Great Expectations

Great Expectations

Yesterday when we read about the agreement between Dexcom and The University of Virginia our initial reaction was what took so long. Not to be redundant but we have consistently stated that CGM has wide ranging applications beyond diabetes. Although this agreement is diabetes focused it continues a trend that Abbott has also joined with their sensor for elite athletes. Dexcom and Abbott both understand that for sensor usage to keep growing and grow beyond diabetes, users have to know what to do with all the damn data. They need to know the same thing patients with diabetes need to know how to turn data into action.

Since it’s Friday we won’t go too far into our it’s not the toys in the toy chest that matter rant.

We’ve been paying close attention to the progress being made by Tandem’s Control IQ just as we did when the 670G first came out. This is how we discovered that it was a love hate relationship with the 670g, patients loved it when the damn thing worked hated it when it didn’t. Specifically they hated the inconsistent unreliable sensor which just so happens is the engine that drives the hybrid closed loop train.

Our hypothesis was patients would like the Control IQ more for the simple reason it worked with a reliable accurate Dexcom sensor. Well things have pretty much turned out as anticipated. Even though we expected it we are still amazed with the results patients are experiencing. Seeing time in range (TIR) numbers in the 90% range on a consistent basis is pretty amazing. As are stories from patients using the Control IQ on how conditions that were related to their previously uncontrolled diabetes have gone away because they are now under control.

Still as amazing as these results are, and to be fair when the 670g works you see and hear the same stories, there are subsets of patients who still aren’t happy. Digging deeper into this unhappiness what you find is the underlying premise is what these unhappy campers really want is perfection. They want a system that they slap on, turn on and never think about. A system that works 100% of the time with no interruption. Something that quite frankly is not possible for as advanced as these systems are they are a collection of medical devices and medical devices can and do fail or malfunction.

Yet there are broader implications here that extend beyond hybrid closed loop insulin delivery systems extending to all patients with diabetes no matter what therapy regimen they follow. Implications that impact the growing number of patient coaching platforms. Expectations.

Everyone simply assumes that patients want all this help and will be receptive to it. They seem to believe that patients with diabetes want to be under good control. That patients now receiving coaching will reverse course and begin to do all the heavy lifting required to achieve good control. When in reality what these patients want is something they cannot have for what they really want is not have diabetes in the first place.

To us this will be the ultimate downfall for the majority of coaching platforms. Sure right now everyone is still riding the digital health wave believing that digital health is the answer to every patient with a chronic disease. These platforms walk into an employer show them all the numbers about how their employees with diabetes are costing them a small fortune. They show them all the stats about how employees with diabetes are not as productive as the ones without diabetes.

Employers who knew this already and frustrated from previous attempts at controlling the cost sign up hoping this time around things will be different. That this time around their employees with diabetes will embrace the advice they get from their coach. That they will use the tools available to them. That finally at long last they achieve good control so that employer will save money and see increased productivity.

We heard this when disease management was all the rage, we heard it again when wellness was all the rage and we are hearing it again now that digital health is all the rage. Now the digital health proponents will say it’s different this time around that the biggest difference between what they do and what was done in the past is they are meeting with the patient on the patient’s turf. That the patient does not have to see a CDE or attend a class or be bothered by someone calling them.

This is all true as for the most part digital health allows a patient to control how and when they receive their coaching. However the problem digital health has not solved is expectations. See for the most part patients are initially very receptive to coaching. Contrary to what many believe these patients are not ignoring their diabetes nor are they stupid. They know diabetes is a serious condition and they know they need to do something about it. Yet they also know they don’t want their diabetes management to run their already busy lives and that time is not a renewable resource. Or as they said in the old days there are only 24 hours in a day.

The problem in essence is improvements in outcomes do not come quickly plus once under good control patients don’t necessarily “feel” better. Diabetes is not like a headache or back pain. Patients don’t “feel” better after a simple and quick treatment such as taking a pain reliver or muscle relaxant. To achieve good control takes work and time, two things the patient does not want. Far too often these coaching platforms ignore this very real aspect of diabetes management failing to set the proper expectations. While we don’t know this for a fact we suspect the reason they ignore setting the proper expectations is they believe it will turn off the patient.

Let’s be very honest here no patient wants to be told that their chronic condition requires them to put in the heavy lifting. Nor do they want to hear even if they do this heavy lifting they still may not achieve the desired results. They don’t want to hear about the complex set of variables they do not control that impact outcomes. What they want most is not to have diabetes and since they can’t have that what they want next is a simple, quick and effective method to manage it.

This is why patients and their physicians have been embracing GLP-1 therapies. GLP-1 therapy does not require glucose monitoring. There is little risk of hypoglycemia. These therapies come with preset doses so there are no complex calculations plus there is the added benefit of weight loss something the patient can see and feel. Even better the newer GLP-1’s are taken just once a week requiring little heavy lifting nor time. GLP-1 therapy is in essence point and shot.

Will any of these facts resonate with investor who continue to value these coaching platforms at astronomical levels? Probably not as they see a hot sector that continues to get hotter. They see Teladoc foolishly valuing Livongo at an incredible $18.5 Billion. They see money pouring into this space faster than water being used to put out the wildfires out west. They see what all investors see MONEY and lots of it.

We don’t know when this fire will be put out and reality sets in, but it will happen, and it will not pretty when it happens. We have nothing against digital health and do believe that it can be a net positive. However we also have spent decades in diabetes and have seen this movie before. You might be able to remake Casablanca but that doesn’t change the ending IIsa still gets on the plane even though she’s in love with Rick.

To all my fellow tribe members who will be celebrating the highest of Holy Days on Monday may your fast be easy. Have a great weekend everyone.