Ever wondered how the convoluted marketing strategies of Medicare Disadvantaged Plans influence our healthcare choices? Join us as we unravel the complexities of these plans, and the limitations seniors face when choosing a Medicare plan. During a riveting general surgery marathon at Tucson Medical Center, I was reminded of how our personal health journeys intertwine with the broader healthcare narrative. We’ll also celebrate life’s milestones, from weddings to weight loss triumphs, and discuss maintaining muscle while you melt away the pounds. We also offer insights from our guest Elizabeth, who tackles the tough topic of obesity bias within the weight loss surgery community.
Weight regain can be a daunting prospect after the triumph of weight loss surgery. Hear the story of one individual’s experience with vertical sleeve gastrectomy, her subsequent weight regain, and how GLP-1 medications like Ozempic and Mounjaro have become game-changers in maintaining control. We’ll dig into the biological factors of weight control and the diverse responses to GLP-1 medications among those with and without a history of surgical weight loss. It’s an eye-opening glimpse into the ongoing battle for sustained health and the critical role of medications post-surgery.
Join our conversation on the power of community post-weight loss surgery, GLP-1 medications, obesity bias, and how to preserve muscle while losing weight. We round up with a look at delicious, healthy pasta options and practical tips for preventing weight regain after gastric sleeve surgery. Tune in for a hearty dose of knowledge and motivation to fuel your journey toward a healthier you.
Transcript
Zoe: 0:33
Welcome back to the Pound of Cure Weight Loss podcast. We have made it to episode 15. The title today is Medicare Disadvantage Plans.
Dr. Weiner: 0:42
Yes. That’s how they’re marketed, and that’s how I think about them. So I had my last general surgery call, probably in a really long time, this weekend. I actually took both Saturday and Sunday, so I’ve basically been working for seven days straight. So we’ll see if I can keep it together when I talk about Medicare Disadvantage Plans.
Dr. Weiner: 1:07
But a general surgery call in Tucson is brutal. I’ve worked in downtown Detroit. I did all my training at Bellevue Hospital and NYU Hospital, and nothing compares to the complexity of the disease or the amount of surgical pathology we see at Tucson Medical Center. It is insane. The stuff that I see is stuff that I read about in medical school and never really saw much in my training. I didn’t see it early in my career, but I see it regularly at TMC. It really is an amazing hospital and how they serve the community, and they really take on a lot of very difficult cases. So my hats off to the general surgeons who take that call regularly, because it is not an easy job. But anyway, you’ve got some exciting stuff coming up. Can you talk to me about what’s going on there? Talk to everyone about it.
Zoe: 2:01
Well, yeah, my wedding is coming up here in, like, less than three months. And so I went, actually, and tasted the food on Thursday. So you know, I love food.
Dr. Weiner: 2:15
Now, what are you doing here? This is a little tricky for you. You’re a dietitian. You really emphasize healthy eating. It’s your wedding, though. How are you going to handle that?
Zoe: 2:23
Well, do you mean for me or for the guests? Both, okay. Well, for me, I like to eat food that makes me feel good, and I, you know, allow a treat here and there. But I do not want to feel icky on my wedding day. I was actually talking to my mom about that this morning, or I think it was yesterday, what we are going to do for breakfast the day of, and like, I might just make my veggie eggs scrambled, because I know it’s one thing that makes me feel my best in the morning. So we’ll see. So, yeah, no, I wanted to make sure we got a good amount of vegetables, a good amount of protein, and a lot of chicken, and then we’re also throwing in some pasta, and we are having a gelato cart, so I’m excited about that. So it should be good.
Dr. Weiner: 3:06
Fun. Well, we’re excited for you, Zoe; that’s going to be awesome.
Dr. Weiner: 3:09
All right. What’s on the show today?
Zoe: 3:10
All right. So of course we’ve got our in-the-news segment for GLP-1s, specifically people over 65. So we also have Elizabeth, our guest today, who is going to be discussing obesity bias and the weight-loss surgery community. Strategies to reduce muscle loss during weight loss. I love this topic. We have our Medicare Disadvantage Plans in our economics of obesity segment, and then our questions from the followers. So is surgery the easy way out? I think we have some strong opinions about that. When to start GLP-1s after surgery, and then those Banza pasta varieties.
Dr. Weiner: 3:49
All right, fantastic. So let’s start with the news. So this article came to us from The Atlantic, which, for obesity coverage, is one of my favorite news publications, and it talks about older Americans using Ozempic for weight loss and what the pros and cons are. About 25% of all the GLP-1 users for weight loss are over the age of 65. And I’ll tell you, we see that in our practice, that’s changed a little bit since a lot of the Medicare rules came around January 1st and made it much more difficult to get these medications. But there are still a substantial number of people who are going to qualify for the medications. And what we see with weight loss, and this is common in weight loss, no matter how you achieve it, is that you never just lose fat. It’d be great if you did, but you also lose muscle. Muscle is very metabolically active, so if you’re in some form of calorie deprivation or some form of famine mode, your body’s smart. It’s going to use some of the muscle because muscle is much more metabolically active than fat. So it’s kind of like, if you lose your job, you stop spending as much. The same thing happens with your body. If you have a lot of calories coming in, maybe you burn up some of your muscle, so you’re burning fewer calories on a daily basis. So, to some degree, that’s unpreventable. There are strategies, which Zoe will talk about later on in the podcast, that you can apply from a nutritional perspective and an exercise perspective. But to some degree, you’re always going to lose some muscle, and so the question is, in the younger people that have some muscle to spare, there’s a little less risk of injury and fall. So with older people, muscle loss is really dangerous, and your goal as you age is to reduce your muscle loss as much as possible. I can tell you personally that my number one goal when I exercise is to build and preserve muscle. Flexibility is number two. I’m not very flexible, but I’m working on it. But preserving muscle is really, really important. And so how does taking these medications (GLP-1s) affect your muscle mass if you’re over 65, and is it really a good thing in this patient population? I don’t know if we know the answer. I think we’re going to. Is there a greater risk of falls? We know from bariatric surgery that, in general, there’s a lot of benefit for people over 65. And I think, in my opinion, what this comes down to is: Are we dealing with clinically significant obesity or are we trying to lose 10 pounds? And I think if you’re trying to lose 10 pounds and you’re over the age of 65, I’m not sure using GLP-1s makes a lot of sense. I think if you’re struggling with clinical obesity, if you’re 50, 75, or more pounds overweight, and you have substantial comorbid conditions like diabetes, high blood pressure, or high cholesterol, then these medications are going to make a lot of sense. The other important thing that I talk to my patients over 65 about all the time is something we call the obesity paradox. So we’ve all been told, “Hey, the lower your weight, the thinner you are, the healthier you are.” But as you age, that’s not necessarily true. All of us have seen these frail older people, and they just don’t have a lot of reserves. So, we look at how unhelpful BMI can be, and we’ll talk about this, I’m sure, in a future podcast. But if you had to throw a BMI number out there — 25 or so for normals — is that what you would use in your practice, Zoe? As you age, that number might be 28, or it might be 30. And so you have to also keep that in mind. So this was a great article. If you’re taking GLP-1s or thinking about taking them when you’re 65 or older, check out this article in The Atlantic. Zoe, what do you do nutritionally for patients who are over 65 and are in the process of losing weight? What’s your approach? And we’ll talk about it a little bit more later, but just give us a little bit of thoughts on it.
Zoe: 7:56
Yeah. So the two main things are: number one, to make sure you’re getting enough protein, and I mean just even if you aren’t losing weight. As we age, we are more prone to decreasing our muscle mass without those intentional efforts. So protein, and then also creating that stimulus on the muscle. So whether that’s through weight training or some sort of weight-bearing activity, that could be yoga or some sort of activity that’s going to help put that resistance on your muscles to create that stimulus.
Dr. Weiner: 8:26
I think that’s great advice. As you get older, you know, in our Pound of Cure program, we don’t really push high amounts of protein. We don’t discourage it either, but it’s not a 100, 120, or even 200-gram protein program, like you’ll see with some keto or carnivore diets. That’s certainly not what we encourage in our patients, and I think there are a lot of good reasons, particularly for younger people. But I agree completely. As you get older, protein really is very, very important, ideally from plants, but it’s hard to get a lot of protein from plants, isn’t it?
Zoe: 8:58
Right, right, you get filled up really fast if you’re trying to get 80 grams of protein from beans.
Dr. Weiner: 9:04
I think we nailed our timing. Elizabeth is ready to share her story of weight loss and obesity and to talk a little bit about obesity bias. So let’s get Elizabeth on the line.
Zoe: 9:15
Well, welcome, Elizabeth. We’re super excited to have you here, just to kind of get us started. Will you do us the honor of sharing your story so far?
Elizabeth: 9:24
Sure, I have been overweight to some degree my entire life. When my son was getting ready to go to college, I was like, “If I don’t do something about my weight, finally, I’m going to be the crazy cat lady who never leaves her house.” So I was 48 when I decided to have weight-loss surgery. At that time, I was 402 pounds. That was almost exactly 10 years ago. It was April of 2014. I had a vertical sleeve gastrectomy. I don’t know if that’s what I would have if I had the choice to go in and do it today, but I think overall I’ve been super successful with VSG. Right now, I’m about 223. So that’s an 180-pound weight loss maintained for, like, nine years. So, I’m pretty happy with that. But I did start experiencing significant regain. A couple of years ago, my highest weight regain was around 270. And then I called Dr. Weiner’s office because I had heard him talking about GLP-1s and have been on GLP-1s, I think, for almost two years now.
Dr. Weiner: 11:17
Yeah, yeah, Elizabeth and I go way back, actually. This is kind of coming full circle because I was on the Naked Truth, right? Was that the name of your podcast way back when? Yeah, I was on that, yeah.
Elizabeth: 11:30
Yeah, a few times.
Dr. Weiner: 11:32
Yeah, so I was on Elizabeth’s podcast. That was a while ago, probably five or six years ago. That was back when I was in Detroit. We actually started on GLP-1 medications. How much weight did you regain after surgery, and then what was your GLP-1 starting with?
Elizabeth: 11:49
So, I think my lowest weight was, I think, 198 for five minutes approximately. And then I started bouncing up, and of course I was somebody who said, “They talk about the regain and getting as low as you can, because you’re going to have this bounce back.” And I was like, “That’s not going to happen to me. I’m working out like a crazy person, and I’m eating the way I’m supposed to. It’s not going to happen.” Well, it did. So my regain, I guess if you look at it from my lowest weight, was about 70 pounds, and if you take into consideration the fact that in that space I had plastic surgery and they removed 22 pounds of extra skin, it may have been even a little bit more than that, if you factor that in.
Dr. Weiner: 12:33
So what GLP-1 did you start?
Elizabeth: 12:38
I started on Ozempic and stayed on that. I think the reason I went off of Ozempic was, I just think, that in general, your practice was recommending Mounjaro, but you stopped being able to buy Ozempic in Canada, and then there was a Mounjaro coupon. So that was why I switched, and I prefer Mounjaro and Zepbound, which I’m on now, to Ozempic.
Dr. Weiner: 13:01
What dose are you on?
Elizabeth: 13:03
I’m on 15 milligrams, so I’m on the highest dose.
Dr. Weiner: 13:06
So you’re maxed out. But do you feel in control of your weight now?
Elizabeth: 13:09
Oh, 100%. I feel in control, and there have been little periods of time when I’ve had to go off of it just because, financially or for whatever reason, my insurance doesn’t cover it, and it’s not a cheap drug.
Dr. Weiner: 13:20
No, it’s not.
Elizabeth: 13:22
And I understand for the first time what it actually means to be in control of my weight and my eating. And even with weight loss surgery, I still felt like this was my fault — that being overweight was my fault. I didn’t have the willpower. And that’s one of the things I always enjoyed about you — that you really put that out, that it’s not your fault. It’s not your fault. This is a biological thing. Talk about set points; talk about all those things. But really, until I took GLP-1s, I was still somewhere in the back of my mind, thinking it was my fault. But this was like, I mean, instant, you’re not thinking about food. I mean, it’s just so hard to even describe it if you haven’t taken it because it’s so significantly different from weight loss surgery.
Dr. Weiner: 14:10
Yeah, I think the thing that I’ve noticed is that when we see lots of patients who haven’t had weight loss surgery and we’re putting them on GLP-1 medications, the results and the response in patients who have not had weight loss surgery are quite variable. Some people have had experiences like what you’ve described. Other people don’t tolerate it; it doesn’t work. It seems to me like people who’ve had surgery, particularly the sleeve, because that’s really where we see the weight regain, have this kind of almost uniform experience. Do you see this too, Zoe? I mean, you talked to probably more people than I do about how they’re feeling after these medications. Is that what you’re seeing?
Zoe: 14:50
Yeah, I would say overall, they tend to respond really well.
Dr. Weiner: 14:55
Yeah, something about surgery. I think it kind of primes you for the medication.
Zoe: 15:01
It’s almost like muscle memory.
Dr. Weiner: 15:05
I think it’s like your set point. This idea that your set point is exactly where it’s at is probably not entirely true. There’s some history behind where your set point is. You got down to a set point of, like, say, 200 pounds and then started to regain. How much did you regain again? 70, you said, I think?. Yeah, you’ve regained 70 pounds. That’s a lot of weight, yeah, and now that you’ve lost 50 of that, are you still losing or do you feel like you’re at a stable weight?
Elizabeth: 15:35
I was off for a couple months, and I just started retaking it again. So I lost the weight that I had put on during those few months pretty quickly, and we’ll see, because I’m just getting ready to pick up my second month after probably about four months off.
Dr. Weiner: 15:49
Yeah.
Elizabeth: 15:51
But I immediately lost weight. I mean, it’s so weird how it works. It’s like, 10 days later, you’ve lost 10 pounds. It’s crazy.
Dr. Weiner: 16:01
Yeah, without really feeling like you’re changing much about your life. So let’s talk a little bit about the weight-loss surgery community. You’ve been really involved in it. What do you think the weight-loss surgery is doing right? What do you think they’re doing wrong? And then, how has it changed since we started, since the GLP-1 medications became popular?
Elizabeth: 16:21
So I started pretty early on in my journey. I started a YouTube channel. That was the thing at the time. I don’t think it’s the thing anymore. I think TikTok and other things have taken over YouTube, but I had a channel for probably five years where I made a video every weekend. It’s still there if anybody wants to go see it, and what’s been so great about having that is that so many people have responded to me and said it’s because I watched your YouTube channel that I wasn’t afraid to get surgery. I was 48 when I had surgery, which is a lot older than most of the people — at least those who were active in that community at the time — were, but so that’s been great. I think that the people that I know who were very active in that community around my weight loss surgery class, that we are all more successful because of having been really involved in that, because we’re talking about it. We’re thinking about it. We’re learning strategies from each other. And when I first started watching videos, it was like the week that I was recovering from surgery, and I learned so much more than I was taught in the Kaiser class that I went to about how to eat after weight loss surgery. So for me, it was a huge, huge, huge benefit, and my best friends in my life now come from that community. And now it’s not about weight loss surgery anymore; now it’s about GLP-1s, because pretty much everybody’s on GLP-1s.
Dr. Weiner: 17:49
All the sleeve patients.
Elizabeth: 17:52
Yeah, one friend did it, and then we’re like, “Hmm, what is this? Let’s go check that out.” But I think the community is hugely helpful. I don’t know what it’s like as much now. I follow people on Instagram, and it has been super interesting because now the people that are still active are talking about GLP-1s, so it’s interesting to hear their experiences. I heard on someone’s Instagram about this Mounjaro coupon. Before I called you, I mean, I knew that it was the thing, because there are people who are as focused on this community as they are on the weight loss surgery community, and I can’t think of anything negative about it. For me, it was purely positive. I had a show for years, The Naked Truth, that you were on. That brought a lot of stories to people, and all this stuff is still out there. But I say it was probably the best thing that came out of weight loss surgery for me — being part of that community.
Dr. Weiner: 18:51
Yeah, yeah, I can imagine.
Zoe: 18:53
So what do you think that we all can do to help eliminate obesity bias?
Elizabeth: 19:00
So I work for the Geena Davis Institute on Gender and Media, which looks at representation and media. Originally, it started just looking at gender, but now we look at six different identities. We look at gender, race, ethnicity, LGBTQIA+, disability, age over 50, and large body type, which I’ve sort of decided to spearhead. And it’s really the last space where it’s okay. You know, it’s okay to make fun of it. So we’re focused on media content and what people see on screen, because sort of the idea is, if they can see it, they can be it. If you have kids who are consuming media where they’re seeing themselves doing amazing things, they know that that’s a possibility for them. And we added this large body type just not that long ago, a couple years ago, and I realized when I was doing that that I was probably 54 before I saw someone on screen who I felt like was a well-rounded character that was overweight, or in my world, we use the word fat. I know that’s kind of a sensitive word for many people, but it’s the word that the activists in this space like to use, and from my personal perspective, I like to use it to destigmatize it. So it’s just a characteristic. It’s like you have red hair, you have blue eyes, and you’re tall. You know, it’s just a descriptor; that’s all it is. The sort of value judgment that we placed on it gives it so much more energy than it actually has. But you just don’t see characters who are married, have jobs, or have lives. The storylines are always super focused on their weight. And so what we try to do is reduce some of the stigma by working to get just that person to be a normal character who’s part of the story. We make up a very large portion of the population (40%). And so it’s getting people comfortable seeing those people in the media and as part of their daily lives because the discrimination is huge. I mean, it’s getting hired for jobs and how much you make when you have a job. It’s the clothes you have access to that are changing. It’s medical care. I mean, there’s a huge bias in terms of medical care, which I’m sure you’re super aware of, and it’s the first thing. I went to a new doctor just on Friday, and I was like, I’m so anxious because they’re going to want to talk to me about my weight. Even though, you know, I’ve kept off 180 pounds for a year, and I probably know more about this and how to do it than most people do. But what’s so great about this doctor is that they said that we don’t need to weigh you.
Dr. Weiner: 21:56
Oh, wow.
Elizabeth: 21:57
I was like, wow, okay, I like you; I picked the right doctor. They were like, “You can tell us your weight if you want to, but it’s not going to drive what we’re talking to you about.” But that’s not the case in a lot of instances.
Dr. Weiner: 22:09
No.
Elizabeth: 22:09
So I hear so many stories about people. You know, serious illnesses have been overlooked because people want to blame them on being overweight.
Dr. Weiner: 22:19
We see that a lot.
Elizabeth: 22:20
Yeah, and so my goal personally and one of our goals at the Institute is to really try to fight for media representation because we are consuming media all the time, and if you never see yourself, I mean, I grew up believing that. Like I said, the first character I saw was Kate on This Is Us because she was married, she was a singer, and she had a job. Some of the episodes in the beginning were about her weight, but that sort of went away, and it’s just this character who’s there living her life, like all the rest of us are, and there are so many kids that struggle with obesity now. The fact that you don’t ever see yourself represented means that you don’t think that any of these things are open to you, and that’s what I thought too as I was a kid growing up, because there were none when I was a kid, nobody who was overweight.
Dr. Weiner: 23:07
Yeah, nobody.
Elizabeth: 23:09
None, so it’s super important.
Dr. Weiner: 23:12
So let’s talk about the F word. You know there’s kind of two F words, one I like and one I don’t like. The one you’re referring to is the one that I don’t.
Zoe: 23:22
One you use, one you don’t use.
Dr. Weiner: 23:23
I don’t use the other F word because we’re trying to keep our ratings clean on our podcast. But, you know, Zoe and I were talking about it. Neither of us really use that word with patients. We don’t use it in our home. It’s really not something — a word that we use. What’s your opinion? I think there’s kind of two parts to this too, and it’s like a lot of these other derogatory terms where if you’re in the demographic that it applies to, then you can use it, but if you’re not, it’s kind of, you know, off limits. Is the F word?
Elizabeth: 23:56
I mean, it’s probably one of the most complicated words out there, and it took me a long time to get comfortable saying it. And we have, like, because we use it at this, we have a paper that’s written up on why we use it. Because it is and it can be here, and if it offends you, I’m super sorry. It’s my choice; I’m okay with it. And for me, it’s sort of taking that word back and having power over it. It’s. It’s just like saying you know you’re tall. But I get that not everybody feels that way. I’m trying to destigmatize it a little bit because it has had so much power over so many of us for so long.
Dr. Weiner: 24:34
I really applaud what you’re doing. I think that you’re approaching it in a really intelligent way, as opposed to saying things like, “Don’t say that word; don’t be biased against people who are overweight.” Instead, you’re trying to get people represented in the media, and that’s what we see on Instagram, on television shows, and getting people who are overweight to be represented doing all the things that everybody else is doing and they really haven’t been, as you pointed out. To me, I think that’s a brilliant way to approach it. It’s very pragmatic; it makes the problem a little more solvable. Instead of it just being another term that people have to talk quietly about behind other people’s backs, it’s getting to the root of the problem and addressing it for the people most vulnerable, which are children.
Elizabeth: 25:24
Yeah.
Dr. Weiner: 25:25
I love that.
Elizabeth: 25:26
Good. Geena would like to hear that.
Zoe: 25:29
We are so grateful that you were able to come on and share your message today. I think a lot of people are going to feel really empowered and relate to what you have to say. We really appreciate you sharing today, Elizabeth.
Elizabeth: 25:43
Well, thank you so much for having me.
Dr. Weiner: 25:45
Thank you, Elizabeth.
Zoe: 25:46
All right. Well, that was just great to hear from Elizabeth. She has a lot of really wonderful values to share.
Dr. Weiner: 25:51
Yeah, I’m so happy to see that she’s working with Geena Davis on addressing obesity bias in such an appropriate, clever, and effective way. So let’s hope they make some headway with that, because there’s still a lot of room for improvement there.
Zoe: 26:07
So, going on to our nutrition segment today, I want to discuss a little bit about how to prevent muscle loss while you’re losing weight because, as I always like to say, I don’t really care if you’re just losing weight. I want most of that weight to come from fat and not from muscle. Just like you mentioned earlier in the show, muscle is more metabolically active. I like to say it’s expensive — metabolically expensive — and it requires more resources to maintain. So we really do want to maximize our effort to minimize that muscle loss. So the two heavy hitters here, like I mentioned briefly earlier, are going to be reaching your protein goals and creating that muscle stimulus through resistance training. So reaching your protein goals primarily through whole, real, unprocessed food. I know I sound like a broken record with that, but that’s the truth, because not only are you getting the protein, but you’re getting all these other wonderful micronutrients as well. And so, in addition to prioritizing whole-food protein and some of that protein coming from plant-based proteins as well, such as beans and legumes, we want to combine that protein with your resistance training. So that can be body weight, that can be bearings, that can be free weights, that can be machines, that can be going to a group class, that can be working with a personal trainer, that can be swimming, right? There are a lot of really great ways to create that stimulus in your muscle so that it has to work and can be maintained, and the combination of the stimulus with the protein can, over time, combined with intentional training, help to increase your muscle mass as well.
Dr. Weiner: 28:01
Yeah, that’s the two together. One without the other doesn’t work. Yeah, and I think that’s really important too when you’re in that weight-loss phase. That’s when it’s really critical, because if you don’t, your body’s going to preferentially lose muscle. And I think that some of the criticism that’s been levied at Ozempic is that if you take Ozempic, you’re going to lose tons of muscle. And I think the truth is that if you take Ozempic and eat like crap and don’t exercise, yeah, you’re going to lose tons of muscle. But if you eat really well, focus on protein — as much plant protein as you can—and exercise, then you can reduce that muscle loss and optimize it for fat loss. So, yeah, that’s really the critical part of weight loss. Once you hit your lowest weight and reach a steady state, protein consumption becomes a little bit less important. I’m not saying don’t eat protein, but you may not have to maximize it the way you are during weight loss. So let’s move on to the economics of the obesity segment, and I want to talk about Medicare Advantage Plans. So there are two different ways that you can get a Medicare policy. So Medicare is provided by the government. It’s healthcare that’s provided for anybody over 65 and then anybody who has been deemed disabled, which is a topic for another conversation about what disability means and how Medicare is sometimes used in that light. But the old-school way was a supplement. So Medicare covers 80% of everything, and then you’re responsible for the remaining 20%, for which healthcare is super expensive. 20% of super expensive is a lot of money. So these supplement plans would come in and basically fill in the gaps, and if Medicare pays 80%, they pay 20%. They may have a little deductible, however it works. And those plans worked out pretty well, and most people were happy. But as the cost of care went up, the cost of these went up as well, and so the insurance companies, because they’re really good at making money, went to the government and said, “Hey, listen, US government, you don’t know what you’re doing. The government stinks at managing healthcare. Let us do it. We’re the insurance company; we’re much, much better at it.” They said, “Here’s what you do: you pay us for the Medicare Plans, you give us the money you were going to spend on the patients, and you give it to us, and we’re going to manage it much, much better.” And that’s what a Medicare Advantage Plan is. It’s an insurance plan that is paid for partially by the government, and then you pay your own portion as well, and they take over everything. And so one thing they did initially was add dental and vision coverage, which sounds amazing, but dental and vision coverage is extremely inexpensive. Medicare doesn’t cover dental and vision, so if you have a Medicare supplement plan, you don’t have dental or vision coverage. But the truth is, compared to the total amount you spend on healthcare, dental and vision care is peanuts. Peanuts — I mean, most of us pay for that stuff out of our pockets, and very few people are going broke because of their glasses and their dental work. It’s expensive, and it hurts, but it’s not a $100,000 hospital stay. And so the insurance companies took over this, and what they ended up doing is what insurance companies do, which is they take the money that’s being assigned for healthcare and profit by not spending it on healthcare. And it became this game of deny and refuse, so that all of a sudden, now that they’re in charge, Medicare would cover most things. We saw Medicare covering Ozempic and Mounjaro very liberally. The Medicare Advantage Plans are going to limit that drug significantly. And so the Medicare Advantage Plan now kind of takes over all the prior authorization, and essentially, they’re making money by refusing treatment. So the attractive part of Medicare Advantage Plans is that they pay for 100% of a lot of things instead of 80%, and they offer dental and vision. But a lot of them are also very regional. So there are some situations where patients are able to get healthcare; they live right on the county line, and they’re only able to get healthcare on one side of that county line. On the other side of the county line, their Medicare Plan doesn’t cover them. So they create these incredibly narrow networks. If you’re on vacation and, let’s say, you need something electronically, you can’t get it because you can only get healthcare in your county. So these things are regional, down to the level of the county. The other thing that happens is that they’re really great for people who are healthy. And so they get you when you’re 65. These Medicare insurance brokers will put out these big seminars, and they’ll educate you and talk to you about how great these Medicare Advantage Plans are. Do you know why insurance brokers like Medicare Advantage Plans? They get paid about twice as much when they sell a Medicare Advantage Plan as they do when they sell a Medicare supplement plan, because Medicare Advantage Plans are much more profitable. United Healthcare’s primary center of profit right now is Medicare Advantage Plans, more so than their supplemental or commercial policies. So we’ve got all these brokers pushing these Medicare Advantage Plans to healthier seniors, and they work out great. They go to the dentist, and care is covered. They get eyeglasses; it’s covered. The problem is, as soon as they get sick, and inevitably, as we age, you’re going to get sick. That’s the unfortunate truth; all of a sudden, you can’t get it paid for. Oh, the good doctor that you really want to see! They don’t accept your Advantage Plan anymore because that doctor got sick and tired of not being paid and having to submit the bill 17 times before they finally got paid, and so they decided to drop the plan. And all of a sudden you’re seeking care, you’re sick, and you’re like, “Well, I’m just going to go on a supplement plan.” There’s only one type of plan right now that can deny you coverage if you have preexisting conditions. Obamacare basically said none of the commercial plans can do that anymore. Way back when, when I first started having healthcare, it was a big thing about preexisting conditions, and insurance companies would refuse to pay for something because, “Hey, we just started taking over care, starting in 2010. And in 2009, you had a health problem, and this is a result of that, so we don’t have to pay for it.” So they made that illegal, except for Medicare supplement plans. So now, if you are on a Medicare Advantage Plan and you want to switch to a supplement plan, all of a sudden it’s way too expensive, and they’re denying you or pricing it through the roof because of your pre-existing medical conditions. And now you’re stuck in this Medicare Disadvantage Plan. So there are Medicare star ratings, so the Advantage Plans are rated, and you do have recourse here. So if you are stuck in a Medicare Advantage Plan, the star rating of Medicare Advantage plans determines a lot of how much the government pays to the insurance company. So they want to have a four-star rating. If you’re four stars above, you get paid more. It’s a more profitable plan. A big component of the star ratings comes from the patient surveys. So if you’re on a Medicare Advantage Plan and you get one of these surveys and you don’t like your plan, let them have it. It’s going to affect them. If you are in a situation where they’re not paying for something, you can complain by calling 1-800-MEDICARE and filing a complaint about drug coverage. If you feel like they should be covering your Ozempic or your Mounjaro, or if you’re not able to find a provider in the right specialty, if you’re having trouble getting stuff covered, you can file a complaint against Medicare, and it will hurt this Advantage Plan. They are very aggressive in reducing these complaints and addressing them because it costs them lots of money. So these complaints are important. Do not blow this off. You actually do have some leverage here. So that’s something to consider if your Medicare Advantage Plan isn’t working. But I think if you’re a healthier senior and you’re just getting started, maybe looking at a Medicare supplement plan and trying to resist some of these temptations of initially lower premiums may actually benefit you in the long run. May serve you very well as you age.
Zoe: 36:34
It’s all so complicated.
Dr. Weiner: 36:36
It really is way too complicated, and the rules are designed by the people who are making all the money, the insurance companies, and the hospitals to some degree as well, but the hospitals are struggling right now, and they’re actually struggling because insurance companies are refusing to pay. We’re seeing tons of this in our office, where we’re getting called by our hospital, and our hospital is kind of one of the last good, honest hospitals in this country. They’re not-for-profit, and they actually function that way. Every other hospital in town is either a for-profit system or a not-for-profit system that is really for profit. That pays their CEO $32 million a year. Our hospital CEOs still make a lot of money, but far less than what other CEOs make at similar-sized hospitals, and I do believe that they have a mission to serve the people of Tucson. I really do believe that about our hospital. I don’t think they’re perfect, but I do think their hearts are in the right place. The problem is, if you don’t know the rules, you can’t play the game. All right, Sierra, what do we have in terms of our user questions?
Sierra: 37:50
“What should I say to someone who thinks weight-loss surgery is the easy way out?”
Zoe: 37:57
The other F word.
Dr. Weiner: 38:00
Yes, Zoe. I have a video about that. But yes, I do agree with you on that. I think, first of all, it’s none of their business. People really shouldn’t be commenting on your medical history or your medical decisions unless they’re close loved ones and really have a vested interest in your health. I think you’ve also seen lots of people go through weight-loss surgery. Does it seem very easy to you?
Zoe: 38:22
No, and it requires a lot of hard work. It requires dedication to long-term habit change in order to have a lasting result. I think that you just have to, it’s hard, but get down like a little sentence or a little mantra, something that feels good and right in how you would say it, but could be something as simple as: I’m not open to your feedback on my medical choices at this time, or thank you so much, but you know F off. I’ve had good ones in the past, but I can’t think of any other ones right now. But I think it’s just being your own self-advocate and knowing that you don’t have to explain yourself.
Dr. Weiner: 39:05
I think that’s the big point. You owe this person nothing, and they’re judging you for the biases that they have.
Zoe: 39:19
And I also think we have several patients who choose not to disclose that they get surgery. If you have maybe been met with this sort of feedback from a lot of people in your life, maybe that’s an opportunity to say that you’re not going to share it anymore. I don’t know.
Dr. Weiner: 39:39
It’s your choice. It’s your choice about that. I think it’s important to understand that this is coming from a place that is not kind, and so when people say things that are not kind to you, there are two responses: the first is to internalize it and get really upset about it, and the other is to ignore it. And this is clearly somebody who doesn’t have your best interest at heart and is not saying something to help you. And so, I think, recognize where it’s coming from and treat it as the invaluable comment that it is. There are other people out there, whether they’re in the weight loss surgery community or, quite frankly, there’s a lot of people out there who are not obese and who are not struggling with their weight, but they also recognize that people make these decisions to better their lives and that this is their decision. And that you trust that any reasonable person would do plenty of research and really do this, and most practices do a decent job of providing support and guidance through the process. So I think this is an unkind statement, and unkind statements really don’t require a lot of our thought and should be just largely ignored.
Sierra: 40:48
Okay, next question: “I had a gastric sleeve 29 days ago, and I’m aware that weight gain is real after gastric sleeves. I’m wondering whether it is more effective to start GLP-1s a few months after the surgery to prevent weight regain, or if it’s just as effective once the weight regain starts?”
Dr. Weiner: 41:07
Well, there’s really two parts to this decision, which is really true for pretty much all of the medical decisions about surgery, or specifically the medications. The first part is insurance coverage. So if you have insurance coverage going in and you have a sleeve, you might dip below that line where your insurance will cover it, and if you take too long of a hiatus from it, you may lose your coverage for it. So I think the first thing you have to keep in mind is that if this is something you think you’re going to be on, you might want to keep filling out that prescription and stocking it away, even if your surgeon is not recommending that you start it. If we get to the clinical piece, it’s very complicated. There’s no right answer for this. There are some practices that will start it as soon as a month or two after surgery, and I think it depends. What I will do is, let’s say I have someone who has a BMI of 55 who chooses to have a sleeve. Before GLP-1s, I would say that’s crazy. It’s just not going to work the way you think it will. That’s a bad choice for you. Now, with GLP-1s, I’ve had a lot of patients with a BMI in the mid-50s, even higher, who’ve chosen a sleeve. We add the medications in, and they do well. But for this person, we’re choosing sleeve and medicine. We know that’s going to be part of the equation. We can always pull back later. That’s someone I would probably start with as soon as they’re eating and drinking comfortably, and I don’t have any concerns about meeting fluid and protein requirements. I’d start a mile on low dose and kind of titrate up very slowly depending on how they’re doing. I think if someone has a BMI of 35, 38, or lower, they may be able to do this without meds, and keep in mind that not every sleeve patient needs meds. Probably 50–50%; maybe even 30 or 40% don’t need meds. So there’s a decent chunk of people who walk who need the medications long-term. In that situation, I might write it out, especially if there’s no insurance coverage concern, and wait until you’re four to six months out to see what your weight loss is looking like. At that point, consider restarting it. There are guidelines and expectations. Again, on our website, we’ve got this calculator, and you can plug it in, and by four months, you should be about halfway to your final weight. If you’re well behind that, then I would start it. If you’re well ahead of it, I might hold off.
Sierra: 43:23
Okay, last question. This is from Rafael on our website: “Hi, you mentioned Banza as a grain alternative. I noticed that they sell pasta variations, but they also sell rice mix and mac and cheese variations. Are those acceptable? They include soy and xanthan gum, and mac and cheese includes cheddar cheese. Is xanthan gum acceptable?”
Zoe: 43:45
This is a really good example of food that has been taken over and given to the health halo. Boxed mac and cheese types, whatever, they are going to have a lot of ingredients. They are going to be highly processed. They are going to have a lot of added sodium. No, that’s not the point. Right? Not lovingly, of course, but having a Banza chickpea-based penne that has one ingredient, and it’s literally chickpeas, versus a long ingredient list of all these other more processed artificial ingredients, it’s not really accomplishing what we want. I would recommend staying away from those boxed processed products and maybe getting creative with making your own versions so that you can be in control of the ingredients, add the flavors and spices that you want, and add vegetables, of course.
Dr. Weiner: 44:46
Over and over again, we see this. Take the thing that everybody’s onto and thinks is healthy, add a bunch of crap to it, and sell it as healthy. It’s not anymore, and people will eat it for three times the price. All right, another great episode. Thank you, Zoe, for staying late tonight; thank you, Sierra as well; and thank you to all of you out there listening. If you want to ask us a question that we’ll answer on the podcast, check in with us on TikTok, Instagram, YouTube, and, I think, even Facebook. I hope you guys have a great week, and we’ll see you next time.
