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. 

Sincerely, 

Dr. Catherine Varney, DO

Obesity Medicine Director, UVA Health