Episode 240: What is the new Medicare GLP-1 Bridge Demonstration Program?

[00:00:00] Welcome back to the Back on Track: Achieving Healthy Weight Loss, where I help you get on track and stay on track with your weight loss journey. I'm your host, Dr. Alicia Shelly. So let's get started.

[00:00:28] Hello, and welcome back to the Back on Track: Achieving Healthy Weight Loss podcast. I'm your host, Dr. Alicia Shelly. Have you ever felt frustrated because you finally found a medication that could help you with losing weight, but your Medicare insurance wouldn't cover it? Or you were told your insurance just excludes weight loss medications? Or simply, guess what?

[00:00:53] You just don't qualify based on whatever standards and criteria your insurance comes up with. So my friends, this may start to be a problem of the past or may start to change. Starting July 1st in 2026, the CMS, which stands for the Centers of Medicare and Medicaid Services, is launching something called the Medicare Bridge Program.

[00:01:17] And today we're going to break it down. What the program is, who may qualify, and which medications may be covered. And why this could be a major turning point in obesity treatment for Medicare patients. This program has the potential to change access to obesity treatment for thousands of people across the country. For years, one of the biggest barriers I've seen in clinic has not been motivation, even hasn't been laziness or a lack of effort.

[00:01:47] It's been access. So many times you have insurances, you have, you know, Medicare, Medicaid, all the different insurances that actually say, Hey, I realize that obesity is a chronic disease. However, we are not going to give you access to these medication because of the cost.

[00:02:11] Even though it's going to cost you more down the line when I have my first heart attack, when I have my first stroke and I'm in the hospital for longer than I have to go to rehab. It's probably you're going to save money in the long run if you would just have access. And so I'm glad that Medicare is taking this step because this may help other insurances looking at Medicare say, Ah, maybe we need to have more access for these medications because, yes, it may be more expensive in the short term.

[00:02:40] But in the long term, I can actually help my employees to stay healthier longer. And with CMS introducing a short term Medicare pilot program called Medicare Bridge Program, this Medicare Bridge Program is part of a larger balance initiative. And so the balance program stands for a better approach to lifestyle and nutrition for comprehensive health.

[00:03:10] This is also a new Medicare focused obesity care model being developed by the Centers of Medicare and Medicaid Services or CMS. The goal of the balance model is to create a more comprehensive approach to obesity treatment for Medicare patients. And it combines lifestyle counseling, nutrition support, physical activity programs, behavioral health strategies and obesity medications like GOP-1s and long term chronic disease management.

[00:03:39] And what's interesting is, is that they've done studies looking at intensive therapy where you're seeing somebody 24 times within a year. So twice, twice a month. And what it showed was that people tend to lose more weight when you had a more comprehensive program, lifestyle change, nutrition, all the thing.

[00:03:58] And right now, many Medicare beneficiaries have very limited access to anti-obesity medications, even when obesity contributes to conditions like heart disease, hypertension, sleep apnea, kidney disease, arthritis and prediabetes. And the balance program is a CMS acknowledgement that obesity is a chronic disease and that requires ongoing treatment, not just medications, but lifestyle intervention.

[00:04:26] And it's not a short term dieting advice. And while we don't have all the details yet about the balance program and the bridge program, I want to say this is a very, very important step because we're getting to a point where we are having access. And some people will get access because not everybody is going to be able to get access with this program. And I'll share with you why here in a second.

[00:04:49] But I also want to just impress upon you is that there is a act called TROA, which is the Shriek and Reduce Obesity Act, which is important. We've been trying to get this act bill passed for the last 10 years. And this bill, if approved by Congress, it will allow basically Medicare recipients to be able to get access to not just nutrition, but also to medication.

[00:05:18] And that this would be more permanent because right now it just depends on who's in office. So the next guy could come in and say, well, we're going to cut this program because it's too expensive. So it's important that we have, you know, something that's set in stone and permanent so our patients can be able to get access to medication. So let's start a little simpler. What exactly is the Medicare Bridge program?

[00:05:44] Like I mentioned before, it's going to get started on July 1st, which is basically over a month from now. And CMS plans to launch the, they're calling the Medicare GOP-1 Bridge demonstration program. So it's a pilot program. I got to see how it goes. It's going to last from July 1st to all the way to January 31st of 2027. So it's a year and a half. And then after that, the balance program will take into effect.

[00:06:13] And once again, obesity treatment is not about medication alone. It's about combining nutrition, physical activity, behavior change, and medical treatment together. Because obesity is a chronic disease and chronic diseases deserve long-term evidence-based care. If you had blood pressure, high blood pressure, high diabetes, no one would say, ah, you know, you need to get off your medication.

[00:06:38] No, they would say you need to be on your medications because they're treating the condition. And so these changes, nutrition, physical activity, medications are all treating the disease of obesity. Now let's talk about the medications that are expected to be included in the Bridge program. Right now, the eligible drugs are the Wegovy shot and Wegovy pill, also Zepbound Quick Pin, as well as Fundayo pill.

[00:07:05] Now I do want to say CMS has also stated that more details are going to be expected soon. And so some of this could all still evolve over time. So definitely keep your eyes and ears on a lookout. But this is still significant because historically many Medicare patients had extremely limited options for obesity medicine coverage. And I can't tell you how many conversations I've had with patients.

[00:07:30] Dr. Alicia Shelly, I want to start this medication, but I just can't simply afford it. And some patients have been paying hundreds and hundreds of dollars out of pocket every month so they could get these medications, these evidence-based medications. And others basically just gave up altogether because the costs were just too high. So even with even having a pilot program, this is going to be a major shift. Now, okay, friends, this is probably the part many of you have been waiting for.

[00:07:59] Who qualifies for these medications? So let's walk through the current clinical guidelines in plain English. Medicare participants are usually for people who are on disability or people who are ages 65 and older. So it just depends on where you are, you know, as far as with your retirement and whatnot, and whether you're eligible for Medicare. Now, there's three different groups.

[00:08:26] The first group is adults ages 18 or older with a BMI of 35 or greater. And they must be using the medication or plan to use the medication along with lifestyle modifications, including nutrition changes, physical activity and ongoing weight management effort. And so this is important. The medication is not intended to stand alone. You kind of need the behavioral changes as well. Now, group two is for adults with a BMI of 30 or greater, plus one of the following conditions.

[00:08:56] Heart failure with preserved ejection fraction, uncontrolled hypertension with a blood pressure of greater than 140 over 90, despite being on two hypertensive medications. And if you have chronic kidney disease stage 3A or higher. So let's pause here. This is important because obesity impacts so many other health conditions. We're not just talking about weight on a scale. We're talking about heart health, kidney health, blood pressure, mobility, inflammation and quality of life.

[00:09:25] And then now we have group three, which is adults of a BMI of 27 or greater. Plus one of these conditions, which is prediabetes, a previous heart attack, previous stroke and symptomatic peripheral arterial disease. And honestly, this reflects what many of us in the obesity medicine have been saying for years. Treating obesity early may help prevent worsening diseases later.

[00:09:51] So treating people when they're at the prediabetes or an A1C of 27 and above, this is where this group of people can be helpful. And the question now is, why does this really matter to me? Well, I want to spend a minute here because this is bigger than just a medication coverage. For years, obesity treatment has often been treated differently. People think of it as cosmetic and they don't think of it as chronic disease.

[00:10:16] But if somebody has high blood pressure, we don't usually say, you know what, you should just try harder. Or if somebody has asthma, we don't say, maybe you should just have more discipline. But when it comes to obesity, patients are often blamed. And many patients delay care because they feel ashamed or discouraged. Meanwhile, obesity increases the risk of diabetes, heart disease, sleep apnea, osteoarthritis, fatty liver disease, and so much more. In fact, it can increase cancer by 14%.

[00:10:46] So obesity can. So programs like this acknowledge that obesity treatment belongs in mainstream medical care and that it matters. Now, before everybody gets too excited, I do want to set realistic expectations. This is still a demonstration program. That means details may change. There may be enrollment requirements. There may be documentation requirements. There may still be prior authorizations.

[00:11:13] CMS has also emphasized that lifestyle interventions must be ongoing. So the patient may need a structural nutrition counseling, exercise program, and or ongoing obesity management visits. And honestly, I actually think that combination approach is important. Medication can be an incredible tool. But sustainable health also requires habits, support, education, and on long-term care.

[00:11:41] So remember, obesity is not simply about willpower. Hormones matter. Genetics matter. Stress matters. Sleep matters. Access matters. And for many patients, medications help to quiet the constant battle happening in the background. And that's why expanding access matters so much. So let's recap the big points.

[00:12:06] The Medicare GOP-1 bridge program is expected to launch July 1, 2026. It is designed as a temporary bridge program into the larger balance program, which will happen in January of 2028. Potential covered medications include Wegovy, ZepBound, Fundale. And eligibility may depend on VMI thresholds, medical conditions, and participating in ongoing lifestyle modifications.

[00:12:33] And while we still need more details from CMS, this represents a major step forward in recognizing obesity as a chronic disease deserving treatment. So friends, if you're listening to this and thinking maybe this could finally help me, I want you to know that there is hope. And even if the system has made things difficult, your health journey is still worth fighting for. And thank you so much for joining me today on today's episode.

[00:13:01] So if this episode helped you, please share with a friend or a loved one who may benefit. And don't forget to subscribe to the Back on Track Achieving Healthy Weight Loss podcast so you never miss an episode. And until next time, keep showing up, keep trusting the process, and stay consistent because you are stronger than you think.