Garbage In, Garbage Out

Garbage In, Garbage Out

Once again the blood glucose monitoring market is undergoing a transition. As Diabetic Investor has noted on several occasions the market is facing several obstacles and the companies involved in the market are desperately looking for new ways to fend off declining margins. It is equally obvious that the center of BGM universe centers on insulin using patients. Again as we have noted previously insulin using patients need this information so they can properly dose their insulin. Although we would not go so far to state that BGM companies have abandoned their efforts to reach non-insulin using patients; we would state their marketing efforts are squarely targeted at insulin using patients.

It’s also true that the BGM market has some unique structural obstacles, the most important being patients don’t actually chose the meter they use, and the choice is made for them by their insurance company. Because there is very little in the way of product differentiation the majority of BGM consumers could care less which meter they use as long as it works. For this reason meters have basically become a commodity where the overriding factor for product selection comes down to price.

Yet price in BGM is different than a consumer buying laundry detergent or paper towels, as unlike these commodities when it comes to buying test strips price equates to insurance co-payments. This is why formulary placement became critical to market share, the better your formulary placement the greater your share. In an effort to compete, companies who were at a formulary disadvantage tried to level the playing field with co-payment equalization programs. The general belief was that since price would no longer be an obstacle patients would choose the meter which best suits their needs. The basic flaw with this belief is that somehow the consumer is actually unhappy with their meter and wants to use a different brand that was previously more expensive due to higher co-payments. While there is a minority of patients who actually care which meter they use; for the majority any meter will do.

Now that everyone has a co-payment equalization program, once again BGM companies are looking towards the next frontier to attract and retain patients.  This new frontier being what Diabetic Investor calls “smart meters”, basically meters that do more than just deliver a test result and actually help the patient more effectively manage their diabetes. Not surprisingly this effort piggybacks on another trend, the growing field of interconnected diabetes management systems. As Diabetic Investor has been reporting everyone and we mean everyone is working on some type of system that not only collects data but combines this data with other data sets, i.e. insulin on board, duration of insulin action, insulin to carb factor and carb intake. The goal being more effective dosing of insulin and by default more effective diabetes management, i.e. better outcomes.

In theory these interconnected systems when used as intended can be extremely effective. The key term here being “when used as intended.” Let’s assume for moment that someone actually solves another problem with these systems and finds a way to actually engage the patient so they test their glucose levels regularly. While there are some who claim that they can assist patients who test infrequently Diabetic Investor is skeptical of these claims. Even so glucose readings are just one piece of data a patient needs when determining how much insulin to dose.

What happens if the patient does not know their duration of insulin action, insulin on board, insulin to carb factor, etc. As we noted previously another issue with these systems is all the data a patient needs to manually enter BEFORE the system can be used as intended. The reality here is that BGM and insulin companies are trying to use these systems to mimic how an insulin pump works without the actual expense and learning curve involved with insulin pump therapy. While they can eliminate the expense associated with insulin pump therapy they cannot eliminate the learning curve.

One reason insulin pump therapy is so effective is not just that insulin is being delivered on a continuous basis, as we have noted before studies have proven that patients using multiple daily injection (MDI) therapy can achieve outcomes on par with those using an insulin pump. A better explanation as to why insulin pump patients do so well comes with the learning curve involved with insulin pump therapy. The fact is insulin pump patients must have a higher level of diabetes education just to be on a pump. The reason MDI patients can achieve outcomes similar to those on insulin pumps are they too have done their homework and understand the importance of using a quality data set. Or put more simply when it comes to effective insulin therapy it’s not just about having good data but knowing what to do with all this data. Like any computer program garbage in equals garbage out.

Now it is possible that BGM and insulin companies can help the patient build a quality data set using an interconnected system but this is a long and expensive process. Truth is the use of a continuous glucose monitor is actually the best method for helping a patient, but the use of such a device is actually counter to the goal of BGM companies who want to sell more, not less, test strips. It’s more profitable for BGM companies to have patients testing 10 or more times each day then using a CGM and testing four or less times each day. The fact is glucose trend data, which requires lots of data points, is extraordinarily effective at helping the patient determine things like duration of action and insulin to carb ratios and a CGM is the most effective way to gather this data.

Yet even if a company can engage a patient and get them to test regularly, they still need a qualified professional, i.e. Certified Diabetes Educator (CDE), to analyze the data and then communicate back to the patient with recommendations and advice. Basically the CDE is doing nothing different then they do when training a patient new to insulin pump therapy, the only difference is they apply this education to someone who is not on a pump.

This process is not impossible and the technology already exists to make this possible, the main issue is who will pay for all this. With margins declining on test strips it’s unlikely a BGM would undertake such a costly approach. A greater possibility is that an insulin company would undertake such an approach as they can offset the cost through the continual sale of insulin, an insulin company who also happens to have a BGM unit offers the greatest opportunity.

The bottom line here is that the technology already exists to help patients more effectively manage their diabetes. However, as we have noted previously technology alone is not enough. Technology can make it easier to gather and disseminate the data but technology does not motivate nor engage the patient to become better educated.  The reality here is not much really has changed when it comes to helping patients achieve more effective diabetes management. For all this advanced technology you still need a patient who not only gathers all this data but actually understands what to do with it or at minimum is willing to learn.

Everyone seems to take for granted the role patient plays in this process. While it’s an admirable goal to make diabetes technology as easy to use as a mobile phone or television, one fact remains – if the patient dials the wrong number – enters the wrong information – they will not connect to person they wanted to call. As noted before garbage in equals garbage out.