November 26, 2024
For More Information, Please Contact
- Valinda Rutledge, APG Executive Vice President, Advocacy and Education, at vrutledge@apg.org
- Jennifer Podulka, APG Senior Vice President, Federal Policy, at jpodulka@apg.org
The Centers of Medicare & Medicaid Services’ (CMS’s) newly announced proposal to expand coverage in 2026 for anti-obesity medications (AOMs) to Medicare Part D and Medicaid enrollees would be a win for public health, health care, and for millions of Americans who are battling obesity and its health consequences, America’s Physician Groups said today. The proposal, which would expand coverage of these medications when used for weight loss or chronic weight management for the treatment of obesity, is part of a new proposed rule that would revise the Medicare Advantage (MA) Program, Medicare Prescription Drug Benefit Program (Part D), Medicare Cost Plan Program, Programs of All-Inclusive Care for the Elderly (PACE).
“Given the extraordinary benefits of many of the newer anti-obesity medications, and the growing health and health care burden of obesity, this proposal to expand coverage for AOMs is, if anything, overdue,” said Susan Dentzer, president and chief executive officer of America’s Physician Groups. “At the same time, we recognize that the proposal raises real concerns about the costs of medication coverage; the sustainability of treatment, given patients’ struggles with adherence to these medications; and other implications for both providers and patient care. We look forward to discussing these matters with our member physician groups and sharing our perspectives with federal regulators.”
Other aspects of the proposed rule also warrant attention, particularly as they apply to Medicare Advantage plans, Dentzer said. APG represents multiple physician groups that share risk with MA plans and are largely or fully accountable for the costs and quality of caring for millions of MA enrollees.
Dentzer and her APG colleagues pointed to these additional key concerns:
Prior Authorization Proposed Changes: APG recognizes that both providers and patients have ongoing concerns about the use of prior authorization (PA) and endorses CMS’s proposal to make patients more aware of their rights to appeal care denials and the details of MA plans’ own internal coverage policies. But at the same time, APG is “concerned about the extent of the some of the additional regulations that CMS proposes, and the degree to which they would unduly impair prior authorization as an essential utilization management tool – particularly to weed out the huge volumes of low-value care that continue to pervade the health care system,” Dentzer said.
Proposed New Requirements on MA Agents and Brokers: APG fully supports requiring agents and brokers who advise Medicare beneficiaries about MA plans to discuss such assistance as their potential eligibility for the Low-Income Subsidy in Part D and the Medicare Savings Programs, as CMS proposes. However, other aspects of CMS’s proposals appear aimed at requiring these agents and brokers to wade more deeply into the practical implications of switching between MA and traditional Medicare – potentially with the intent of discouraging them from entering MA in the first place. Assuming that there is value in alerting Medicare beneficiaries to these implications, CMS should develop standardized materials that are available on Medicare.gov or through State Health Insurance Plans to which brokers and agents can refer Medicare enrollees.
Comments on the proposed rule are due by January 27, 2025, and APG will conduct learning and review sessions with its members in coming weeks to develop its responses. “We also recognize that this proposed rule will be finalized under the new Trump administration and look forward to sharing the perspectives of our member groups with the newly installed CMS leadership once it takes office,” Dentzer said.
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About America’s Physician Groups
APG’s approximately 360 physician groups comprise 170,000 physicians, as well as thousands of other clinicians, providing care to nearly 90 million patients, including about 1 in 3 Medicare Advantage enrollees. APG’s motto, ‘Taking Responsibility for America’s Health,’ represents our members’ commitment to clinically integrated, coordinated, value-based health care in which physician groups are accountable for the costs and quality of patient care. Visit us at www.apg.org.
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