which would make obtaining consults practically impossible. If there is any way possible this class of medication could be held at same criteria for approval that is currently in place would be ideal, making changes to the new criteria would be detrimental to the people of Lee County and many would be disqualified mainly for the inability to not have consults with dieticians. Thank you for your time and thank you for taking interest in the people of Southwest Virginia.
As with any chronic treatable disease, as affirmed by the AMA in 2013 and most related professional medical organizations, access to the most effective treatments for obesity should not be made more difficult to access; rather, it should be made easier. Those proposed stipulations that are specifically problematic are as follows:
Thank you for the opportunity to opine on this very important topic that is up for discussion.
Obesity is an epidemic! Why are you going to make it harder for these people. Decreasing obesity will intern, decrease comorbidities. Look at the forest and not at the tree.
Please don’t change the criteria for wegovy because my daughter really needs this and it has been working exceptionally well for her. Without this medication she would not be able to get back to her active life prior to using this medication.
As a Board Certified Obesity Medicine Specialist for a decade, I would like to comment on the plan to change the criteria for accessing Wegovy for Medicaid Patients. While as a taxpayer I applaud your efforts to maintain the solvency of the system by limiting prescriptions of expensive GLP medications, I think it is important for me to advocate on behalf of my patients.
My Medicaid patients are often examples of the close statistical association between poverty and obesity, and massive weight loss (such as by Bariatric Surgery) is known to be associated with an improvement in employment and life circumstances. GLP meds used as a tool with an individualized program such as mine can be truly life changing and can treat or prevent a number of expensive-to-treat comorbidities. Wegovy can be used safely with hypertension and mental health meds/problems (common in this population) and has the best total weight loss of any of my medication options, so it is critical that it remain available to my patients without onerous criteria. I agree that patients should be seen by EITHER a dietician or a medical provider (MD/DO or NP/PA) and should be engaged in exercise and dietary changes, and I don't have a huge objection to a BMI criteria of 35, OR 30 with any comorbidity (HTN, Pre-DM II, OSA, SUI, OA of weight-bearing joints, HLD) but I worry that if you change the criteria to be different that the package labelling (BMI 30 or 27 with comorbidity) that this may be a slippery slope leading to very reduced availability. I also already spend a HUGE amount of time submitting these forms, often repeatedly and also repeatedly faxing practically the whole medical record when I and my staff should be seeing more patients or going home to our families and I am concerned that you will make this worse.
Thank you for your time,
Rachel Chastanet, MD, FACP, Board Certified in Obesity Medicine
I would like to begin by expressing my sincere appreciation for the crucial role the Virginia Department of Medical Assistance Services plays in ensuring that the Medicaid population in our state receives access to essential healthcare services. Your commitment to providing anti-obesity medications to this vulnerable population is commendable, given that they face the highest risk of healthcare-related mortality and morbidity due to obesity.
While I acknowledge the importance of balancing fiscal responsibility with the delivery of high-quality healthcare services, I feel that it my duty to address certain concerns regarding the proposed restrictions on anti-obesity medications outside their FDA-approved indications, as part of your efforts to optimize the insurance plan's financial sustainability.
First and foremost, it is essential to emphasize that obesity is a complex medical condition associated with numerous risk factors and over 200 medical diseases, including 13 types of cancer. Limiting eligibility for anti-obesity medications based on just five risk factors (CAD, dyslipidemia, hypertension, sleep apnea or Type 2 Diabetes) does not capture the full scope of medical conditions and complications that can arise from obesity. This approach risks leaving many patients, especially Black and Hispanic patients, at high risk of developing Type 2 Diabetes including those with Metabolic Syndrome, Polycystic Ovarian Syndrome, Insulin Resistance and Pre-Diabetes without access to effective treatments that prevent this progression.
Furthermore, the requirement for patients to attempt and fail a non-GLP-1 weight loss medication for six months before considering GLP-1 weight loss medication is problematic for several reasons. This approach not only wastes valuable time and resources but also undermines the autonomy of physicians and providers with decades of education and experience to make treatment decisions based on each patient's unique medical history and needs. It effectively mandates physicians and providers to make non-evidence-based medical decisions, which can be both inappropriate and potentially dangerous.
To illustrate the inappropriateness of such a requirement, consider a parallel scenario in which a patient with a life-threatening condition such as breast cancer is asked to try a less effective and non-evidence-based treatment for six months before receiving a treatment that has been proven to be twice as effective. This approach would rightly be seen as medically unsound and ethically questionable.
Additionally, we must address the issue of requiring patients to be evaluated by a registered dietitian, particularly in rural areas where there are critical shortages. This population is at the greatest risk of healthcare disparities in Virginia. The shortage of registered dietician in our state hinders the ability of patients to receive timely and appropriate nutritional assessments. According to the Commission on Dietetic Registration, there were 2,546 Registered Dietitian and Nutritionists as of April 2022. Given Virginia's current population of adults with obesity, this equates to 1 Registered Dietitian Nutritionist for every 882 adults with obesity. This does not even take into account the 60% of Virginia adults that fall into both the overweight and obesity category or the 31% of Virginia children with overweight or obesity. Factoring in all of these, the ratio would be 1 Registered Dietitian Nutritionist for every 1,834 adults and children with overweight and obesity.
I understand the concern about the upfront cost associated with anti-obesity medications. However, numerous studies have consistently shown that treating and preventing obesity results in cost savings, with significant benefits becoming evident as early as one year and certainly after five years. These findings are supported by studies from the Harvard T.H. Chan School of Public Health which clearly demonstrate that addressing obesity leads to substantial financial benefits for the healthcare system in the long term. Delaying comprehensive treatment for obesity only compounds future costs and extends the burden to the Virginia Medicaid program.
In conclusion, I urge the Virginia Department of Medical Assistance Services to reconsider the proposed restrictions on anti-obesity medications. I believe that addressing obesity comprehensively, without undue barriers, not only improves patient outcomes but also represents a sound fiscal strategy in the long run. I am confident that, by working together, we can develop policies that prioritize both the health of our Medicaid population and the financial sustainability of our Medicaid program.
Thank you for your time and consideration. I am happy to volunteer my time and expertise in obesity medicine to the Virginia Department of Medical Assistance Services and serve as a resource in future decision-making regarding anti-obesity medication coverage. I look forward to further dialogue and collaboration to ensure the best possible outcomes for all Virginians.
Dr. Catherine Varney, DO
Obesity Medicine Director, UVA Health
I am 34 years old on Wegovy and I have lost 125 pounds and counting. I used to have depression, low self-esteem and confidence, fatty liver, prediabetes, high cholesterol, high blood pressure, sleep apnea, unable to exercise, and have to buy 2 seats on the plane, and probably other issues I haven't mentioned too. Since I have been on Wegovy and lost weight, all of these issues have improved and resolved. I am happier, I am able to exercise, and I just generally feel and live better. Wegovy has absolutely changed my life. I cannot imagine being without this medication or restricting other from getting it even further. I think I am preventing many costly complications down the line like so many of the doctors have said in other comments.
I wanted to state that I believe that the current proposal for access to GLP-1s is overly restrictive and has to potential to limit access to a significant portion of patients that would greatly benefit from the medication. Obesity, and often as resulting in diabetes, is a significant challenge in the Medicaid population. My experience is that ability to treat with the current prior authorization process and guidelines provides this population with the potential to significantly impact their quality of life while also decreasing the risk of diabetes and the comorbidities that go along with it. The timeline of only 6 months seems overly restrictive. Speaking from personal use of the progress. I have been on Wegovy for over 12 months and continue to see additional weight loss and also movement of blood sugar from prediabetic to normal levels and a continued . The majority of alternative products tend to increase blood pressure which tends to go along with obesity. The proposed steps for approval are also prohibitive and has the potential to decrease access due to the steps required for approval. The new proposal has the appearance of an unfunded mandate that will increase the time both pharmacists and physicians must spend to get the product approved without an increase in reimbursement which again will limit this populations access to a beneficial medication.
I strongly disagree that preconditions for access to weight loss medications should follow the proposed model. To say we cannot treat a condition until it is life threatening or urgent argues against all common sense. We who work in primary care teaching our patients about lifestyle changes and guiding them with medications to help understand this best. Respectfully would allow providers trained and licensed to judge who needs what to do just that.
As a physician who provides obesity care and is trained in Internal Medicine, I know without a doubt the damage that will be done when patients cannot access medications for assistance with obesity treatment. The fact that this refers to "weight loss medication" is telling. Using tools to treat obesity is not about the weight loss, but weight loss is one tool for managing chronic disease.
The evidence is clear that excess adipose tissue (resulting in higher body weight) is a major factor influencing the risk of many disease states, including cardiovascular disease, diabetes, NAFLD (quickly becoming the most common cause of liver transplants in this country) and cancer. We also know that both relatively small and large losses of body fat improves these outcomes and reduces the risk of disease. Until recently, we have not had studies that show these hard outcomes because we have not had adequate tools to create the body weight loss necessary to see that signal in the data.
Based on the information in the SELECT trial of Semaglutide, we now have proof that use of medication can not only drive weight loss but also lead to decreases in adverse cardiovascular outcomes such as stroke and heart attack.
For many years I practiced in an environment where patients with medicaid did not have access to the gold standard of medications to treat obesity, and in the last year I have been able to offer my patients life changing treatment. Many patients have resolved or significantly improved their diabetes, been able to get their knee replacements, or come off of their blood pressure medications. I have had patients that are able to recieve a kidney transplant and lung transplant because their BMI finally qualified. THIS IS NOT JUST ABOUT WEIGHT LOSS. IT IS A TOOL FOR SURVIVAL.
I refuse to believe that we would be back to allowing the patients with the most need to not have a tool that we know would change their lives. Because a patient does not have an employer providing insurance coverage should not mean that they die on a transplant list, or continue to be bed bound because of their severe osteoarthritis pain. Patients shouldn't need dialysis because their diabetes remains severely uncontrolled.
My patients need access to obesity treatment.
Obesity being a disease should motivate law makers and insurance companies to decrease "the hoops" patients are forced to jump through for medication to treat the disease. Increasing the requirements for approval for this medication is another example of ignorance and discrimination.
I am an advanced practice nurse practitioner who has been prescribing Wegovy since earlier this year. It had changed some of my patients' lives. The prescribing limitations, requirements, hoops we are being asked to jump through are truly disturbing and a barrier to care. Please make this medication easier to obtain, no more difficult.
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.
Sommer Knittig, M.D.
The proposed changes are not in line with current literature that supports access to care to treat the disease of obesity. Making changes that are discriminating toward patients who are affected by the disease of obesity and therefore restricts access to care to medical treatment. This is not keeping with current medical Scientific base guidelines or FDA guidelines are indications for pharmacotherapy. The medical and financial costs to delaying therapy should also be considered when making such policy decisions.
I am a NP treating the disease of obesity both in the medically managed population and the surgical weight loss population. I use anti- obesity medications in both populations and it has been imperative to the treatment of this chronic recurrent disease that associated with numerous risk factors and over 200 medical diseases, including 13 types of cancer. The proposed changes are not in line with current literature or national recommendation for treating the disease of obesity.
The BMI mandate changes alone are not keeping with current medical Scientific base guidelines. Specifying mandating that this education must be done by a dietician is impractical.
There are NOT enough dietitians in the state of Virginia to meet the demand and consultation are generally NOT covered for the diagnosis of obesity.
Having to have a patient fail medications that are unsafe for that patient to be on in the first place is unsafe and unethical.
I am an internal medicine nurse practitioner and request for Wegovy to be more available to patients. The obesity epidemic is out of control, and our focus needs to on attaining healthier BMIs in our patients. Please take this into serious consideration IF you have the best interest of patients in mind, NOT profits. Thank you!
Please do not make obesity medicine any harder to treat! As a medical assistant working in this field and someone who has struggled with being obese most of my life, I know the hardships faced by not only the patients who are trying to receive help, but also the staff in the medical offices who are trying to help our patients live healthier lives. Please do not make the prior authorization process for these medications any more difficult to complete and be approved than they already are!
It costs more to treat the comorbidities caused by obesity than it is to treat the obesity itself. Increasing the coverage requirements for people to be severely obese before treatment can begin is ridiculous!
Obesity is a major health crisis and contributes significantly to health care costs. Wegovy works effectively to help patients achieve normal BMI and reduce comorbidities. Wegovy should continue to be available to patients with BMI of 30 or greater and 27 or greater with one comorbidity.
I am a physician assistant in Internal Medicine writing in opposition to the plan to change approval criteria for Wegovy weight loss medication. Treating obesity is not always about the weight loss, although that is usually what excites patients the most. Treating obesity is about managing and preventing chronic disease early on, which improves quality of life. I have only experienced great results with this medication in practice, that is for patients who are lucky enough to receive it after jumping through various "hoops" with insurance coverage and pharmacies. These patients are often very exhausted after years of trying alternative lifestyle modifications, diets, exercise programs and nutritionist consults. The debilitating chronic diseases that result from obesity need to prevented and treated as best as possible, and GLP-1 agonists are very promising for this reason. Patients and providers do not need more barriers to access these medications.
Wegovy and other GLP-1 medications are evidence based weight loss medications to prevent mortality. Access should be increased, not restricted.
The criteria of 27 BMI has been effective in treating comorbidities for HTN, Chol, Sleep Apnea, and pre-DM, and weight reduction in patients, increasing self-confidence, and decreasing depression issues. Changing this criterion is taking a step back in healthcare and medicine . Please don't change the criteria as this has made a significant impact for patients' overall health outcomes.
This medication is essential in the overall health of the community. Please do not restrict this as this will affect the overall community and health crisis.
September 27, 2023
Commonwealth of Virginia
Department of Medical Assistance Services
600 E Broad St
Richmond, VA 23219
Via Electronic Submission
RE: Service Authorization Form for Weight Loss Management
Dear Board of Medical Assistance Services,
On behalf of the Obesity Action Coalition (OAC), we are pleased to provide comments to the Virginia Board of Medical Assistance Services (DMAS) in line with our organization’s strong support for coverage of comprehensive person-centered obesity care. Specifically, we urge DMAS to continue providing coverage for anti-obesity medications (AOMs) for Medicaid beneficiaries according to current clinical guidelines and Food and Drug Administration approved indications. The Obesity Action Coalition (OAC) is the largest non-profit in the United States that provides education, support, and advocacy for people living with obesity. OAC is 80,000 members strong and has 1,887 members living in Virginia.
We all know that obesity is a serious chronic disease that requires treatment and management just like diabetes, cancer, or high blood pressure. Obesity has been recognized as a disease by major medical organizations such as the American Medical Association, American Academy of Family Physicians, American Association of Clinical Endocrinologists, American Heart Association, National Institutes of Health, and the World Health Organization. Nevertheless, millions of Americans continue to battle the stigma associated with obesity, disputing notions that it is a lifestyle choice. Obesity is driven by powerful biology, not choice.
Recent clinical guidelines recommend the comprehensive access to obesity treatment including the use of AOMs, such as the American Diabetes Association’s 2023 Standards of Care, the American Gastroenterological Association’s obesity management guidelines for adults, and the American Academy of Pediatrics new “Clinical Practice Guideline for the Evaluation and Treatment of Children and Adolescents with Obesity.”
In 2022, the adult obesity rate was at or above 35 percent in 22 states with Georgia, Virginia, and Wisconsin joining this group for the first time. Virginia now ranks 21st highest of states affected by obesity – with 67.3% of the population living with overweight (32.1%) or obesity (35.2%). Obesity is often the root cause and driver of other health complications – with a recent report finding that treating obesity can reduce diabetes (-8.9%), hypertension (-2.3%), heart disease (-2.6%), cancer (-1.3%), and disability (-4.7%) over 10 years in private insurance coverage and Medicare. The same assumption may be applied to Medicaid programs.
Given the growing obesity rate in the Commonwealth and its disparate impact on minority populations, with nearly 47 percent of black Virginians affected by obesity, we find it troubling that DMAS is proposing to make it harder for patients to access the full range of FDA-approved AOMs. We strongly urge DMAS to review the comprehensive comments from Virginia healthcare professionals who are expressing deep concern about how these proposed new hurdles to care will hinder their ability to treat patients on Medicaid effectively and efficiently.
We recognize the program’s concern over the high cost of these new medications and understand some of the steps that DMAS is taking to control costs. While we would prefer to see the DMAS Service Authorization Form for Weight-Loss Management follow clinical guidelines and FDA-approved medication indications, we do appreciate that coverage policy does exist for anti-obesity medications. We agree that step therapy is better than stopping therapy for patients needing treatment for their obesity.
The Obesity Action Coalition has worked tirelessly to improve the world for people with obesity since its founding in 2005. OAC believes that all individuals should be treated with respect regardless of their weight or size, that those affected by the disease of obesity should have access to safe and effective treatment options in the same way that we treat other chronic diseases. We also believe that clinical care decisions should be made between the healthcare provider and the patient, without restrictions on coverage policies.
Should you have any questions or need additional information, please feel to contact me or OAC Policy Consultant Chris Gallagher via email at firstname.lastname@example.org. Thank you.
Joseph Nadglowski, Jr.
OAC President and CEO
 Jastreboff A. et.al. “Obesity as a Disease: The Obesity Society 2018 Position Statement.” Obesity. Jan 2019
 American Diabetes Association. Diabetes Care 2022;45(Supplement_1):S113–S124. https://doi.org/10.2337/dc22-S008.
 American Gastroenterological Association. https://www.gastrojournal.org/article/S0016-5085(22)01026-5/fulltext
 American Academy of Pediatrics. https://www.aap.org/en/news-room/news-releases/aap/2023/american-academy-of-pediatrics-issues-its first-comprehensive-guideline-on-evaluating-treating-children-and-adolescents-with-obesity/.
 Obesity Action Coalition, Virginia State Fact Sheet, 2022. https://www.obesityaction.org/wp-content/uploads/Virginia2023-1.pdf
 Sexton Ward, A. et.al. “Benefits of Medicare Coverage for Weight Loss Drugs.” USC Schaeffer, April 2023.
please do not restrict
Thank you for the important work you do in delivering healthcare services to those enrolled in the Medicaid program. And I understand the need for balance in determining what services to provide. But further restricting access to life-changing and life-saving GLP-1s and other anti-obesity medications neither promotes the goals of Medicaid nor helps those Virginians served.
I have lived in the Commonwealth of Virginia for almost 40 years. During that time, I have seen obesity rates climb unabated. Currently, 35.2% of Virginia adults fall into the obesity category, leaving Virginia with the 21st highest obesity rate among all states. The Trust For America’s Health, The State of Obesity: Better Policies for a Healthier America 2023 (https://www.tfah.org/wp-content/uploads/2023/09/TFAH-2023-ObesityReport-FINAL.pdf). When you add in those who fall into the overweight category, the total rises to 67.3% of Virginia adults who are impacted by excess weight. These dire statistics call for immediate action rather than for restricting obesity care.
Providing a full range of obesity care, including broad access to anti-obesity medications, is particularly important in the Medicaid context because obesity has a disproportionately high impact on those at lower socioeconomic levels. The Trust for America’s Health just last week recognized the importance of providing access to the full range of obesity care when it specifically recommended that “State Medicaid programs should also expand coverage of obesity-related services, such as obesity and nutritional counseling provided by professionals like registered dieticians, obesity medications, and bariatric surgery.” Your proposed policy change does the opposite by further restricting those who could greatly benefit from GLP-1s and other anti-obesity medications.
As a person who has lived and struggled with obesity since childhood, I know first-hand how important it is to have access to all science-based tools to treat this vicious, complex, chronic disease. I can no longer count the number of diets and exercise programs I’ve tried to manage my weight over my lifetime. I would have some short-term success, but I could never sustain any weight loss I achieved. In the past decade, I have finally found true obesity care that has included behavioral, nutrition, and psychological counseling as well as anti-obesity medications (including a GLP-1). Combining these tools has led to sustainable weight loss that has improved my health and my quality of life.
Notably, the excess weight I have carried has taken a toll on my body (e.g. osteoarthritis, gall bladder disease, high blood pressure, blood clotting) that has required extensive medical treatment and associated costs. Had I been able to control my weight at an earlier time, these costs likely would have been avoided or at least minimized. The savings in hospital stays alone would have been far greater than the costs associated with years of GLP-1 use.
You have the power to help people gain control over their obesity and their lives with good, science-based care. Please don’t take that away by further restricting access to anti-obesity medications.
I work with an FQFC medical practice in a rural area. And I do not agree with all of the guidelines proposed. I submit prior authorizations with the existing guidelines. And among a lot barriers (aside from backorders and the drugs not even being available for at least since early/end of spring). It is important for these medications be available for people it was rightfully intended for people and for the reason it is indicated for. Regardless of it's cost. While media and even agents that work for insurance companies medicaid not excluded still offer recommend coverage of a drug that is not fda approved for weight loss is beyond me! When there are drugs there rightly indicated for... Already fda approved for it! If the standards of a persons bmi haven't been adjusted then neither should the requirements for coverage. I am NOT pro weight loss drugs on any day. And I understand the importance of lifestyle and personal responsibility. But still don't support the guideline changes as purposed.