Another Angle

Another Angle

Lately we’ve been spending a great deal of time about how to engage patients with Type 2 diabetes, in particular those who do not use insulin. Our belief is that the biggest obstacle standing between this huge population and better outcomes is medication adherence. That this is not a story about way cool whiz bang cloud enabled toys that also have a diabetes coach. This is a story about applying the correct motivational stimuli. Which we happen to believe is financial, mullah, the green stuff or simply known as cash.

Let’s say for sake of argument that instead of giving these patients free cloud enabled meters or free CGM sensors that instead we establish cash rewards for achieving clear targets. And no, these cash rewards do not have to be cold hard cash and can be given in terms of lower health insurance premiums, perhaps lowering or elimination of co-payments, it could also be payments to the patients’ health savings account or even the lowering or elimination of deductibles.

In fact, we would go even further and make the patient pay for these way cool whiz bang toys. Yes, you read that right make them pay for the toys in the sandbox. Why is an advocate of incentivizing patients to reach better outcomes asking patients to pay for the toys? Simple then they will value them and more than likely actually play with them. And the reward system could easily be set up so that patients that do buy the toys get their money back, just don’t call this a discount.

Honestly Medtronic (NYSE: MDT) had the right idea by charging patients $299 for the 670G and then allowing them to get this money back by doing certain things over a set time frame. The problem was they called this a discount which it clearly wasn’t. Perfect example of a good idea and very bad communication. But we digress.

While it may have seemed brilliant at the time but the beginning of the end for conventional BGM came when meters were given away for free. Yes, the razor/razor blade business model was great for BGM companies but ultimately this model was a contributing factor for the coming death of this technology.

Anyway, getting back to the people that matter, the patient our belief is that when these people find out they can save money by taking better care of their diabetes most will become engaged in a hurry. That they will look at all the toys in the toy store and do their own cost benefit analysis. Some will choose conventional cloud enabled BGM while others will go for CGM. They will look at the cost and the potential reward and see which makes the most sense for their family budget.

We can almost guarantee they will also take full advantage of something called the internet, that they will start searching for the most effective ways to manage their diabetes. They will download some of way cool whiz bang apps to their smartphone and through the process of trial and error figure out which one’s work and which don’t.

The key here is establishing a reward system which keeps the patient happy while they begin their diabetes management journey. For example, these patients will be more motivated to stay engaged if they get something before their next HbA1c test. Given that all these toys communicate with the cloud why not give them something for using them on a regular basis.
One thing we would not do and this is going to sound radical to the toy makers but we would not FORCE the patient into any one app or system. The toy makers would stand a much better chance if they incentivized their app/system but did not penalize the use of another app/system. The surest way to turn these people off is tell them they MUST use something. Quite frankly they hear this enough from their physician and this just makes them tune out.

Now here comes the hard part as the toy makers just love to over complicate things. Base rewards on easy to understand metrics and don’t go overboard. Obviously HbA1c is the low hanging fruit here an easy metric to understand, as is weight loss or steps per day. It also helps that these metrics are verifiable using guess what- the toys. See the toy makers can in their own way game the system as no rewards can be issued without data and the only way to get this data is by using ….the toys.
Think we’re finished – of course not no one writes that when they are finished. Don’t just reward them for getting under good control REWARD THEM FOR STAYING THERE. Yes, we know this may seem like a crazy concept for the toy makers who are obsessed with their toys but this is just common sense. How many people do you know that have lost weight only to gain it all back and more a few months later.

We consistently state that when it comes down to it this is all about money because it is. To us the problem is where this money is going. As it stands today all the money flows to the toy makers and none to the patient. With a simple and small reallocation of the money path everyone would win. The toy makers would make their money while the patient would be saving money and it certainly doesn’t hurt that these patients will also be achieving better outcomes. Which by the way is the whole point!

Perhaps the easiest way to view this is to look at what we call the diabetes money pie, all the money spent on patients with diabetes. After years of getting bigger this pie is now moving in the other direction as everyone is attempting to drive cost out of the system. The reason non-intensively managed Type 2 patients are the target for cost savings is simple the sheer size of this patient population.

Truth be told it’s not all that difficult to drive down cost for intensively managed patients, all of whom use insulin. The goal with these patients is rather simple, keep them out of the emergency room. It is with these patients that IDM shines. And the reason it shines is also simple by the nature of how they manage their diabetes they are more educated and more engaged. Quite frankly they really don’t have a choice.

Although it may seem obvious, that is to everyone but the toy makers, non-intensively managed Type 2 patients live a much different life than an intensively managed insulin using patient. They are not wearing a device which delivers a lifesaving yet also lethal drug. A device which if it malfunctions can kill them. They do not have to constantly monitor their glucose levels so they can dose their medication properly. For these patients, it’s simply a matter of remembering which pills to take and when to take them.

Whereas intensively managed patients understand why they are doing what they are doing, the exact opposite is true for non-intensively managed patients. These patients are being TOLD what to do and when to do it with little to any attention paid explaining WHY they should be doing all this stuff. Rarely do any of the programs designed to help these patients manage their diabetes consider that diabetes isn’t the only condition they are also managing. Most of these patients are not just taking pills to manage their diabetes they are also taking other pills to manage hypertension, cholesterol, etc.

To these patients their diabetes is just one more thing they must worry about. Unlike intensively managed patients they are not laser focused on their diabetes management.

The fact is when it comes to non-intensively managed patients a more effective approach would be to view them holistically, not just as patients with diabetes. To understand that diabetes is just one more thing in a long list of things they must deal with. Hence the reason why we believe that incentivizing them will be very effective. It will change the way they view their diabetes management. It will give them a tangible benefit, something they can see and feel.

It would be interesting to see what would happen if any of the toy makers attempted such an approach. We wonder if they could understand that not all patients are alike and that there are very real differences between intensively and non-intensively managed patients. Yes, all these patients have the same chronic disease but they live vastly different lives based on how they manage it. It would be wise if the toy makers understood this.