By Janet Coulter, MSN, MS, RN, CCM, FCM
The Centers for Medicare and Medicaid Services (CMS) has proposed a groundbreaking rule to expand Medicare Part D coverage to include anti-obesity medications (AOMs). This landmark proposal can potentially transform the management of obesity and its associated conditions. Obesity is a leading cause of Metabolic Dysfunction-Associated Steatotic Liver Disease (MASLD). MASLD affects millions of Americans and can lead to severe liver damage, including cirrhosis and liver cancer. Currently, many patients cannot afford AOMs. Studies show that AOMs and lifestyle changes lead to significant weight loss, better outcomes, and cost savings for Medicare. For instance, a 25% weight loss can reduce healthcare costs by 31%, saving over $5,400 per patient annually. AOMs combined with lifestyle changes can lead to sustained weight loss, reducing obesity-related healthcare costs and saving lives.
Obesity significantly increases the risk of developing a range of comorbid conditions, including type 2 diabetes, cardiovascular disease, and MASLD. MASLD, formerly known as non-alcoholic fatty liver disease (NAFLD), is characterized by excess fat accumulation in the liver unrelated to alcohol consumption. It can progress to non-alcoholic steatohepatitis (NASH), cirrhosis, and even liver cancer if left untreated. Currently, MASLD is one of the most common causes of liver transplants in the United States. The economic burden of obesity and its related conditions is staggering, with direct healthcare costs exceeding $260 billion annually.
Including AOMs under Medicare Part D would mark a paradigm shift in treating obesity within the U.S. healthcare system. Until recently, lifestyle modifications—including diet, exercise, and behavioral therapy—have been the cornerstone of obesity management. While these interventions are essential, they often yield modest results for individuals with severe obesity or those with a genetic predisposition to weight gain. AOMs, including medications like GLP-1 receptor agonists, have shown promise in achieving significant and sustained weight loss combined with lifestyle changes. These medications aid in weight reduction and improve metabolic parameters, potentially preventing or delaying the onset of obesity-related conditions such as MASLD. By expanding coverage under Medicare Part D, CMS can help reduce health disparities and improve outcomes for millions of Part D beneficiaries. At this time, the cost of AOMs prevents many CMS beneficiaries from receiving the medication.
For professional case managers, the proposed CMS rule presents an opportunity to advocate for comprehensive care plans for our clients that include AOMs as a component of obesity management. As case managers, we can play a pivotal role in educating our clients about the benefits of AOMs along with the risks. The multifaceted nature of obesity can be addressed by recognizing and discussing the stigma associated with obesity and liver disease, dispelling myths, and coordinating interdisciplinary interventions. The stigma surrounding obesity and liver disease often prevents individuals from seeking help. It is particularly important that case managers stay informed about Medicare Part D updates so that we can assist clients navigate coverage and access to AOMs. In addition, case managers need to advocate for routine screening and proactive interventions. Early identification and treatment of obesity can prevent the progression of MASLD and other obesity-related conditions.
The inclusion of AOMs under Medicare Part D coverage represents a critical step in the fight against obesity and its associated conditions. By addressing one of the root causes of MASLD, this policy has the potential to reduce healthcare costs and improve quality of life for millions of Americans. As CMS works toward finalizing this rule, professional case managers have a unique opportunity to lead the charge in integrating AOMs into obesity treatment plans, ultimately contributing to better health outcomes for our clients and communities.
CMS’s proposed new rule can improve liver health and improved the lives of many Americans.
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Bio: Janet Coulter, MSN, MS, RN, CCM, FCM is President of CMSA. She is a transplant case manager with a wide variety of experiences including educator, administrator, team leader, and Director of Case Management. Janet holds a Master of Science in Nursing from West Virginia University and a Master of Science in Adult Education from Marshall University. She has published many articles in CMSA Today and the Professional Case Management Journal and served as a reviewer for the Core Curriculum for Case Management Third Edition. She has served as President-Elect of CMSA, Chair of the CMSA Today Editorial Board, Chair of the Nominations Committee, and Vice-President of the CMSA Foundation board. Janet was the recipient of the CMSA National Award of Service Excellence and Southern Ohio Valley CMSA Case Management Leadership award and was recently inducted as a Case Management Fellow from CMSA.