News|Articles|October 23, 2026

Roundtable Wrap: Dallas Panels Say Coding, Coverage Gaps Block Team Care

Key Takeaways

Obesity, CKM, and atopic dermatitis panels in Dallas traced undertreatment to coding, coverage, and prior authorization gaps, not clinical uncertainty.
A WellMed physician asked why obesity, pre-diabetes, and chronic kidney disease have ICD codes but cardio-kidney-metabolic syndrome still does not.
Follow-up AJMC coverage is planned on obesity pharmacy workflows, atopic dermatitis biologic access, and CKM staging from this event.

Dallas population health roundtable exposes prior authorization hurdles, ICD coding gaps, and copay barriers delaying care coordination.

Clinicians at 3 separate roundtables in Dallas spent 2 hours apiece describing, in disease states as different as obesity and atopic dermatitis, the identical experience of watching a patient qualify for treatment on paper and then lose it to a biller, a missing code, or a $50-a-month co-pay they could not spare.

The Dallas Population Health Roundtable, hosted by The American Journal of Managed Care^® (AJMC^®), convened 3 concurrent tracks on September 15, 2026: multidisciplinary care teams for obesity and type 2 diabetes, moderated by Melissa Shoemaker, MD, MPH, of UT Southwestern Medical Center; treatment escalation in atopic dermatitis, moderated by Aaron Farberg, MD, FAAD, a Dallas dermatologist; and closing cardio-kidney-metabolic (CKM) care gaps, moderated by Michael Almaleh, MD, chief of cardiology and specialty care for WellMed’s Greater Texas Region. Panelists were drawn from UT Southwestern Medical Center, Baylor Scott & White Health, independent and academic dermatology practices across North Texas, and WellMed’s value-based primary care network.

Primary Care Owns Obesity Care, Until Insurance Intervenes

Panelists from UT Southwestern Medical Center and Baylor Scott & White Health agreed that obesity care begins, almost without exception, in primary care, before a patient ever reaches an endocrinologist or bariatric surgeon. A dedicated pharmacy staffer emerged as the unofficial backbone of that system. Marconi Abreu, MD, an endocrinologist at UT Southwestern, said his clinic’s pharmacy technician secures prior authorization for a glucagon-like peptide 1 (GLP-1) receptor agonist before a patient with diabetes even leaves the exam room, and he questioned how any practice functions without one. Sully Anne Drotar, DO, medical director for medical weight loss management at Baylor Scott & White Health, said hiring 1 employee to work prior authorizations full-time transformed her clinic, even though the position bills nothing on its own. Panelists credited the Medicare GLP-1 Bridge Program, which offers the drugs to eligible Part D beneficiaries for $50 a month, with widening access, but said it also drew a sharper line between patients who could absorb even that cost and those who could not.

Uma Gunasekaran, MD, an endocrinologist who leads Parkland Health’s Global Diabetes Program, described a patient assistance program that has grown more, not less, burdensome even as it remains free: an application that once took a signature now requires a Medicaid rejection letter, an electronic signature tied to the prescriber’s personal email address, and a 4-month dispensing limit that discourages dose titration. Patients who clear every hurdle still wait on a single, nationally backlogged specialty pharmacy. Gunasekaran said the result was a widening gap between patients with the resources to pay cash for newer formulations and those priced out even of a subsidized drug, calling it a split between “haves and have nots” that obesity medicine had not faced before GLP-1 therapies arrived.

Bethany Agusala, MD, a general internist and medical director of UT Southwestern’s faculty practice, said the barrier to treatment was rarely clinical anymore. Cost, she said, now shapes decisions that used to be made on pharmacology alone.

“The saddest thing I heard from my patient was, ‘I went to the food pantry and they didn’t have food,’” Agusala said. “There is nothing you can say. How am I supposed to help you treat anything if you can’t even tell me that you’re eating?”

Atopic Dermatitis Panel Confronts an Illogical Coverage Maze

Farberg opened his session with figures showing that roughly 40% of adults and 33% of children with atopic dermatitis have moderate to severe disease and that more than half of adults with moderate to severe disease report inadequate control. Panelists, drawn from independent and academic dermatology practices across North Texas, said their documentation tools have not fully kept pace with that burden: body surface area and itch-severity scores now satisfy Merit-based Incentive Payment System reporting requirements, but panelists said those numbers only partly capture what bothers patients, and most clinics still lack standardized, high-quality photography to track improvement over time. Rosemary Son, PA-C, RDN, a physician assistant and registered dietitian who treats dermatology patients at Parkland Health, said access, not recognition, was her bigger obstacle, describing a largely uninsured and Medicare-underfunded patient population for whom declining literacy complicates even basic patient education materials.

Treatment escalation surfaced its own access gaps. Panelists said the newest biologic approved down to 6 months of age had expanded options for severe pediatric disease, but several described young children for whom the injection itself, not the underlying disease, had become the barrier. Some parents, panelists said, now ask for topical numbing agents or simply refuse another monthly injection regardless of how well controlled the disease has become. Panelists also disagreed on how far to extend trust to non-dermatology colleagues managing patients on systemic therapy, with several saying that internal medicine and family practice physicians often do not understand why a biologic should not be stopped before routine surgery the way an anticoagulant might be.

Insurance logic itself drew the sharpest complaints. Kathryn Durham, MD, of US Dermatology Partners, described a denial that still startled colleagues around the table: a payer rejected her prescription for hydrocortisone 2.5% cream as not covered, then approved an identical substitute.

“They said that’s not covered,” Durham said. “But what is covered is hydrocortisone, 2.5% cream. That’s where we’re at.”

Cardio-Kidney-Metabolic Care Has No Code and No Clear Owner

Almaleh framed CKM syndrome as a workflow problem rather than a knowledge gap, citing 2026 guidelines showing that nearly 9 in 10 American adults carry at least 1 CKM risk factor.¹ His panel, drawn entirely from WellMed’s value-based primary care practices across North and Central Texas, spent much of the session on who owns a CKM diagnosis once a patient is identified, since cardiologists, nephrologists, and endocrinologists each manage only their own piece of an interconnected disease. No consensus emerged. Almaleh described the choice as either a single “quarterback” coordinating every specialist’s input or a “matrix” of specialists managing their own organ systems in parallel, and panelists said their own systems operate as a mix of both, often producing duplicate outreach to the same patient rather than the gaps the model was meant to prevent.

Vishal Malpani, MD, a WellMed medical director in Austin, argued primary care should start guideline-directed therapy itself and escalate only when complications arise, once trust is built with specialists; others in the room, incentivized under their own value-based contracts, said they increasingly want that ownership too. The absence of a dedicated CKM diagnosis code, under the International Classification of Diseases (ICD) system insurers use to determine coverage, surfaced repeatedly as the practical root of the problem.

Tamika Perry, DO, MPH, an associate medical director for WellMed in the Dallas-Fort Worth area, said the gap undercuts everything from clinical documentation to insurance benefit design. “Prediabetes has an ICD. Obesity has several ICDs,” Perry said. “Why doesn’t CKM have one?”

The Through-Line and What It Means for Coverage

Whatever form the barrier took (a prior authorization, a coverage denial, or a missing diagnosis code), every track eventually arrived at the same complaint: billing and documentation infrastructure has not caught up with how clinicians say they want to practice.

The rooms split on where the fix should come from. The cardiology panel reached for simple, rule-based system logic, such as embedded order sets and automatic follow-up triggers, to catch patients earlier. The dermatology panel, weighing a similar problem of patients going undiagnosed, floated artificial intelligence-driven intake tools instead.

Across all 3 tracks, utilization management functioned less as a clinical check than as an administrative tax on coordination: time spent securing prior authorizations, appealing denials for drugs with no interchangeable alternative, or working around a diagnosis code that does not exist. Panelists suggested payers could narrow the gap by formally coding CKM syndrome, reimbursing the pharmacy and care-coordination labor that currently generates no billable revenue, and extending the Medicare GLP-1 Bridge Program’s lower-cost pathway beyond its current pilot phase.