Conquer Your Weight

Dr. Sarah Stombaugh: Before we get into the episode, I am thrilled to announce we are launching an online course, The GLP Guide. The GLP guide is a must have resource for patients who have been prescribed any of the GLP medications such as Wegovy, Ozempic, semaglutide, Zepbound, Mounjaro, tirzepatide, Saxenda, liraglutide. There are a lot of them and this course is available for anyone to purchase. We often hear from people who haven't been given much information about their GLP medications. No one has told them how to handle side effects, what nutrition recommendations they should follow, or what to expect in the longterm. And it can be really intimidating and simply frustrating to feel like you're alone in your weight loss journey. With the GLP guide, you'll get access to all of the answers to the most common questions for patients using GLP medications, not sure how to use your pen, struggling with nausea, wondering how to travel with your medications. We've got you covered for only $97 for one year access. This is an opportunity you do not want to miss. The course is launching on October 1st. For more information and sign up, please visit www.sarahstombaughmd.com/glp. You don't have to be on this journey alone. We are here to guide you. And now for today's episode, this is Dr. Sarah Stombaugh and you are listening to the Conquer Your Weight podcast. Announcer: Welcome to the Conquer Your Weight podcast, where you will learn to understand your mind and body so you can achieve long-term weight loss. Here's your host, obesity medicine physician and life coach, Dr. Sarah Stombaugh. Dr. Sarah Stombaugh: Hello everyone and welcome to this week's podcast. I have a guest with me today, Dr. Kratovil. She is an internal medicine trained physician who is practicing obesity medicine, does weight management with Sentara and Norfolk. I'm so excited to have her here today because we are talking about a super important topic, which is insurance coverage of obesity medications. And the conversation over the last couple of years has been around some of these newer GLPs, the Ozempic, the Wegovy, Mounjaro, Zepbounds, and we are going to talk about do you have coverage? How can you look into that? And then are there other options for people who don't have coverage? So it's going to be a great conversation. I'm super excited to have her here today. So Dr. Kratovil, thank you so much for joining me. Dr. Kristina Kratovil: Oh, no problem. Thank you for having me. Dr. Sarah Stombaugh: So tell me a little bit more about yourself, how you got into obesity medicine and a bit about your practice. Dr. Kristina Kratovil: Actually, I got into obesity medicine early on in my career. I was in the Navy for nine years and in 2007 timeframe I was working with a mentor who was giving Byetta to his diabetic patients and saying, this is going to revolutionize our diabetic patients treatment because it's going to help them lose weight and they're not going to need their insulin anymore. And so I kind of followed suit because he was brilliant in my eyes and obviously he was. And so I started kind of doing the same, giving biota to my patients when I could. And then in 2010 when I got back from my general medical officer tour, I started working with Karl Nadolsky, who's up in the, who's a big name in obesity medicine and endocrinology who he and his brother. But he got me into it in the Navy and we started working on trying to get obesity management medications to our active duty population because it wasn't available to them at that time. So it kind of evolved from there. And when I got out of the Navy in 2014, went into private practice, started an obesity management program with my private practice from scratch, that was pretty successful. And then when I joined Sentara in 2020 as their bariatrician got a program that had been around for about six years, but more as a side hustle for lack of a better way of putting it to the bariatric surgery program, really helped it become its own department and really a co-department to bariatric surgery. So that's how my career has evolved over time. Dr. Sarah Stombaugh: I love that and especially the evolution of some of the medications that we use has really evolved in the same time as well. And we think about some of the earliest medications that were officially approved for the treatment of obesity, like Saxenda and Contrave and Qsymia for example. And so being able to start your practice and utilize those, I mean, isn't it funny, I was using Saxenda in my residency training and people would be like, oh my gosh, I do not want to take an injection. Isn't there something that's not an injection available? And I think it's really funny to reflect almost a decade later that people are begging for the injections. Dr. Kristina Kratovil: Right? Yep, exactly. Dr. Sarah Stombaugh: Yeah. So tell me, when we look at these medications, when we think about insurance coverage for it, I think this is one of the biggest pieces that we're really struggling with as a population is how do we best support people and is there coverage? If there is coverage, what does that look like? Tell me a little bit about your program, how you guys support and teach patients about learning insurance coverage for medications. Dr. Kristina Kratovil: So in that initial visit with my patients when I first meet them, I expect if you're coming to see a specialist, I'm not just going to talk to you about your diet and behavior, even though that's the foundation of obesity management, we're going to get started with let's talk pharmacology if that's most likely indicated. And I approach it as unfortunately this is an uncomfortable truth, but the coverage for these medications is spotty and it is inconsistent and it's inconsistent even within carriers. So they'll change with time. And depending on how often the pharmacy committees meet, will depend on how coverage will even change. So I find out first from people what their carrier is, and we go from there. In my area in southeastern Virginia, our largest carriers are tricare, federal coverage, Medicare and Medicaid. I do see a large Medicaid population. And then we have, Sentara Health Plan is a large carrier, blue Cross Blue Shield anthem. Those are kind of our top carriers. So I look at that and we go from there. Unfortunately for my Medicare population, as we know, there is no what we used to call or most still call anti-obesity medication or a OM coverage or now transitioning to obesity management medication coverage. There is none. However, I do point out that there's two, in my mind, ways of approaching the pharmacology of treatment of obesity. There's the behavioral older generation medications like phentermine, topiramate, bupropion, naltrexone, which are our oral medications. And then we have the newer generation GLP-1s that come into different names that are FDA approved, but one actual medication for each of those two names, meaning for Ozempic and Wegovy, they're both semaglutide or semaglutide. I explain that to patients. And so for my patients who don't have any coverage, whether they be Medicare or otherwise, I try and reassure them there are still options. We are going to need to really look closely at these oral medications and see how they may apply for you depending on what challenges you've encountered with your efforts to reduce weight in the past in order to treat the disease. There are some other oral metabolic medications that we could try off-label to help underlying metabolic issues such as things like Jardiance, Metformin, et cetera, that may have some weight reduction, weight loss benefit. But I typically stick with the ones I mentioned, the phentermine, topiramate, bupropion, naltrexone at first to address those behavioral challenges that a lot of us are struggling with when we're first entering a weight reduction program. And throughout the weight loss journey, I mean this is a cyclical disease. Habits are difficult to form and they're difficult to break. So that's where I try and focus my attention when a patient does not have coverage. Dr. Sarah Stombaugh: Absolutely. When I think the piece that you're saying in terms of coverage is going to, we think a lot, the conversation's been around the GLP medication, so the semaglutide products, Ozempic, Wegovy, the tirzepatide products, Zepbound, Mounjaro, and those medications are wildly expensive sometimes even with insurance coverage. And some of these older medications, many of them are right, many of them have been around like phentermine's been around since 59, 1959. Dr. Kristina Kratovil: 1959. Yep. Dr. Sarah Stombaugh: It's been a minute, right? So we've got medications that we have really good and long-term data and those are quite affordable. So I think one of the things that's really nice is that often there is a option, even if it's not what someone came into the clinic really excited about, potentially a GLP medication. Now, one of the things that I feel like I have to clarify a lot in my clinic and I think is important in the broader narrative is the difference between the brand names and the difference between treatment indications. And so one of the things that I encounter pretty frequently, both with patients but then also sometimes in social media conversation is a patient will reach out to their insurance and say, Hey, do I have coverage for Ozempic? And the insurance company is like, yes, you do have insurance coverage for Ozempic and the patient doesn't have diabetes. So when we look at those products, you've got semaglutide products, the Ozempic is FDA-branded for the treatment of type two diabetes, and that's, it has no other indications. It's used off-label sometimes, although rarely covered off-label meaning for anything beyond type two diabetes. And then you have Wegovy, which is the treatment for obesity. Although we do have just this year the cardiovascular risk reduction indication. And so I think one of the pieces that's really important is when someone's reaching out to their insurance that they're asking not about coverage for Ozempic or for Mounjaro, which are medications that are approved for the treatment of type two diabetes unless they have type two diabetes. But checking about do I have coverage for specifically for Wegovy, specifically for Zepbound? Dr. Kristina Kratovil: Yes. And that is definitely a clarification I make with people when I am talking to a patient about the GLP-1s. I then send a message to them and I list all of the GLP-1s, what their indications are and what they should be asking about to their insurers. And I make it very clear that no matter what your insurance company or that person tells you on the phone, if you don't have type two diabetes, Ozempic, Mounjaro, Victoza, Byetta, Trulicity, they're not getting covered. They're not getting covered. And I don't care what they tell you on the phone, and I have not been wrong yet, I'll let you know and to speak to your point and you can do appeals, I do have one patient who is on the liver transplant list that she has. I have her on Ozempic and she had no other options for weight reduction to get her so that she could be on the transplant list. And so that's how I was able to get her on Ozempic with insulin resistance and liver disease. And we know that I think, and I had a meeting with some of the Novo reps that they are for Q1 2025 submitting semaglutide, I think Ozempic for a mash indication, a metabolic associated steatohepatitis. So fatty liver will hopefully be approved and approved indication for that medication later next year. So that is also something I talk to my patients who don't have coverage. I reassure them that these medications are rapidly evolving and the pharmaceutical companies are on top of seeing the good that has been done for patients and knowing that we are seeing reduction in or improvement in CKD. So Ozempic will likely have a CKD indication late next year, chronic kidney disease, we'll likely see one for heart failure late next year probably for MASH. We're likely going to see Zepbound with an indication for obstructive sleep apnea late next year because we're seeing a reduction in the apnea hypopnea index and people don't require their CPAP as much, and these are all happening independent of weight loss. So if a patient has no matter the amount of weight loss that occurs, these things are happening. So the reason I point that out is because I do think we are going to see a domino with insurers are going to start having a more inclusive language, probably a first more restrictive language. But I do think that there is going to be some hope for patients with treating their obesity with some of these comorbid conditions that are most likely being driven by the obesity in some ways. And unfortunately we're going to get the indication for that comorbid condition and then treat the obesity and hopefully get some resolution of both or remission of both. Dr. Sarah Stombaugh: Absolutely. I love that you point that out. And I think we've started to see that shift when, earlier this year in 2024 when Wegovy, so the traditionally thought of as weight management version of semaglutide medication, when that got the approval for cardiovascular risk reduction in patients with a history of cardiovascular disease such as heart attack or stroke, and seeing that in the Medicare population was huge. And because Medicare has been as a whole, really the biggest holdout when it comes to the treatment of obesity at this time, Medicare has no treatment for or no coverage for the treatment of obesity medications, but they did approve wegovy for this secondary indication for the risk reduction of cardiovascular disease in those patients. And so that was huge, and I think that was really a big milestone and speaks to some of these other indications like you're talking about because we saw Medicare did that. We've seen other of course commercial insurers who've done that. And then it's really exciting as we think about these other indications because it's so many of us in the field recognize that obesity is a chronic disease. And the amazing thing about specifically the GOP medications is that they are really shifting the entire narrative. There's so much happening physiologically with those both in terms of weight and then also independent of weight as you mentioned. So that's really, it's pretty exciting. Dr. Kristina Kratovil: It is it. So I definitely counsel people on that and let them know, Hey, we're on top of, you're in the right place. We're on top of what's going on in this field, but let's get you started with something today so that we can get the journey going and not delay any Dr. Sarah Stombaugh: Further. One of the important pieces there too is that sometimes we see step therapy requirements, meaning that of course you know what that means, but for my listeners that insurance companies will say, yes, we will cover a expensive medication like a GLP, but first you need to have tried a different medication. And that is often some of the older medications like contra of that combination of bupropion naltrexone like Qsymia, the combination of phentermine and topiramate, sometimes like Orlistat, the lipase inhibitor. We do not have a video, but Kristina, Dr. Kratovil is rolling her eyes, which is the most accurate, the most accurate response to insurances that say you need to use Orlistat. For anyone who doesn't know, I don't know if I've talked much about Orlistat on the podcast, but it is an old medication. It is a medication that inhibits lipase, which means it inhibits your ability to properly absorb fat and the side effects of that medication if you eat any fat in your diet, even healthy fats, even avocados and olive oil and all that terrible greasy stool leaking, oily discharge, yuck, yucky, yuck side effects. Dr. Kristina Kratovil: For anyone who remembers those potato chips in the nineties that had, that's what it's like. Dr. Sarah Stombaugh: Yeah, exactly. Actually, and maybe I've short shared this story in my podcast before, but I worked as a lifeguard in waterpark and a bunch of girls in their late teens, early twenties decided to take Ally, the over-the-counter version of Orlistat and lose weight over the summer. And it was a disaster because they were constantly calling for breaks to urgently use the restroom. Terrible, terrible side effects. So all of that being said, sometimes these insurances come and say, Hey, we've got these step therapy requirements. You need to either have tried other medications or have a contraindication. And doctors like myself and Dr. Kratovil, I'm sure gladly say Orlistat is contraindicated because we recommend a diet, blah, blah, blah, blah, blah. But it's so good to get started with someone like Dr. Kratovil, like myself, like another board certified obesity medicine physician in order to start that process. Because sometimes the process of using a medication like contrave, like the generic components of those medications, one, you might find that they actually really support you, or two, if they don't, that may be a step in the direction of getting another medication approved in the future. So tell me about how that shows up in your practice. Dr. Kristina Kratovil: So what I typically do, because a lot of the insurers do have a step requirement, or if they do not have a step requirement, they have, you need to be six, a patient needs to be six months in a program or have shown six months of lifestyle intervention prior to getting an approval for a medication. So I often will take that opportunity then to use one of the generic components of Qsymia or contrave or a combination thereof to get it started in those six months because of what you just mentioned, they're affordable. And Walmart will have a $4 coupon for phentermine for a month, and so you can get it for four bucks. So if you can take phentermine, it's a great medication. It's been around since the fifties for a reason. It works great for a lot of people. That's all they ever need. So now it doesn't show any of the comorbidity resolution like we're seeing with the GLP-1s. But if you don't have any of the major comorbid conditions, then yeah, something like phentermine for weight reduction and prevention of risk, reduction of development of future disease, it's a great medication to try. So that's usually what I'll do is I'll talk within that first six months, I'll say, Hey, this is what we need to do. We need to start something like this show you've responded or not responded. And then when we get to that six month mark, we can talk about the next step. What's nice is with try tricare, for example, for the military and retired military members, the only medication you have to try now before you can move to a GLP-1 is phentermine. And it's basically try phentermine. You need to try it for I believe either three or six months and show if a patient does not have more than a 5% body weight loss, then move on to the next step. I don't think that is actually unreasonable. I call the GLP-1s for someone who comes in with a BMI, let's say of 33, no other comorbid conditions. I don't necessarily think Wegovy is what's necessary if nothing's been tried yet, we do need to build that foundation of nutrition, lifestyle and behavior and try something from a pharmacologic standpoint like phentermine or similar first and see if we can get some reduction, save those big guns for when they're really needed and go from there. And that's kind of how I've started putting it. Hey, we know they're there. We know the big guns are there, and if you've got coverage, great. That's not necessarily where we need to start and let's see what we can accomplish with something else and see depending on what's appropriate. Dr. Sarah Stombaugh: Absolutely. Well, I think that piece too, when we think about what are we starting with also just thinking about the long-term trajectory of whatever it is, whether it's one of these pill medications, whether it's the injectable. I think one of the most damaging things recently has been this narrative about jump-starting your weight loss journey. And you can use some of these injectable medications for a period of time and then discontinue them. And while that may be true in a very small subset of patients, by and large, that is not the data that we see when we look at long-term studies. And simply put, I like to say the way you lose weight is the way that you keep it off. And so when we're starting on a journey, you don't have to commit forever. I understand that there's a lot of trepidation and some people getting started on a journey may have some concerns about that. So of course at any point we can consider, do we transition to another option? I believe very strongly that my patients are the boss of their body. If you want to trial off of medication, totally fine. And the population data shows that people need to be on these medications. And so having that conversation from the get-go, thinking about what does long-term look like? Because a lot of times long-term, when we think about some of the pills, for example, one, we know long-term there's going to be affordable coverage of these options. And two, it may be more palatable to consider. Let's say you're taking bupropion on a component of contrave. It may be augmenting mood support. It may be helping with cravings. Is it palatable to think taking that medication in your sixties and seventies and eighties for example, maybe that may be more tolerable compared to some of these injectable medications. And if coverage changes, we're not having such a panic state because we know that these medications, some of the older oral pills are really well covered and will continue to be Dr. Kristina Kratovil: Oh, and they're safe. They're very safe and well tolerated. I like the boss of your body. I like that. I might steal that because that is well said for people because that's exactly the conversation I have. They say, I don't want to be on this forever. I said, and I heard that that's what you have to be. I said, well, that's what the studies say now, but we don't know that yet. We don't know the long-term data for obesity treatment of these medications, specifically the GLP-1s. What I can tell patients is I don't think that that's necessarily going to be the case if we see resolution of comorbid conditions and obesity and remission. What I do ask of my patients is, once we get you to the health state that we both find acceptable, that, and that's a conversation once we get there, let's stick with the medication, let's stick with the treatment plan for at least six months a year and then talk about coming off of medication. And I ask patients of that, even if their copay is very high, that is something we talk about. I want them to know that I'm not doing this as a quote jumpstart because that's not what this is. I'm not in the business of weight loss. I'm not in that industry. I'm in the field of obesity medicine and I'm here to treat a disease and make sure that people are healthy and reduce their risk of future disease and help treat current disease. So there's a very different goal there, set a goals there. So I want to make sure that we've reached those goals and that we feel that we're at a place where we are safe to maybe pull back a little bit, start reducing, pulling off some medication, seeing how we do and do a trial off meds. I do ask that to please, let's make that a conversation and I am open to it obviously. Another thing you said earlier on that I do point out to patients when I first meet them, look at this as this is a journey. Obesity is a chronic disease. It's cyclical. I hope that the hope is that we put it in remission and we try and keep it there, but it's going to require monitoring the next 12 to 18 months for most when they're working with me are what I call the phase of active weight reduction, where we're going to be actively reducing your weight and working toward that. So look at that as like a 12 to 18 month commitment. Now the first six months are more intense. And then from there, hopefully we'll have you in kind of a stabilization of what the plan is. But this isn't forever. This is like we're hitting this hard to get you treated and get the disease under control. And then from there, I compare it to something like the treatment of cancer where you're undergoing chemotherapy, you're in that chemotherapy window for six, 12 months. It depends on the type of cancer. And then from there, you go into a phase where, okay, we wait and see and now we're going to see what's going on. And then we go into the surveillance phase that is similar for a lot of disease processes to include obesity. So we need to kind of approach it as a chronic disease in that way. We're going to really treat the disease upfront with medication, with lifestyle, and then we'll go into a surveillance phase from there. So I try and get to help people release that stigma of it not being a disease and focus on, no, this is something that we're treating and we're taking seriously in this way. Dr. Sarah Stombaugh: And I think your cancer analogy is really a valuable one, not to really give people that understanding and acceptance that this is not, we hear about it's a willpower disease, calories in versus calories out, these very simplistic and archaic explanations that do not support our patients. And so many people come into medical weight loss programs, not really having that buy-in or not, they have the buy-in, but not having that belief that they aren't to blame, that there's not this belief about what does this mean medically? What does this mean as a disease state? And so I think really treating it with the emphasis that it deserves and the intention that it deserves and being really committed and in a program that's going to be supportive and in a very structured way to help you, not just in six months or 12 months, but really start to think about this long-term trajectory of how do we support you? Because like you said, early it can be this sort of relapsing of the disease too. And five years from now, 10 years from now, do you have the tools in place to lean back in if you need to because that can absolutely happen. Dr. Kristina Kratovil: Exactly. Exactly. And that's where we go into an annual surveillance program where patients will see us every six to 12 months depending on what medications they're on, where they're at in the journey. And I've had patients on phentermine off and on for five years in order to 10 years to maintain their weight loss. And now I'm coming into where they've been on GLP ones for that amount of time And without that foundation of the nutrition behavior. And I like keep calling foundation because I always tell my patients, foundations have to be monitored because they can develop cracks and that's when whatever we've built on the foundation can become unstable. So the pharmacotherapy, even surgery cannot be as effective if that foundation is faltering. So we have to cycle back to the foundation in order to make what we've built with the foundation continue to work. And so it's not that the pharmacology, so my patients who are on GLP ones long-term who are having weight recurrence, let's go back and look and see what's happening from a nutritional behavioral, what's happening in life in the world, if that's not what's going on, do we have any comorbid conditions that have occurred? Oh, have we developed a cancer? Are we not using our CPAP as much? Oh, are we entering menopause? There's a lot of things that go on that need to be monitored over the course of a lifetime of someone having this disease. And that's going to change with time. So I think monitoring the foundation, but also recognizing that normal process of time for patients with the disease also hasn't, I don't think has come to light that much for people, especially for the aging process. People who lose weight early on or get their obesity into remission in their thirties, but then start to have recurrence. I haven't changed anything. I'm doing everything the same. Well, there's a lot of things that are going on that we need to reevaluate, and hopefully with the way the science is going with these pharmacologic options, we're going to have more tools in the toolbox to offer people. So Dr. Sarah Stombaugh: Yeah, I am so excited to be in this field and thinking about the future 5, 10, 20 years from now and the evolutions we've already seen, and we'll continue to see. It's a cool place to be in and be able to support patients in this way. I have a feeling, Dr. Kratovil, that you and I could talk all day long. Dr. Kristina Kratovil: I did, yes. Sorry. Dr. Sarah Stombaugh: No, this has been so fun. I'm glad we've been able to address this topic. Let me ask you, before we wrap up our conversation today, is there anything you think is really important for my listeners to know that we haven't talked about yet? Dr. Kristina Kratovil: Just that be open to treatment for the disease and be open to all treatments because this is a very complicated disease and there are a lot of options out there. And one is not necessarily going to work for everyone the way that everyone thinks. So meaning some people don't respond to the GLP ones. And I think that that's something that can be very devastating because they've been put out there as this magic cure and they're just not, because that's just one gut hormone that they're simulating when there are dozens that can contribute to the development of this disease as we're seeing with more and more of these types of medications come out, but have faith that there are more going to be more treatments. But I think just being open and seeking out a specialist, if you've struggled with this disease and looking at it as a disease and not as a character flaw or a fault that is, I say this almost every day, but the disease of obesity is the last acceptable form of discrimination. And for some reason, I'm not really sure why, but it's, and so don't allow yourself to get sucked into that, I guess, and realize, no, it's a disease. It needs to be treated. And if you struggle with for 5, 10, 40 years, that's too long and you deserve treatment and be open to that. Dr. Sarah Stombaugh: Absolutely. I love that. And there's been such a growth in this field as we were talking about a growth in the number of physicians who are board certified and obesity medicine such as yourself, such as myself. And so for any of my listeners, there's so many people who support weight loss, right? We see it sort of on every corner at this time. And making sure that you're getting support from someone who really understands this as a medical process can provide that comprehensive support seeking out a diplomat, a board certified obesity medicine physician. I'll put in the show notes for this visit, how to do that as well, because you can look in your area, type in your zip code, type in your town, and find someone who is certified near you, which is a really valuable thing to have as part of your health journey. Well, Dr. Kratovil, thank you so much for joining us today. Let me ask you, if patients are interested in learning more about you and working with you, how can they do that? Dr. Kristina Kratovil: So yes, so I am with Sentara Medical Group, Sentara Comprehensive Weight Loss Solutions. I should just be able to go to the website and find our number there. And we do have a little bit of a waiting list, but we work to get people in usually, hopefully within six months is what we're working toward, but that's where we're at. But we have locations in Suffolk, Norfolk, and Hampton. Dr. Sarah Stombaugh: Okay, excellent. And we will include those links too in the show notes, so we'll make sure to get those from you. Thank you so much for joining us. This has been really fun to have this conversation about such an important topic. And unfortunately, like we said, really a crux of a lot of the conversation because of what coverage looks like, but I think this conversation shows that there are so many options out there right now, and so working with someone who understands those and can support you is really the next best move.