Most know me for my insights about medical malpractice litigation. However, ever since the 2000s, my practice has focused on medical weight loss management, and I have developed other insights. I developed these insights as a private practitioner, as an employee of a medical weight loss clinic, which may have gone out of business because it no longer has a public persona, and as a general contractor for a weight loss medical practice.

I start by saying that medical weight loss management has tremendous potential for a physician because 70 percent of all Americans over 18 years of age have a BMI over 30 and 40.3 percent have a BMI over 40.5. There are 25.2 million teenagers. Teenagers are the most susceptible group for obesity because they are pubertal. There is a total of 173.1 million people with obesity and an additional 37.1 million people, who are overweight but not obese. Overall, I cannot imagine a patient base larger than this.

There are four basic medical weight loss protocols:

• Lifestyle alterations: With appetite suppression and the management of associated medical conditions, such as insulin resistance. Medications include phentermine, fluoxetine, furosemide, metformin and topiramate plus or minus weekly injections of vitamin B-12. Costs range from $250 to over $400 per month; too expensive.
• The use of GLP-1 agonist: Like a generic semaglutide, or Ozempic, Wegovy, and GLP-1 drugs, like tirzepatide, plus or minus weekly injection of vitamin B-12. Costs range between $400 and $1000 per month; too expensive.
• A combination of the two: Plus or minus weekly injections of vitamin B-12. Costs range between $500 and $1200 per month; too expensive.
• HCG (human chorionic gonadotropin) or hormones: This is usually in combination with options 1 and 2. Cost is, at least, $1000 per month; way too expensive.

Most of the time, the above medications are supplied by the practice, itself, which purchases them from a compounding pharmacy. There is, also, a subgroup of patients, who weigh 600 lbs and have BMIs of over 100. They see bariatric surgeons.

Functionally speaking, these 173.1 million people can be separated into two groups: (1) those who regard weight as a medical problem and have limited means for out-of-pocket expenses but make the sacrifice anyhow, and (2) those who regard weight as a cosmetic problem and enjoy a higher socioeconomic status, for whom expense is not an obstacle. They prefer to engage in the use of GLP-1 agonists. They, more likely than not, have BMIs between 25 and 29 and most are women. They are largely influenced by social media and aesthetic trends, like “Ozempic face.” They desire a quick fix, not a lifestyle alteration.

From my experience, if a doctor focuses on the first group, cost is an important factor to consider when attracting patients. If a doctor focuses on the second group, cost is less of a factor but such patients are likely to have high expectations and low tolerances for unsatisfactory results or complications, which are random and are not caused by any medical intervention.

Because of the “TrumpRx” direct-to-consumer platform negotiated in November 2025, the average monthly cost for injectable GLP-1 drugs will start at or below $350 per month in January 2026. Also, as of now, insurance covers no medical intervention for medical weight management and/or a diagnosis of obesity. However, starting mid-2026, Medicare will cover medical weight loss, and this may spread to private insurers. Remember, when obesity is a covered benefit, the doctor is paid the allowable, adjusts the balance and pays the taxes. To whose benefit does this accrue? The doctor or the federal government?

Litigation risks will undoubtedly increase as more patients avail themselves to such services. This is inevitable whenever health insurance intervenes. High patient volume increases the likelihood of medical mistakes due to overwhelmed support services (e.g., lab, pharmacy) and delays in treatment. Increased volume can also lead to communication problems, resulting in increased opportunities for things to go wrong or for communication breakdowns to occur. With increased accessibility, all patients have higher expectations for positive outcomes, and if the outcome is less than perfect, they may be more inclined to consider litigation. The fear of litigation leads to defensive medicine. Defensive medicine increases liability risks rather than reduces them.

Nevertheless, this future is avoidable. In my experience, at first glance, it appears that increased insurance coverage is a good thing. However, when looking closer, whenever health insurance intervenes, medical practices suffer. As coverage for medical weight loss expands, control of medical weight loss contracts. Providers scramble to join accountable care organizations and they agree to their practice guidelines just to remain competitive. Ergo, control goes out the window.

To avoid this, doctors must compete with the market force, not the marketplace. First, take advantage of the TrumpRx platform by writing scripts rather than handing out medications and charging for them. Second, lower the cost of treatment. This is expected once there is no compounding pharmacy to pay. Third, there is and should be a value added, i.e., a doctor visit based on the standard of care not a practice guideline. Most patients will appreciate this, having to deal with an accountable care organization for other encounters with a doctor. Let the accountable care organization get sued. Last, join nothing. You do not need a third-party payer to survive. If patients paid when you were expensive, they will pay when you are affordable. Remember, their out-of-pocket medical expense is 100 percent tax-deductible. They need no statement of medical necessity or referral just to save a few bucks.

Howard Smith is an obstetrics-gynecology physician.