Coding, Coverage Gaps Hamper Multidisciplinary Obesity Care

Even as glucagon-like peptide-1 (GLP-1) receptor agonists have transformed the treatment landscape for obesity, the condition remains chronically undercoded, underresourced, and unevenly treated. This was a recurring topic of discussion among clinicians and pharmacists from Temple University Health System and Penn Medicine who gathered in Philadelphia on June 4, 2026, at an American Journal of Managed Care^® Population Health Roundtable exploring how health systems can build more effective, coordinated care teams for patients living with obesity and type 2 diabetes. The discussion was moderated by Geoffrey Mills, MD, PhD, vice chair for clinical services and medical director of quality at Jefferson Health.

ICD-10 Coding Gaps Leave Patients Unaware of Obesity Diagnosis

Ajaykumar Rao, MD, chief of adult endocrinology at Temple University, opened by noting that failure to code for obesity in electronic health records creates a cascade of downstream problems, including patients leaving visits unaware that their weight was even addressed. "If we don't code for it, then the patient doesn't understand that it's a problem," he said.

Anastassia Amaro, MD, medical director of Penn Metabolic Medicine and professor of clinical medicine at the University of Pennsylvania, observed that coding practices have improved since semaglutide's approval for weight management, but added a broader caution: the group had drifted quickly into drug-focused discussion. "Obesity care is not always drugs," she said.

Clinical Pharmacists Drive GLP-1 Access, Titration Beyond Dispensing

Nina Thoguluva, PharmD, lead clinical pharmacy specialist in ambulatory care at Temple University Hospital, described a model in which clinical pharmacists serve as a bridge between prescribers and payers. At Temple, her team uses a medication access group to process prior authorizations through CoverMyMeds, with denials escalated back to her for an appeal strategy. Beyond authorization, she emphasized the clinical value pharmacists bring to GLP-1 titration—seeing patients on a 4-week cadence and integrating lifestyle counseling around resistance training, dietary changes, and adverse effect management.

Kristin Criner, MD, associate professor of medicine at Temple University, noted that Thoguluva's guidance on documentation language has helped streamline approvals. "Nina helps us a lot on protocols and wording in our notes in order for our authorization team to see keywords and get things approved," she said.

Thoguluva also flagged a structural gap in how pharmacist positions are funded on the East Coast compared with the Midwest and West Coast, where clinical pharmacists routinely bill for patient visits and carry panels of 20 or more patients per day. She is working to revive the billing infrastructure at Temple that previously existed but lapsed.

Medicaid Rollbacks, Payer Incentives Stall Obesity Treatment Access

Sharon Herring, MD, MPH, professor of medicine at Temple University, described carrying Pennsylvania Medicaid formulary guidance in her bag to counter misinformation patients receive directly from their insurers. She also described Pennsylvania's January 2026 rollback of Medicaid GLP-1 coverage for weight management as a sharp reversal after 3 years of growing access. "We were going forward, and then we got slammed against the brick wall," she said.

Daniel Rubin, MD, MSc, FACE, professor of medicine at Temple University, situated the issue within structural incentive misalignment: Payers don't retain members long enough to recoup the downstream cardiovascular and metabolic savings that obesity treatment would generate. "Insurance providers are incentivized not to pay for it," he said. Stigma, he added, remains an underappreciated barrier—both in the lay public and among providers who view obesity as a moral failing rather than a disease.

Temple, Penn Obesity Programs Vary in Integration, Specialty Mix

Joseph Teel, MD, FAAFP, FACHE, CAQHALM, chief of regional primary care at Penn Medicine, described variation across the Penn system, with downtown Philadelphia sites operating with obesity medicine largely separated from bariatric surgery, while the Lancaster practice colocates medical and surgical obesity services in a single physical setting. He also noted that bariatric surgical volume has dropped sharply as pharmacologic options have improved, with some health systems reducing bariatric surgery staff.

Herring described Temple's multidisciplinary model, which pairs a generalist obesity medicine physician with an endocrinologist, a nurse practitioner, and a gastroenterologist performing endoscopic procedures, along with close pharmacy collaboration on access challenges.

Amaro's program at Penn focuses on a highly specialized niche—complex referrals including syndromic obesity, pediatric-to-adult transitions, and clinical trial participation—leaving the bulk of obesity pharmacotherapy to primary care and general endocrinology across the Penn network.

Imali Sirisena, MD, an endocrinologist at Temple University, and Regine Boutin, MD, assistant professor at Temple University, both pointed to the absence of a validated severity-stratification system for obesity as a barrier to rational triage, making it difficult to determine which patients warrant subspecialty referral versus primary care management.

Medicare GLP-1 Bridge Program Raises Access, Coverage Questions

The group discussed the pending Medicare GLP-1 Bridge program, set to launch in July 2026 as an 18-month pilot through Part D for eligible beneficiaries with a BMI of 35 or above and qualifying comorbidities. Thoguluva noted that Humana is administering coverage under the program, with a projected $50 co-pay, though implications for dual-eligible patients remain unclear. Amaro flagged the urgency: "The program is 18 months only, so we'd better learn it quickly."

Participants closed with a call for standardized ambulatory care pathways, broader physician advocacy at the state formulary level, and expanded cross-specialty education, particularly around GLP-1 prescribing comfort in pulmonology, cardiology, and hepatology, as concrete steps health systems can take within the next 6 to 18 months.