Obesity Deserves Diabetes-Level Coverage: Fatima Cody Stanford, MD

Weight loss percentages alone no longer capture the value of GLP-1 therapy; cost and access, rather than side effects, are the main reasons patients stop taking these medications, and obesity treatment should be covered the way type 2 diabetes treatment is, according to Fatima Cody Stanford, MD, MPH, MPA, an obesity medicine physician at Massachusetts General Hospital and associate professor of medicine and pediatrics at Harvard Medical School.

Stanford discusses how cardiometabolic and functional trial outcomes are changing what counts as a meaningful result beyond the scale, why patients in Massachusetts came off therapy after major insurers dropped coverage, and what sustainable coverage pathways should look like.

In part 1 of the interview with The American Journal of Managed Care^® (AJMC^®), Stanford explained how administrative burden and narrow eligibility criteria are limiting the reach of the Medicare GLP-1 Bridge program, even as its flat $50 copay leaves many patients outside the program facing steep out-of-pocket costs.

This interview has been edited for clarity.

AJMC: Looking at trial data, how is the evidence from cardiometabolic trials making the leap to value-based coverage decisions, and which outcomes beyond the scale matter most?

Stanford: I pay very little attention to the scale. We're seeing many outcomes that go beyond the scale. The Lancet Commission—I'm one of the Lancet commissioners—shifted away from BMI [body mass index], particularly for those who don't have severe obesity.¹ For anyone with severe obesity, we still pay attention to it, but for patients who don't have severe obesity, we really need to be looking at non-scale victories and the whole health of the patient.

I think we're starting to see that shift, particularly because the trials are supporting it. We're seeing changes in the overall cardiometabolic health of individuals in SELECT, SURMOUNT, and TRIUMPH.^2-4 All of these trials have consistently supported the idea that this isn't just about an individual's weight. Working with patients—not just in the trial environment, but on the ground—really highlights this. When I'm going over a patient's labs, their health, and the removal of other medications, that can really speak to what the story should be: Are we removing their antihypertensives? Are we removing other medications used to treat diabetes? Is their liver function improving? What's happening with their cholesterol medications? What's happening to the individual? I think the trials are demonstrating that.

I have patients who say, “I'm able to run up the subway stairs,” or “I'm able to do things I wasn't able to do before.” Those are non-scale victories, and they have so much more impact than just the number on the scale. Someone can’t look at me and tell me, “Fatima weighs this amount.” What does that mean? Just because I weigh a certain amount doesn't tell you how healthy or unhealthy I am. You can't look at me and tell me my health status. Getting patients to understand that and look at their full health and getting pharma to align with that and getting government bodies like the FDA to look beyond just 5%, 10%, 15%, or 20% weight loss matters.

The finances need to align with that too, because as we look at percentages of weight loss, we start seeing they align the percentage of weight loss with value, and a dollar amount is put on achieving X percentage. But that percentage doesn't always reflect the best quality, because these medications don't distinguish between lean and fat mass, particularly in older adults. If you can't get out of your chair because you've lost so much weight and muscle, how well have we really done? We have to think about all of these things.

AJMC: Do we feel like quality of life and functional status are being captured? How can they better be captured?

Stanford: I think we're seeing trials shift. I'm one of the principal investigators for TRIUMPH-6 [NCT06859268],⁵ which is Eli Lilly's retatrutide study. In this study, we look at functional measures: sit-to-stand, hand grip, DEXA [dual-energy x-ray absorptiometry], and MRI. We're doing all of these things, and we have dietitians assigned to all of our study participants. We're looking at cardiometabolic values, all the laboratory studies, and the like.

When you combine all those things, it's not just about the percentage. We already know retatrutide is the most powerful drug studied to date, with numbers that align with what we see with metabolic and bariatric surgery—28.3% in certain key TRIUMPH studies.⁶ We know these triple agonists—GLP-1, GIP [glucose-dependent insulinotropic polypeptide], and glucagon receptor agonists—are effective, but what are we seeing in terms of functional outcomes? We're starting to see pharma—Lilly, Novo Nordisk, Amgen, Boehringer Ingelheim, AstraZeneca, and others—begin to think about what else is happening. What else do we need to focus on? We're starting to see them pay attention to things beyond just total body weight loss, which, of course, investors in the stock market also pay attention to. But it's more than that for the patient.

This is a chronic disease. Most of my patients have been with me for 10 to 15 years or more. It's not just about what happens today, in 2026—it's about what happens in 2036 or 2045. We must pay attention to all of these factors because it's more than just this one point in time. It's about the longevity of these medications, or surgical interventions, or lifestyle modifications, and a comprehensive look at those things.

AJMC: There are high real-world discontinuation rates for GLP-1s. What primary factors are driving patients off therapy, and how can care teams support longer-term adherence?

Stanford: I think the number one issue—and studies have demonstrated this, but I'll also talk about what's happening in the real world—is cost and access. Regarding side effects, we do know issues like GI [gastrointestinal] side effects—nausea, constipation—can drive patients off medications, but I think the number 1 issue is still cost and access.

If I look at the landscape of coverage here in Massachusetts, which had the best coverage through January 2026: The big 4 insurers here—Blue Cross Blue Shield of Massachusetts, Mass General Brigham Health Plan, Harvard Pilgrim, and Tufts Health Plan—all covered these medications for patients with overweight and obesity until January 1, 2026.⁷ At that point, those insurers said, “We're not covering these medications on a routine basis for patients with overweight and obesity,” but they’re still covered for patients with diabetes, because that’s a “real” disease. I care for patients exclusively with overweight and obesity, some of whom happen to have diabetes, and I disagree emphatically with that decision.

A lot of this is based on decisions like CBO [Congressional Budget Office] cost estimates,⁸ but I completely disagree, because when we withdraw these medications, we see a re-emergence of weight gain, which is a re-emergence of cardiometabolic issues. When patients have their coverage discontinued, they come off the drugs not because they want to, but because they can no longer afford somewhere between $300 and $450 a month, which is the out-of-pocket price through NovoCare [Novo Nordisk's direct-to-consumer pharmacy] or Lilly Direct [Eli Lilly's direct-to-consumer pharmacy]. For middle- or upper-middle-class families, prices of $300, $350, or $450 per month aren't prohibitive. But for everyone else, that's very cost-prohibitive. It's not sustainable; they can't handle it.

Now, what about circa 2021, 2022, and 2023, when prices were $1000 to $1600 per month? Big Pharma will say, “We brought the prices down,” and yes, they did. But $300 to $450 a month is like a car payment or a rent payment for people who don't have a substantial income and don't have disposable income to put toward that amount every month. So, they came off the drugs, and they're really disgruntled about it. Those who have the money retain their coverage.

The next driver of discontinuation is patients who have side effects that weren't mitigated by slowing titration. One of the key things we can do to mitigate side effects is keeping the dose low and going slow. I'd say the third reason is non-responders, or relative non-responders. We have to recognize that the mechanism of action for these drugs may not be conducive to everyone's pathophysiology, depending on where the dysfunction occurs. Some people have dysfunction in other parts of the brain, or in the periphery, and it's important for us to recognize that.

AJMC: With the Medicare portion of the Bridge program only extended through the end of 2027 and some insurers scaling back coverage, what do sustainable, permanent coverage pathways for GLP-1s need to look like?

Stanford: I think we need to treat obesity like every other chronic disease, for instance, diabetes. We as doctors, both here in the US and outside of it—Australia, Asia, and almost all of the countries in Europe—treat diabetes as a chronic disease because it is.

What happens when a patient who has obesity develops diabetes? This is sad, but it's true: We get excited. How horrible is that? Why do we get excited that our patient has developed diabetes? Because our patient with diabetes receives coverage for their GLP-1.

I have a patient whom I care for, along with his wife and daughter. I started treating him back in 2012, and he got his wife and then his daughter to start seeing me. At one point back in 2014 or 2015, his hemoglobin A_1C reached 6.5%, which is a clinical diagnosis for type 2 diabetes. That means it's always in his chart, which means he always has coverage for GLP-1s. Neither his wife nor his daughter has that in their chart, so their GLP-1 isn't covered. His pathway is always covered. What do permanent coverage pathways for GLP-1s look like? It looks like the pathway we have for type 2 diabetes: always covered.

We know there's a tremendous overlap: about 80% of patients with type 2 diabetes also have obesity.⁹ Yet we cover their treatment for GLP-1s because they have diabetes and don't cover patients with obesity alone. We have to stop discriminating, and if one disease process doesn't exist, it's a matter of willpower. We need to treat patients with obesity with kindness, dignity, and respect, and understand the biology behind that disease process, in the same way we do for patients with type 2 diabetes. Coverage should look like it does for type 2 diabetes, both here in the United States and worldwide.

References

1. Rubino F, Cummings DE, Eckle RH, et al. Definition and diagnostic criteria of clinical obesity. Lancet Diabetes Endocrinol. 2025;13(3):221-262. doi:10.1016/S2213-8587(24)00316-4
2. Lincoff AM, Brown-Frandsen K, Colhoun HM, et al; SELECT Trial Investigators. Semaglutide and Cardiovascular Outcomes in Obesity without Diabetes. N Engl J Med. 2023;389(24):2221-2232. doi:10.1056/NEJMoa2307563
3. Sattar N, García‐Pérez L-E, Rodríguez A, Kapoor R, Stefanski A, Hankosky ER.Tirzepatide and cardiometabolic parameters in obesity: Summary of current evidence. Diabetes Obes Metab. 2025;27(10):5386-5392. doi:10.1111/dom.16549
4. Lilly's triple agonist, retatrutide, successful in two additional Phase 3 obesity trials, delivering significant improvements in weight and A1C. News release. Eli Lilly. July 23, 2026. Accessed October 14, 2026. https://investor.lilly.com/news-releases/news-release-details/lillys-triple-agonist-retatrutide-successful-two-additional
5. Eli Lilly and Company. A study of retatrutide (LY3437943) in the maintenance of weight reduction in individuals with obesity (TRIUMPH-6). Lilly Trials. Accessed October 14, 2026. https://trials.lilly.com/en-US/trial/580035
6. Lilly's triple agonist, retatrutide, delivered powerful weight loss in pivotal Phase 3 obesity trial. News release. Eli Lilly. May 21, 2026. October 14, 2026. https://investor.lilly.com/news-releases/news-release-details/lillys-triple-agonist-retatrutide-delivered-powerful-weight-loss
7. GLP-1 spending in Massachusetts projected to decrease significantly in 2026 after changes in commercial coverage. Press release. Massachusetts Health Policy Commission. September 17, 2026. Accessed October 14, 2026. https://masshpc.gov/news/press-release/glp-1-spending-massachusetts-projected-decrease-significantly-2026-after-changes
8. Congressional Budget Office. How would authorizing Medicare to cover anti-obesity medications affect the federal budget? October 8, 2024. Accessed October 14, 2026. https://www.cbo.gov/publication/60441
9. Zanni GR. Dangerous liaisons: obesity and diabetes. Am J Manag Care. 2014;20(Spec 1):e10.