A horse can’t finish if it can’t get out of the gate

A horse can’t finish if it can’t get out of the gate

As the impact of competitive bidding continues to rumble through the diabetes world everyone, not just glucose monitoring companies, is trying to figure out how they will be able to make money in the future.  Insulin pump companies, although not yet impacted by competitive bidding, are the next logical target for competitive bidding, drug companies on the other hand are fending off the coming onslaught of generics which will have as much impact as competitive bidding is having the device area.

There are many who believe that the future of diabetes management is not selling the individual pieces of diabetes management rather sell a complete diabetes management system that contains everything a patient needs to manage their diabetes including coaching. The main differences between these various system based solutions are how they will be paid for. There are some who believe companies will charge a monthly fee which covers all the elements included in the system; while others see a more traditional reimbursement model where each component of the system is reimbursed individually.

The one thing most everyone agrees on is that the old way of doing business is no longer viable and that due to the changing nature of healthcare demonstrating that a system based solution improves patients outcomes is an absolute must. The reality is insurers, the people who will eventually pay for these systems, want to make sure that the money their spending is actually doing something rather than just lining the pockets of drug and device companies.  The simple truth is payors bought into what these companies were selling before, that all these fancy new devices and drugs would ultimately lead to better patient outcomes which in turn would ultimately lead to lower costs and it didn’t work out that way.

Although far from perfect it is not unreasonable to state that patients with diabetes have a much wider array of viable treatment and device options than ever before. While better drugs and devices are always welcome, it’s not like a patient cannot achieve solid control using what’s already available. The problem isn’t the drugs and/or devices; the problem is getting the patient to use the drugs and/or devices as intended. The same can also be said of the physicians who treat patients with diabetes, as they too need to know what drugs and devices are effective and how these drugs and devices should be used. It is a mistake to believe that just because someone has a medical degree that they truly understand how to treat a person with diabetes.

Yet in the coming world where outcomes will matter, where physicians and patients will be incentivized to achieve better outcomes, either by higher reimbursement rates or lower co-pays or premiums, a systems based approach makes sense. Especially in the coming world of interconnected diabetes management systems, systems which not only allow devices to communicate with other devices but also communicate with the patients’ healthcare team who using this information should be able to provide greater guidance to the patient who in theory would follow this advice which should lead to better outcomes and therefore lower overall costs.

While this all sounds good in theory the foundation supporting this theory isn’t all that solid as it based on the premise that patients will actually provide the data necessary so that their healthcare team can provide informed advice. A critical piece of data is also the most problematic to get, that is getting a patient to regularly monitor their glucose levels. While it is likely payors will use HbA1c as the metric for measuring success or failure, physicians will soon realize, if they don’t already, that daily glucose readings are an accurate predictor of future HbA1c results and will do everything they can to insure they receive their bonus. However, these physicians will also realize what they also know already is that most patients don’t regularly monitor their glucose levels and even fewer download their readings to their computers, smartphone or tablet.

Whether they want to acknowledge it or not, BGM companies and physicians share the blame as to why more patients don’t test regularly. BGM companies did their part by concentrating on whiz bang technology rather than helping patients understand what these numbers mean, why they are important and ultimately what they should do with them. Physicians did their part as the vast majority either did not encourage regular testing or when the patient actually did what they were supposed to do they didn’t even acknowledge or thank them for the work they had done.

The reality is when used properly data provided by a conventional glucose meter or a continuous glucose monitoring system, has the greatest impact on improving patient outcomes. With the possible exception of patients on a GLP-1, regular monitoring provides a glimpse of what’s really going on with a patient allowing the physicians to more quickly judge the success or failure of a particular therapy option. Unfortunately today most physician still follow the old treat to failure protocol and aren’t proactive with their diabetes patients.  While following this protocol is not entirely the physicians fault it does come with its own set of unintended consequences as once beta cell function is gone it won’t come back.

We are also gaining a better understanding of glycemic variability. Early research suggests that while HbA1c is the current gold standard for measuring control, it’s fails to provide a true picture of how a patient is doing. Research suggests that there can be two patients with exactly the same HbA1c measurements, yet the patient with lower glycemic variability experiences fewer diabetes related complications.

This is why Diabetic Investor is somewhat skeptical of any system based approach, it’s not that we don’t see the benefits, rather we see the real world limitations of these systems. Systems which are based on having information that patients don’t want to provide. This is like having a thoroughbred racehorse in a race and not letting it get out of the starting gate so it can run the race. Opening the gate doesn’t guarantee it will win the race but at least the horse will have a chance at winning.