The Pound of Cure Weight Loss Podcast
Hosted by obesity specialist Matthew Weiner, MD and dietitian Zoe Schroeder, RD, The Pound of Cure Weight Loss Podcast provides a comprehensive approach to weight loss. We cover nutrition, the new GLP-1 medications, and Bariatric Surgery in depth and answer tons of questions from our audience every week. Check out our website for video versions of the podcast: www.poundofcureweightloss.com/podcast
The Pound of Cure Weight Loss Podcast
Profits Over Patients
In Episode 53 of the Pound of Cure Weight Loss Podcast, Dr. Weiner and Zoe dive into meaningful topics, from celebrating non-scale victories to understanding the limits of BMI and exposing the troubling influence of pharmacy benefit managers (PBMs) on healthcare costs. This engaging episode not only informs listeners about these issues but also empowers them to advocate for a better, patient-centered healthcare system.
Celebrating Non-Scale Victories on Your Weight Loss Journey
Weight loss is about more than numbers on the scale, and non-scale victories (NSVs) are a powerful reminder of the progress often missed. Dr. Weiner and Zoe discuss these achievements, which include everything from improvements in flexibility to walking up stairs without fatigue. Zoe suggests keeping a running list of NSVs to stay motivated, especially during weight loss stalls. This practice can give you a balanced perspective on success, showing that even small victories matter. Tracking NSVs is a great way to remember that you’re moving forward, even when the scale doesn’t reflect it.
The Limits of BMI as a Health Measure
The Body Mass Index (BMI) has been widely used to assess health, but it’s far from perfect. Dr. Weiner and Zoe critique the BMI’s shortcomings, explaining how this 200-year-old formula, which simply compares weight to height, fails to account for muscle mass, body composition, and other essential factors. Dr. Weiner points out that BMI often mislabels individuals, especially those with high muscle mass, as “overweight.” They discuss alternatives, like the Body Roundness Index (BRI), that consider waist and hip measurements, offering a more nuanced health picture. Dr. Weiner underscores the importance of moving beyond BMI and adopting more accurate, holistic measures.
Pharmacy Benefit Managers: Putting Profits Over Patients
In their discussion on pharmacy benefit managers (PBMs), Dr. Weiner and Zoe reveal how these intermediaries have shifted from helping lower drug prices to prioritizing profits. PBMs now control nearly 80% of pharmacy claims, often inflating prices to serve their bottom line. For example, PBMs have been known to hike up the cost of drugs like Zytiga from a wholesale price of $229 to as high as $6,000, placing a heavy burden on patients and taxpayers. Dr. Weiner argues that PBMs’ monopolistic practices highlight the urgent need for more transparency and regulation in healthcare. By better understanding the role PBMs play, patients can advocate for policies to lower drug costs and improve access to care.
How to Advocate for a Patient-Centered Healthcare System
In the final segment, Dr. Weiner and Zoe encourage listeners to take an active role in changing healthcare. They urge you to research healthcare legislation, support representatives pushing for lower drug prices, and vote for candidates focused on putting patients over profits. Advocacy, they emphasize, is essential for reforming healthcare to make it more accessible and affordable for everyone.
Episode Takeaways
This episode tackles the critical issues of weight loss success, BMI’s limitations, and the role of PBMs, leaving listeners with actionable steps to navigate the healthcare system and celebrate their own achievements. Episode 53 of the Pound of Cure Weight Loss Podcast is a must-listen for those interested in health reform, practical weight loss advice, and a more compassionate approach to healthcare.
Keep a running note on your phone or on a notepad. Anytime you experience something you're proud of, whether that's on the scale, a change in body composition, any of those other non-scale victory measures. Jot it down, because then you can go back and remember that you are making progress. Hi there, welcome back to the Pound of Cure Weight Loss Podcast. Profits Over Patience, dr Weiner. What are we talking about today?
Dr. Weiner:Well, we talk about profits over patience A lot. I mean, you know, I don't know, sometimes I feel like part of me. I started this podcast to like help educate people. I always try to keep it from being a little bit of a pardon my language but a bitch session about the healthcare system. We're in private practice, we run our own practice, we do our own billing, we deal with insurance companies. I mean we are really, I think, just ground zero in terms of the health care crisis, because we see lots of patients in our practice and we're constantly battling insurance. We're fighting for these GLP-1 meds and we're seeing how it impacts people's lives. And it's so frustrating to me because we got the technology. It's there Like we shared obesity. I mean we really have.
Dr. Weiner:It's just a matter of the industries that surround the payment for healthcare, whether it's pharma, health insurance. They've just extracted so much money. They're all publicly traded. Their CEOs are making $10 million, $20 million bonuses every year, maybe even more, and they must keep driving their stock price up. There's just this intense pressure on the people who run these companies to just be more and more and more profitable and less about the patient, and so they have to. That's just the nature of health care is, if the companies and the health insurance companies and direct it in the right way, we can do this.
Dr. Weiner:And so one of the hopes of this podcast is that we bring attention to this. And again, I keep saying this, but we've got an election cycle coming up and I urge all of you out there to look over the candidates in your district, and not so much than the presidential candidates, but your congresspeople, your senators, your state congresspeople, your state senators. Look at them and see what they stand for, and see if there's anybody out there who's going to help you with your health care issues. So, anyway, so let's move into their in the news segment. Our article comes from the New York Times and it's very cleverly titled Is it time to say goodbye to BMI and?
Zoe:I'd say yes, yes, I vote yes.
Dr. Weiner:You, I think. On one episode in the past you said the BMI is trash.
Zoe:And I stand by it. It still is trash.
Dr. Weiner:I think this article would certainly support that statement. So first of all, let's talk about what the BMI is. So body mass index is your weight over your height squared, and they use a metric system. And if you really got to break down the math and I'm a math guy, so I like this kind of stuff it's essentially designing or measuring the density of a cylinder. That's more or less where BMI comes from, and so really, some people are cylinders. If you're thin, you're a cylinder, but if you're overweight you're thin, you're a cylinder, but if you're overweight you're not really shaped like a cylinder. And so they're looking at some other options.
Dr. Weiner:Now BMI is 200 years old, so go back to 200 years ago. If you're going to calculate someone's BMI, they could do it. Long division, long multiplication, you can figure it out. But now we have computers, we have calculators, we have a lot of other stuff we're going to cover on this episode, and so there's the option to come up with a much more sophisticated measure of obesity.
Dr. Weiner:I'll tell you in the operating room, I'll go in sometimes I'll do a bmi 60 case and boom, easy peasy, no problem whatsoever. And then I'll do a patient with a bmi of and it's a difficult case. There's lots of abdominal fat, it's a very challenging surgery, and so I learned a long time ago that BMI alone is just not going to do it. There's other things at play that determine the difficulty of a surgery the severity of the obesity, the texture of the tissue, all of these things. So this article talks about the body roundness index, and it was developed by a mathematician, and she basically created a formula that essentially helps to measure the human body as a more of a circle an oval, I think, is actually what it's based on, which makes sense.
Dr. Weiner:Makes sense. Yeah, it's a much more complicated formula. You really have to plug it into a computer and they do have some websites. If you look it up body roundness index, you can plug your info in and it looks at your first of all. It looks at your age, it looks at your gender, it looks at your waist circumference, it looks at your hip circumference. So it's looking at a lot of different measurements and comes up with this body roundness index, and normal is less than three, but the number goes all the way to 20. I like the idea that there's a huge range.
Zoe:It makes it able to be more specific.
Dr. Weiner:Yeah, Most people will fall between one and 10. And they've shown that a BRI body roundness index greater than seven shows increased mortality, increased cancer rates, increased risk of heart disease. We also see that, as you, I think. What also is interesting, if your BRI is less than 3.4 and you're over 65, that that also shows increased mortality.
Zoe:Because we know that some fat as you get into those elder years has a protective effect.
Dr. Weiner:Yes, absolutely, and so when we know these things and this starts to, that's consistent with things that we know that also shows that this has some value. It's a complicated formula. It really is a measurement of your visceral fat, your intra-abdominal fat, and I think it's a much better way. I think there may be some. My hunch is this may be just a step along the way.
Zoe:Might not be like Apex.
Dr. Weiner:But it was an interesting article. I like seeing it. They talk about how Arnold Schwarzenegger at his peak bodybuilding would have been classified as obese. I think there's a large percentage of the football players are technically obese, even though these are really elite athletes, and so it detracts from the fact that there's a lot more to someone's health and fitness than just their height and their weight. I mean, what do you think when you were in school, did they put a lot of stock in BMI, or did they kind of pull back and say, hey, maybe it's more complicated?
Zoe:No, it absolutely was kind of one of those main measures. And then it was, of course, discussion around well, this is not a good measurement, but yet, well, that's what the health care system uses and that's what's so ingrained in medicine. So you have to use it for malnutrition diagnoses, for, obviously, the diagnosis of obesity and different things like that. But of course the conversations were had, but it was yeah, yeah that's. We know that BMI is trash, but you still have to use it anyway. But I like what you said about this BRF, bri. It mostly measures the visceral fat, which is what you have to dig through, which can make the surgery more difficult, as opposed to subcutaneous fat, which is the fat underneath the skin.
Dr. Weiner:Right. It's also the fat that's associated with heart disease, diabetes and the comorbidities as well, and so we continue to use the same criteria for bariatric surgery. They're now using not the same criteria, but they're using BMI for GLP-1 indications, and so we continue to just be stuck in this BMI rut. It's going to take a long time for us to get out of it because, as you pointed out, there's dogma in medicine and when you've been doing something for 200 years, it's hard to get out of it. Because, as you pointed out, you know there's there's dogma in medicine and when you've been doing something for 200 years, it's hard to break out of it.
Zoe:It's in every emr that bmi is built into every emr, you type in the height, you type in the weight and it's going to spit out the bmi for you yeah, well, and I recently was having a conversation with somebody and we were talking about what you know, their goals, their long-term goals and that kind of thing and, um, they were saying how they just want to get into the normal range of BMI and all the time.
Zoe:Can we please like you're? And then they had been lifting weights and really working on their nutrition and their body composition was changing and I was like you're going to? You're going to set yourself up for disappointment If we're really only looking at BMI and weight as your measure.
Dr. Weiner:We see that a lot, particularly with women. With 200 pounds, the wonderland Right. So many women are like I just need to have my weight. Start with a one. But if you take a step back and you zoom out, as you say, and look at it, well, that's because someone wants to find a pound is whatever a pound is and we decided on a base 10 numerical system. Well, that's because someone once defined a pound as whatever a pound is and we decided on a base 10 numerical system. And you know so many assumptions have come that make that weight 200 pounds.
Zoe:Your gravitational pull to the earth in that one moment.
Dr. Weiner:Exactly. It's all you know. There's a lot of randomness to what makes 200 pounds, but yet we are putting so much energy into that number as like, my measure of success. And I am not successful if I'm 201, but I am successful if I'm 199. And there's so many other more important things.
Zoe:And I often like to ask people like okay, if you were to visualize yourself, would you rather see a certain number on the scale, or see a certain physique, or like, look a certain way or feel a certain way? You know, have your diabetes go away, whatever it is? So there are so many more powerful ways to measure progress and success.
Dr. Weiner:Well, I think that segues very much into our nutrition segment. Perfect. So, Zoe, what do we have today for nutrition?
Zoe:very much into our nutrition segment. Perfect. So, zoe, what do we have today for nutrition? Well, I did just want to further dig into those non-scale ways to measure success, specifically non-BMI, because we're going out with the BMI, right. So, again, that BMI, as Dr Weiner had explained, is a mathematical equation, basically a ratio of your height and your weight, if you will. What your weight does not take into consideration is your body composition, which is your fat mass versus your muscle mass, right?
Zoe:And so if we wanted to have a more accurate measure of progress, it would be really great to be able to measure body composition changes, and there are many ways to do that. There's like the DEXA scan. That's pretty expensive for people to go and do. There are, you know, different scanners, like an in-body some gyms have, or a little handheld bioelectrical impedance. There is a. There's a pretty good margin of error with that, you know, right, but it's better than it's at least another data point, right. But we are now seeing these 3D scanners that basically map out, take your measurements, map out your body composition, which is a really interesting and cool new way to see those changes over time in body composition.
Dr. Weiner:Right, you can essentially measure every inch of your body.
Zoe:Right, because think about the human error. I say all the time, if you want to be tracking measurements over time, probably a better idea or not a better idea than the scale, but in addition to so we have more data points is maybe taking your waist circumference, but of course there's human error there. There's again all of those factors that could play a role into that number not being super accurate, but being able to measure all of the data points on your body and track that over time, and then not only having the measurements but being able to see you're with yourself all day, every day, like it's hard to see your body change when, when you have that, um, that's close proximity. But if, maybe monthly or quarterly, you see these changes in your body scanner, that to me is way not only cooler but more significant to measure actual progress and change in body composition, especially if you're really dialed in with your nutrition and you're working on your building muscle and that kind of thing. So I think that's a very interesting area that I hope to see more of soon.
Dr. Weiner:Yeah, I think, especially with like weight loss stalls. Yeah, you know.
Zoe:Oh, all the time I hear people oh, I only lost a pound this month, but I lost three inches. What do I need to do?
Dr. Weiner:I'm like that's amazing, but. But I lost three inches. What do I need to do? I'm like that's amazing, but something like that, these secondary endpoints that we're looking at, because it's not just about what happens on the scale every month, especially when you're looking monthly, which, truthfully, even weighing yourself monthly, you'll still see stalls, you'll still see a lot of noise in that signal and so everybody's got to weigh themselves at least monthly. It's hard when you're trying everybody's got to weigh themselves at least monthly, like it's hard to when you're trying to do this, to weigh yourself less than once a month.
Zoe:So, yeah, I think these, these scanners are interesting and some of these other methods of kind of measuring your body and comparing is it's really helpful, yeah, but also knowing that just to remember and staying motivated with the fact that there are so many non aesthetic or non body composition ways to measure your progress on this journey your health markers, your med, the medications you're able to get off of your labs, your performance, whether you can walk up a flight of stairs without needing a break, or maybe you signed up for a 5k, or you're now lifting 20 pounds and said, right, there are so many markers.
Zoe:And so I just want to leave my nutrition segment with this little tip to keep you motivated on those days that, of course, we're all going to experience down, like feeling down, feeling frustrated, whether it's through a stall or just you know whatever. Keep a running note on your phone or on a notepad. Anytime you experience something you're proud of, whether that's on the scale, a change in body composition, any of those other non-scale victory measures that I was explaining, or even just like a little aha moment. You're like, oh my gosh, I was able to just bend down and put my sock on. So anytime you have a little like glimmering, exciting, exciting moment, jot it down, because then you can go back and remember that you are making progress, reinforce yourself that you are doing the right things and it's okay to feel a little bit down, but just kind of like reigniting that and pumping yourself back up, like yeah, I have done all of this, I have made this much progress, and just kind of reminding yourself I can find I find really beneficial in terms of reigniting that motivation.
Dr. Weiner:Yeah, the human brain is kind of screwed up. That one piece of bad news, that one bad thing that happens to you, we'll let that ruin our whole day and we'll focus on that for the rest of the day, even if three good things happen to us on that same day.
Zoe:Just same thing with compliments versus negative comments yeah, absolutely Right.
Dr. Weiner:Ten people say you look fantastic and one person kind of gives you a nasty look and all you can think about all day is that nasty look. Yeah, you're right. So I think that's a great tip for that. All right, so our economics of obesity segment is next. This really comes from a MedPage Today article, and how crooked they are and how much they're compromising our healthcare and really where the title of our episode Profits Over Patients comes from.
Dr. Weiner:Pbms overpay their own pharmacies to the detriment of insurers, taxpayers. Ftc says that's even a little tricky because the PBMs are the insurers. The PBM we've talked about this before a lot. I'll just kind of give you everybody a quick reminder of what a PBM or pharmacy benefit manager is. This is that Express Scripts, that OptumRx. There's a separate phone number you have to call if you're getting prescription coverage versus if you're seeing your doctor. That's your PBM. You're calling, that's that separate phone number and they regulate the price that you pay and what you're covered for for the medication.
Dr. Weiner:Now why do we even have PBMs? Pbms' job is to negotiate with the pharma industry so that you get the lowest price possible for the medication. Now we all say, well, our insurance company pays it, I don't pay it. But that's not how insurance works. If you're paying a lot for it, your insurance is going to go up, and everybody you know. Look at your health insurance premiums over the last 10 years, they have skyrocketed. Look at your co-pays on medications they have skyrocketed. Look at the price of medications in this country they have skyrocketed. So if PBM's job is to keep the price of prescription drugs low, they're doing a really crappy job, and so this also points to why we're seeing this. So what's happened and I think a big problem that we've had is that the health insurance companies have bought all the PBMs. So there's six big PBMs and they're responsible for, I think, 94% 94% of all pharmacy claims come through the six big PBMs. So we really have essentially not a monopoly because there's six companies, but they're behaving like monopolies. So CVS, caremark I think they're the biggest that's owned by Aetna. So Aetna owns Aetna, it owns CVS and it owns Caremark. It owns the whole pipeline, the whole pipeline, every single step. It's got all of it. And Cigna owns Express Scripts. Optumrx is owned by UnitedHealthcare. These three CVS, cigna and United that's 79% of all the prescriptions in the US. Humana Pharmacy, medimpact and Prime Therapeutics are the other three.
Dr. Weiner:In the article they talk about Zytiga, which is a prostate cancer medicine. The wholesale price of Zytiga is $229. However, if they look at the top three PBMs, the average price is $6,000. Wholesale $229. However, if they look at the top three PBMs, the average price is $6,000. Wholesale $229. Average price paid. That's a cancer medication, cancer medication. So they know, cancer is money. Got to get paid for it. Got cancer, man, I'm sorry. Oh, we got to pay. It's cancer. Oh, we got to pay for it. Yeah Well, whatever it costs, we're going to pay for it. It's cancer. Make it happen. Right right, obesity, you're on your own. Yeah, like cancer, it just eat less.
Dr. Weiner:Yeah, it totally eat less. So they pay twice as much for this medication than if you go to an unaffiliated pharmacy. So what are the unaffiliated pharmacies? It's like your Safeway here in Tucson, it's your grocery store pharmacies. In the past you would say, oh, you're locally owned pharmacies. Those are all gone.
Zoe:That doesn't exist anymore. Do you remember that?
Dr. Weiner:I think you're still-.
Zoe:Well, I also grew up in a town of 10,000 people.
Dr. Weiner:Right, but there was a pharmacy and it was a locally owned small business. That person who owned it was often the guy who was giving you your medicines. They were a pharmacist that doesn't exist anymore, and so what happened with those is that the PBMs started buying up all the pharmacies and they went to these local owned pharmacies like, oh, we're not paying you, we're paying you garbage for these medications, we're not paying you anything. And they essentially ran them out of business. And what happened is they more or less ruined their business. They're like oh, we're CVS, we'll buy you.
Zoe:Yeah.
Dr. Weiner:You know kind of mob boss stuff. We're going to ruin your business and then offer to buy you up, and so that's why there's a CVS on every corner and all these local pharmacies have kind of been bought up by CVS and Walgreens and even things like Rite Aid. I feel like Rite Aids used to be around, but they just didn't play the insurance game right and they got pushed out of this. So all of this money is passed on to you, it's passed on to taxpayers, it's passed on to employers, it's passed on to employees. It's passed on to taxpayers, it's passed on to employers, it's passed on to employees.
Dr. Weiner:There's really, when you receive your salary, your payment, you're actually receiving payment two different ways. You get your paycheck, which is what goes in your bank account, but then you also get your health insurance. If you get your health insurance through the employer, that's what you get, and so your employer is paying money to the health insurance company. If your employer didn't have to pay as much money to the health insurance company, they could pay you more wages and that would absolutely happen. I mean, we run our practice. I know when I calculate what someone's salary, I have to calculate their health insurance cost into this. So this money that's being spent is your money. It would otherwise go to you, whether it's paid by your insurance company or not. And here's the trick that they pay, and we've all seen this.
Dr. Weiner:Oh, you want a 90-day supply. What do you have to do? If you want a 90-day supply? You've got to use our mail-order pharmacy. You've got to use our OptumRx. Oh, if you go through OptumRx, the copay is lower. Yeah, that's $6,000 medicine Instead of a $60 copay. We'll charge you a $40 copay, but we're charging your employer, your insurance company, $6,000. And so they incentivize you through longer, because who wants to go to the pharmacy every month? Right Through 90-day prescriptions, through reduced co-pays, they incentivize you to use their own pharmacies, which they then pay a substantially higher rate to for the same drug that they do if you went to a locally or non-PBM owned pharmacy. And so there's no question. Pbms are doing a terrible job at the thing that they're there for, which is keeping the cost of medications lower for Americans. That's the job. That's why PBMs exist.
Zoe:They're doing a terrible job.
Dr. Weiner:A terrible job. So I have a chart and it's the monthly list prices for weight loss drugs in the US compared to every other country. To me this is just infuriating. We know this. The list price of Ozempic, which is a diabetes version of semaglutide, is $936, and Wegovi is $1,349. First of all, already same exact drug $400 upcharge.
Zoe:Yeah.
Dr. Weiner:Just because it's for obesity. But then we look at what it costs in other countries Canada, Ozempic $936. $147. I want a Canadian PBM. How do I sign up for a Canadian PBM Right, Sweden, ninety six dollars.
Zoe:It's not just that the US is double, it's like it's not double.
Dr. Weiner:It's five times higher.
Zoe:Exactly, it's sickening, sickening.
Dr. Weiner:And so these medicines literally are five times more expensive in our country than in any other country, and it's not even twice. I would love if it was twice as expensive. Fine, that'd be amazing. Yeah, twice as expensive. Japan's the next highest country for Ozempic $169. $340 for Ozempic Boom Done, everybody, everybody. Yeah, I think it happened. Dempick Boom Done, everybody, everybody. Yeah, make it happen. So it is time for us to start looking for alternatives to our traditional PBMs, these big six PBMs. They are not doing anybody any good unless you own stock in the companies or work for the companies, and so this stuff has to stop, or work for the companies, and so this stuff has to stop. And I think it's time for us to write letters to your congresspeople to start taking a stand against this and recognize what's happening. There's plenty of money in the system, it's just not being allocated appropriately. So, all right. That wraps up another bitch session. I mean podcast.
Zoe:We keep ending on such positive notes. Yeah, but I think it's important we got to know it. I know, and you know, I have learned so much throughout this podcast as well, about the insurance and the PBMs and all of those things.
Zoe:So I mean, I know that our listeners are getting so much value out of it and I think it's learning which we're providing the information. But then that that call to action of okay, what can I do to actually make a difference? And and writing a letter trying to get some change, and I think that's really important.
Dr. Weiner:Yeah, yeah. I think what we really need is some politicians who are not bought and sold by the health insurance company in the farm industry.
Zoe:How many politicians do you think actually like take the time to understand all of that and care in the first place?
Dr. Weiner:So you know, if you're interested in this, google Bernie Sanders. Bernie Sanders was the lion's running back, lions running back bernie. Bernie sanders letter to the ceo of novo nordisk, september 24th. He's going to be testifying in the senate hearing and uh it he really it's a great letter and he hits on all of these points like he nails, each and every one of these points about about the cost of these medications in our country versus other countries, the difference in the price, whether it's for diabetes or obesity, for the same exact medication. And so it really only through this type of thing, only by being brought in before Senate, by through legislation, is this going to change. That's the only way it's going to change, because it's being allowed because of the laws we have, and only by changing those laws can we put an end to PBMs, which is honestly they're really stealing from the American public.
Zoe:Well, I'm excited for us to be able to update on that next, after that happens.
Dr. Weiner:We can do a podcast segment on it. All right. If you're having trouble with your getting coverage for weight loss medications, or if you're able to do it successfully, let us know. Drop us a line on social media, on TikTok, instagram, on our YouTube channel, through our website. If you have a question you want to see us answer on the podcast, please reach out to us.
Zoe:We'll see you next time.
Dr. Weiner:See you.
