Hey, plus science community. Before we jump into the podcast, do me a favor, like, subscribe, and share if you haven't already. This helps us get referred up in the algorithm so we can find more people that need our help and guidance from our doctors. Thanks so much for supporting the show. Let's jump in. Hi, Dr. Albert. Welcome in.
SPEAKER_03Hey, thank you for having me.
SPEAKER_01We need a pause, we need a pause effect. Well, um, yeah. So sorry about that, Dr. Albert. But yes. Anyway. Well, we're glad to have you back.
SPEAKER_02We're so glad to have you back. Um, if you could tell us for people who most people like they go back and watch season one and they've seen you on there a couple of times, but tell us a little bit about who you are and how you help people outside of UTD.
SPEAKER_03Absolutely happy to. Um, so I'm an ABC medicine physician by training. Um, currently I'm the chief medical officer and a staff physician at a clinic called Vineyard. That's a national telehealth direct care clinic that helps people manage their weight and kind of broad cardiometabolic health issues. Um, I'm also a I hate using the term, but people use it, an health influencer, however you want to think about that content creator uh at Michael Albert MD. Um, and that's how a lot of people know me from the content I put out into the world.
SPEAKER_02So I love that. Yeah. Dr. Albert um has been with us since the OG days. He was one of the first doctors that was going, hey guys, you want to look at these studies? Let me tell you what's actually going on here. It's a bunch of crap they've been telling you all these years, you know. And so he's um he go back and listen to our first episode of the podcast and our last episode because we talk about it quite a bit. Um, I will say one of the best things I ever heard you say, Dr. Albert, is we would take insulin resistance more seriously if we would call type two diabetes what it actually is, which is organ failure. You know, and that was like what I don't feel like anybody says that. And that is a big deal, and this is something to be taken seriously. It really is. So we're so glad to have you. Um, I would really like people to understand a little bit, because we've been talking a lot about Medicare and insurance baloney and all that different stuff, but I think that this is a big deal, what's happening here, right? In terms of having covered on Medicare for obesity at all. And could you kind of like explain to us why and then maybe where this could go, you know, once and if it is covered?
SPEAKER_03Yeah, I think it's important to recognize the sort of you know backdrop that all this is happening on. Like historically, Medicare has treated obesity medicine access differently than treatments for every other chronic disease, right? And so when Part D was passed, Part D being the pharmacy benefit that sets formularies for Medicare beneficiaries, it in and written into the law uh excluded medicines for weight management, which they really framed as cosmetic for weight loss at the time. And that had to do with a lot of the legacy bias around diet pills and diet eras and uh and the like. And it wasn't until later that you know, CMS, the American Medical Association, formally came out and made statements and resolutions to the effect that obesity is a biological chronic health issue, chronic disease, and needs to be afforded the treatment that all other chronic diseases uh are afforded. And and so the issue we ran into is we're dealing with legacy statutes within the the sort of description of benefits for um, you know, our seniors, and uh, and that has to be uh redone, updated, changed for it to meaningfully sort of percolate, you know, in the market. And and the relevance in all of this is that this is the first time since Part D was passed in 2003 that the government has committed to covering obesity medications for the specific intent of helping people manage their weight long term. Um, aside from that, it's only been covered for non-obesity conditions. And so what we're hoping to see is uh over the next few years, the government's running this unique program. They're calling it a national pilot or demonstration. Um, and what's unique about it is it's separate from the core Part D benefit. And this is super important for people to understand. Their $50 a month copay, which will be part of their participation in this program, is carved out from their Part D. It will not go to their out-of-pocket, it will not go towards their deductible. Everyone needs to think about the bridge program as its own entity, it's going through its own railways and it's being judged and evaluated completely separate from Part D and traditional Part D benefits. But if it's successful, when they look at the data, when they look at utilization, health benefits, claims data, and the like, the implications are massive. Because if CMS starts to cover obesity medications long-term for long-term use, for weight management specifically, then typically what happens in the market is that commercial payers, self-funded employer plans will follow suit. So this could be the catalyst for a change in the way that obesity medication coverage and access uh is looked at and uh operationalized moving forward. And so that's the significance. The significance of this is it potentially could be a watershed moment in the way that we cover and allow access and support access uh to these medicines.
SPEAKER_02Hey, have you remembered to comment, like, subscribe, share, click the reminder bell wherever you're watching or listening to this podcast? If not, please do it now so that you can help us grow and help more people. We love you. Hope you're enjoying the show. Okay, I think let's do some rapid fire um Medicare Bridge program questions. That way I can chop this up and put it all over the internet and help people. How's that sound? Sounds great. So I think we talked about a little bit in the top half, but if we can just summarize real quick, what is the Medicare Bridge program?
SPEAKER_03It's a short-term CMS demonstration that provides eligible Medicare Party beneficiaries with access to certain GLP1 medications to help them manage their weight and maintain that. And that's really important because CMS uses that language specifically, which is a big deal. Maintain weight as well. The program starts July 1st, 2026, and it runs through December 31st, 2027. To be eligible, to be considered, you must be enrolled in a Part D program. All right. If you're in another program that's not part D, then you are not eligible. And this doesn't, age is not a restriction. There are some people because of disability, because of particular medical conditions that have Medicare benefits and are younger than 65. This is it's age agnostic. It has to do with enrollment status in Part D.
SPEAKER_02Okay. So who will qualify for GLP1s in the Medic Medicare Bridge program?
SPEAKER_03So typically it's framed as people that have a certain BMI level, and the lowest level that qualifies is 27 with certain uh comorbidities like pre-diabetes, chronic kidney disease, or a BMI greater than 30. Um, if you have a BMI that has separate coverage indication through Part D, I'm not BMI, condition with separate coverage, uh, like diabetes, like uh prior history of heart attack, stroke, or peripheral arterial disease, uh, like obstructive sleep apnea of moderate severity, uh, then you are not allowed to use the bridge program. So the at least not for the specific medication that that has that Part D coverage. Uh, they're really trying to make that distinction. So, really, the bridge program is for people that have a qualified, qualifying BMI, have a comorbidity that CMS recognizes, that doesn't have a traditional coverage policy around, those are the people really that they're trying to steer uh bridge uh to. And and so um there they they are drawing that distinction. This doesn't overlap with traditional Part D coverage. If you have you can qualify for treatment through Part D, then they're gonna steer you towards that and you won't be eligible for um for for this new program.
SPEAKER_00Um, Dr. Albert, the you were mentioning the 27 and then you said 30, and there were additional comorbidities with comorbidities with 30, but there's also 35 and above with no additional comorbidities. That's correct, right?
SPEAKER_03Yeah, I mean, there so the to get the specifics, there's a lot of different ways you can qualify. Definitely go through the whole rundown, right? You know, because it depends on your threshold. I think the basic way that people can think about it is, you know, did you at least have a BMI of 27? There are nuances around the qualifying uh comorbidity status. Um, but just as a general rule, I think that's a place to start for people to think about and have a conversation around. Their doctor, their clinician, whoever they're working with, is gonna have to help them figure out if they also have a qualifying comorbidity for their BMI history. Um, but I think it's probably the easiest for people to think about well, if I at least have a BMI of 27, there's probably a conversation that's worthwhile to have around this.
unknownOkay.
SPEAKER_02Um, and then I know we talked about documentation, but let's just say, let's just put it here so we have it. So documentation that you may need to qualify or that you want to get together would be lab work, you know, several things you mentioned, were there?
SPEAKER_03Yeah. Baseline weight, baseline BMI, date of therapy initial uh initiation, like if you've been on GLP1 in the past, you know, what what obviously what is your current weight? Do you have any obesity-related comorbidities? You know, your medication history, any other prior, you know, weight loss efforts. Um, you know, that getting all that information along with the labs, as you stated, is going to be important to put together as part of a documentation package for the authorization. And so what you can do is you can, you know, do some work to find that information and then either share it directly with uh the clinic or provide it verbally during your you know assessment visit. And and then they can obviously document it and and you know put that information together as part of the submission process.
SPEAKER_02Okay. So if you think you qualify for some of these things we've talked about, the first step step for you to take would be to gather this and then make an appointment with your doctor. Does that sound right?
SPEAKER_03I think that's right. Yeah.
SPEAKER_02Okay. Um, what are some common hurdles that patients might face when they're seeking coverage through the program?
SPEAKER_03I the one we've already highlighted is, you know, the distinction between qualifying for bridge versus one of the standard Part D coverage qualifications, right? Um, so if you're someone, uh that your doctor's gonna need to help you figure out, but it really has to do with do you meet criteria that is currently approved for one of the specific agents that Part D does cover? So it would be a non-weight related uh condition. Um other issues that you know people are gonna run in is just not having this information documented. So like it needs to be documented in the note that's submitted with the authorization. So you might have to advocate to your doctor or nurse practitioner, whoever is seeing you, to make sure they're capturing that and they're submitting it along. Um, you know, if you have fractured documentation, that's what always gets automatic denials, requests for additional follow-up. It's gonna delay approval, slow everything down. Um I think recognizing that it's a fixed cost, right? And and the the cost doesn't go towards your out-of-pocket or your deductible, right? So you're paying $50 a month. There's not an additional responsibility on top of that. It's it's a flat 50, and the government's picking up the rest. Um and I think just you know, with everything, just making sure that the pharmacies process this correctly, one of the things I'm concerned about is the implementation of this. There's been a lack of clarity. It's been a little bit confusing on what the right sequence is in order for people to qualify. I'm not gonna try to confuse people too much, but it may be true that before you can get a prior authorization processed, that your doctor or your nurse practitioner or whoever has to send a prescription to the pharmacy that's going to be filling it. And a claim needs to be generated and actually rejected initially. And that's what CMS has said. That's been a little bit odd. My understanding and my read on that is the reason that you need a pharmacy claim that is initially created and denied or rejected is because it creates a it creates that history around it that that the CMS is then using to monitor uh, you know, the bridge qualification. So it's like just like creating a ticket, you know, you become your the system is now aware of you. Um and then on the back side of that, after the claim gets rejected, the prior authorization can be submitted. Um uh and I I think it has to do with the funky way how they're they're taking this off the railways of Part D and it's in its own separate category and has to be processed uniquely. Um, so I'm sure we'll get clarity. As with all things, there's especially with the government, there's very, you know, cloud implementation. So I think we're all gonna still be learning, but that might you know trip some people up because maybe they're not used to sending a prescription first before the prior authorization. And so that may be something you have to educate your doctor about that hey, uh, you might, in order to kick this thing off, you might have to send an initial prescription, that prescription get denied at the pharmacy, and then the prior submitted on the backside of that. So that's the those are some of the the hurdles I'm I'm worried about for people, but hopefully, you know, we'll get more clarity on that in the coming weeks as it's implemented.
SPEAKER_02I think that's really good because I I agree. Like it's think about how many people get it rejected for these treatments ever, and then they think, oh, like I'm done. Like they don't even bother appealing, right? Or exhausting their appeals. And we should always tip, hear me out. Always exhaust your appeals. Okay, like you have rights, okay? Um, I know we covered this a little bit, but um, are there there any special eligibility or documentation considerations for patients who have previously paid cash for treatment, um, use telehealth services, or received compounded medications? I think the answer was that's all part of your medical history, right?
SPEAKER_03Yeah, I mean, it doesn't preclude you from qualifying for pre-GP the standard criteria. Um, and it's certainly uh a credit to your history, you know. So if you were someone that's done compounded, you know, I don't you've done whatever and you've lost a bunch of weight, like you still get credit for that. So you should still be using your starting weight in BMI as your reference weight uh during the submission, you know. So that that's probably an area where some clinics are gonna get tripped up. They're gonna use the current weight in BMI and it's not gonna qualify you, especially if you're someone like Cat who's lost a you know a lot of weight in the past. If it's not represented your history the right way and documented as such, then you're not gonna get credit for it.
SPEAKER_01Yeah. Uh for listeners who didn't or don't qualify for the Medicare Bridge program, um, what options are available to them today? And what steps would you encourage them to um take next?
SPEAKER_03Yeah, so there are a few options. Um, one would be do you cover for another can are you do you have any coverage for another indication, like type 2 diabetes, like some of the cardiovascular pathways? Uh we have a new uh indication for Wagovi, which is uh stage two, stage three fibrotic liver disease, also called MASH. Um, sleep apnea is one that's gotten a lot of attention with Z-Bound uh for a expanded zip bound indication. So can you be covered for something else? Once again, uh many of those are covered under commercial plans uh for those kind of other indications. Um, there are uh a number of cash pay options now where uh pharmacies, even pharmacies affiliated with the manufacturers, offer like direct pay uh and have transparent pricing on many of the FDA-approved GLP ones. There are non non-uh GLP1 therapies that are currently generic medicines or have branded alternatives that you can pay cash for right now if if you don't qualify. So there are a range of medication therapy options now that expand beyond, you know, just needing to have insurance coverage.
SPEAKER_02Yeah. And I think like um things to consider, like that, you know, I've I've we've talked about before things like Contrave and Qisemia, like these older anti-obesity medications. And um, I think uh what also is important to guys is four years ago and we were going through this, this medicine was 1400 bucks a month, you know, and now it's you know 350 to 500. So even though that's quite outrageous, we've come a long way in a short amount of time, right? And the fact that it's you have these options available that our brand, like you know, everybody knows I just want you to get safe medicine, right? And now we have good care, right? But there are a lot of options, like there are, and I don't think people know about them. I mean, I think one of the other ones to mention is there's a generic um, I don't know how much it costs now, lyri glutide. That was the first one I was on, yeah, you know. Um, and so that's a daily one, but I experienced no food noise on it. I lost weight on that. I I experienced inflammation reduction on that. So I think that one gets kicked out of bed a lot. Um, but honestly, sometimes it's just me, right? What is best for you? And now the Wagovi pill that has come out, right? Um, even it's I want to say like 150 a month to get started, isn't it? Yeah, I mean, it's like it's I don't know what it depends on when you're watching this, but regardless, none of these are, you know, ideal prices, right? But it's way better than $1,400 a month. So I don't want people to freak out and still think because they haven't really been, you know, in the land of TikTok with us, right? That these are still $1,400 a month and that's your only option. There are options, there are good options. Okay. So it's focus on focus on getting good care first. That'll all fall into place, I promise. Okay.