Two months after Medicare launched its GLP-1 Bridge program, providing eligible patients access to certain GLP-1 medications for weight management with a $50 copay, my practice is seeing an influx of patients with questions about eligibility and enrollment, as well as pharmacy and coverage issues.
As an obesity medicine specialist, I welcome the program and the access it promises. For many older adults, this is the first realistic chance to afford a treatment they may have discussed with their primary care clinician for months, or even years, but could not access due to cost.
Patients with obesity deserve evidence-based treatment regardless of their ability to pay out of pocket. Obesity is a chronic relapsing disease, and medications that help treat it should be accessible to all patients.
However, a lower-cost prescription is not the same as comprehensive obesity treatment. A patient’s GLP-1 is only as good as the medical care around it, and right now, Medicare’s coverage infrastructure is not set up to support the care patients need.
Currently, much of the public conversation focuses on whether patients can get these medications and who will pay for them. Those questions matter. Affordability has been one of the biggest barriers to obesity care. Yet the next challenge is already here: Ensuring that patients who receive medications also receive the monitoring, lifestyle and behavioral counseling, and long-term follow-up needed to use them safely and sustainably.
Sustainability concerns
I’ve been talking with colleagues who are concerned about the program’s long-term sustainability. Many are operating with limited staff and administrative support and struggle to absorb the pharmacy coordination, prior authorizations, appeals and ongoing patient communication required to help patients obtain treatment.
GLP-1 medications are not short-term fixes. They are chronic disease medications that require clinical judgment before they are prescribed and careful follow-up after treatment begins. Evidence-based care includes screening for contraindications, reviewing other medications, setting realistic expectations, adjusting doses, monitoring side effects, assessing nutrition, protecting muscle mass, and planning for treatment interruptions or discontinuation.
Physicians and other clinicians should not simply prescribe these medications and then disengage from care. Follow-up is essential. Side effects remain one of the leading reasons patients discontinue treatment within the first year. Importantly, many of these adverse effects can be prevented or managed when clinicians and patients communicate regularly.
We see that in clinical trial data – when patients receive structured follow-up – rates of discontinuation due to side effects are far lower than in real-world settings.
Older adults need particular attention. For example, recent reviews of GLP-1 use in older adults have highlighted sarcopenia and sarcopenic obesity as major issues, and clinical discussions increasingly emphasize the importance of preserving muscle during pharmacologic weight loss.
Generally speaking, treating a 72-year-old patient requires nutrition guidance, resistance exercise, attention to protein intake and monitoring for excessive weight loss. Ideally, this patient is being treated by a clinician who has received education and training in obesity medicine, even if they are not a dedicated obesity specialist. Additionally, they may also require a registered dietitian, a behavioral health professional and/or an exercise professional.
The care gap
The program itself recognizes that these medications should be used alongside lifestyle modification. The CMS says that clinicians must attest that eligible beneficiaries are using the medication with current and ongoing lifestyle modification, including structured nutrition and physical activity consistent with the FDA-approved label.
But while Medicare covers obesity behavioral therapy for eligible beneficiaries with a BMI of 30 or higher, that benefit is tied to specific rules, including delivery by a primary care clinician in a primary care setting, and it also depends on meeting certain weight-loss requirements. Medical nutrition therapy by a registered dietitian or nutrition professional is nationally covered for certain beneficiaries with diabetes or renal disease, but not for obesity alone.
This leaves a gap. We are expanding access to a modern obesity medication while relying on an outdated care model.
Administrative strain will make the gap even harder to close. The program uses a central processor for prior authorization, claims adjudication and pharmacy payment. But clinicians still must submit prior authorization requests, attest to clinical criteria, write prescriptions, answer patient questions, respond to denials, and help patients and pharmacists navigate a program operating outside the Part D benefit.
How the CMS can help
The CMS has an opportunity to make this right. The program should be treated as the beginning of a more serious national commitment to obesity care.
First, Medicare should pair GLP-1 access with coverage of comprehensive obesity care, including registered dietitian services, behavioral counseling, lifestyle programs, medication monitoring and individualized treatment planning. Second, the CMS should reduce administrative workload and increase the availability of training and guidance for clinicians and pharmacists to streamline processes. Third, every patient starting a GLP-1 should have a comprehensive care plan, especially older adults at risk of frailty, excessive weight loss, side effects or treatment disruption. Lastly, that effort must include dedicated training and operational guidance for retail pharmacies, as well as technical assistance for smaller and community-based practices that lack specialized pharmacy or administrative teams.
Affordable GLP-1s for Medicare patients are an important step forward, but the program’s success should not be measured solely by prescriptions filled. It should be measured by whether older adults receive treatment that is safe, sustainable and supported by the care these medications require.
Opinions expressed by SmartBrief contributors are their own.
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