Has anything changed?

Has anything changed?

Now that the wacky dance is over the question needs to be asked when it comes to our wacky world has anything changed? The honest answer is not much. We say that not from the perspective of the players in the diabetes sandbox rather the people who are supposed to matter; patients with diabetes. Here we are in 2017 with some great new drugs and devices yet the fact remains that almost two thirds of patients are not under good control. Is not the goal of all the money being spent to get these patients under good control?

The fact is when judged solely on patient outcomes there has not been a great return on investment. But the fact is the players in the sandbox are not judged by patient outcomes they are judged by sales and ultimately profits. The fact is their real customers are not patients with diabetes but the people who pay for all these drugs and devices. As we keep stating it really doesn’t matter if a company has the greatest device or drug if they can’t get that drug or device into the hands of patients.

Herein lies a major problem, when it comes to patients with diabetes the philosophy of the payer is not to see better patient outcomes. No, the philosophy is to manage these patients as cheaply as possible, for payers are also for-profit entities. What payers hope for is that by the time costly complications from poorly controlled diabetes sets in these patients will be off their plan or on Medicare. In other words, these costly complications will not be their problem, it will be the government’s problem. Put even more simply it will be the taxpayer’s problem.

Now before everyone starts accusing payers of being nothing but a bunch of money grubbing capitalist who care only about profits and not about patients, think again. Just as drug and device companies must satisfy the needs of the payers so they can make money, payers are up against their own set of obstacles if they are also to make money. This set of obstacles is a major reason we aren’t seeing better patient outcomes.

Although there is little publicly available data it is widely known that patients change health insurance providers every 30 months or so. This is a major reason why payers aren’t interested in patient outcomes, they just don’t have the patient long enough. Payers aren’t stupid they know what everyone else in diabetes knows, the costly complications from poorly controlled diabetes do not develop quickly. These complications develop after years of poorly controlled diabetes, likely when the patient has moved onto another plan or Medicare. Think of it this way, a person does not develop lung cancer from smoking one cigarette, they develop it after smoking for years.

The payer has no financial incentive even when the patient is under good control. This why when it comes to their patients with diabetes, the majority of whom have Type 2 diabetes, the goal is to manage them as cheaply as possible. This is also the reason they hate insulin pump patients, as they are not only the most expensive but also the ones most likely to develop costly complications more quickly. Same goes for patients following multiple daily injection (MDI) therapy. The goal with almost every insulin using patient no matter how that insulin is delivered is to prevent them from going to the emergency room.

Why do you think companies like Novo Nordisk (NYSE: NVO) and Sanofi (NYSE: SNY) make such a big deal about fewer hypoglycemic events? Why are there so many companies working on insulin dosing algorithms? This has nothing to do with better outcomes and everything to do with keeping insulin using patients out of the hospital.

The latest trend in diabetes, actually it’s not new, are companies who believe they can drive cost out of the system for non-intensively managed patients. Patients who use oral medications, orals plus insulin or GLP-1’s. Most of these efforts center around behavior modification which is really nothing more than improving medication adherence. We’ve said it before and we’ll say it again the biggest obstacle between better outcomes and this huge group of patients is medication adherence.

The problem facing almost every company attempting to improve medication adherence runs into is that behavior modification doesn’t work all that well. And the reason it does not work all that well is that for non-intensively patients they have no incentive to change their behavior. They have no incentive to do all the heavy lifting required to manage their diabetes properly. As we say often managing diabetes is job, a job that must be done every day and there are no days off. These patients want to live their lives with diabetes and not for their diabetes. They want diabetes management to party of their lives not to run or dominate their lives.

The fact these companies miss no matter how many times they are told is that these patients have a chronic disease they do not want and do not understand. These patients aren’t told why they should do all this work, they are just told to do the work. Even worse if they do the work they don’t get anything and please do not say they feel better, they don’t.

Now if these non-intensively had an incentive, a vested interest in achieving better outcomes this would change. We have long contended that you could give these patients free test strips and they still wouldn’t monitor their glucose levels. That the reason these patients do not monitor their glucose levels regularly has nothing to do with “pain” or cost. It has everything to do that this number is meaningless to them, they do not understand WHY they should be testing. They have no vested interest in testing, to these patients it’s just one more thing they are told to that they don’t want to do.

Think about how the paradigm would change if these patients paid a lower premium if they achieved better control. Or what would happen if their co-payments were lowered or eliminated if they achieved better outcomes. Even putting money in their health savings account would help. When it comes to non-intensively managed patients they must get something, something they can feel and touch, something that impacts them directly, something that will make all the heavy lifting worth the effort and this is NOT better outcomes, these patients do not feel or touch better outcomes.

Now this should not come as a shock to anyone in the wacky world, at least not anyone who’s been reading Diabetic Investor. We’ve been talking about this for years, to us anyway this is not a new concept. The only thing new here is the technology we have which does make incentivizing the patient easier. Yet this technology will only be used if the patient isn’t told what to do, it will only work if they are told WHY they should be doing it.

Which brings us to what also hasn’t changed besides patient outcomes, attitude. Way back when Diabetic Investor was a teenager, and not a granddad to be, the Wizard constantly reminded me that I had an attitude problem. (Momma Kliff left these talks up to the Wizard.) Well it turns out the Wizard was right when it comes to companies in this wacky world especially the newbies. Living with diabetes is not something that can be learned from a focus group. Nor can it be learned by listening to patients who are intensively managed. While intensively and non-intensively patients have the same disease, they are two diametrically different worlds.

These people can talk all they want about behavior modification. They can talk about all the way cool whiz bang cloud enabled toys. But what they don’t get and quite frankly have never gotten is what it is like to live with diabetes. Worse still is they think they understand which is not just foolish but also dangerous.

What these companies need is a major attitude adjustment or as Momma Kliff used to say; “Don’t tell me what my life is like. Don’t believe for a moment that you can understand my life. Now if you want to try and live my life or actually listen to me without preconceived notions you might just get it.”