New tools same problem

To say that telemedicine has received a boost from the coronavirus is like saying the Chicago Bulls of the mid to late 90’s were a pretty good basketball team lead by a decent guy named Michael Jordan. Pretty damn obvious for sure. However in the midst of this transcendence from a technology that was used once in a while to now a technology that has become indispensable many seem to have forgotten that the same problems that existed before telemedicine still exist.

We are not trying to be Debbie Downer here but when it comes to diabetes management and telemedicine- digital health or whatever you want to call it – the technology will only take us so far. Yes, it’s great that every diabetes toy in the toy chest – CGM -BGM – Insulin Pens and Insulin Pumps – all talk to the cloud. Yes, it’s great that we have hundreds, perhaps thousands of apps which track everything we eat, every step we take and record our weight every time we step on a scale. And yep we have companies like OneDrop, Onduo and of course our favorite Livongo who provide coaching, helping the patient deal with all this data and the many challenges they face each day while managing their diabetes.

We have lots of toys, tools and people who can provide the patient with the how to manage their diabetes. What we don’t have, what we have NEVER had are any toys, tools or people who can MAKE the patient WANT to manage their diabetes. This has been and will continue to a problem no matter how many toys we have in the toy chest. It will continue to be problem whether the patient sees their doctor in person or virtually. It will continue to be a problem no matter who well the patient is coached as it’s not the coach who has to manage the diabetes.

As Momma Kliff used to say coaches’ coach but it’s up to the players to go out and perform. Listen we’re big fans of Phil Jackson but let’s be honest if it wasn’t for that guy we called MJ we wouldn’t have six Bulls championship banners hanging in the United Center.

Now diabetes for most patients is not complex to manage. You wouldn’t know this from any investor presentation given by the companies in our wacky world. Presentations which point to the global epidemic and the fact that nearly two thirds of all patients are not achieving good control. Each companies notes the many costly complications associated with poorly controlled diabetes – blindness – kidney failure, etc. They all say they have the magic potion; they have found the Holy Grail and with a few million bucks they will forever change the diabetes management paradigm.

Let’s state for the record THIS IS COMPLETE AND UTTER BULLSHIT.

To fully appreciate the non-complexity of managing diabetes let’s look at the facts. By far the largest group of patients are ones that manage their diabetes using oral medications alone. It is this group by the way that gets the least amount of help from all the toys in the toy chest. Why? Because it is this group of patients who rarely play with the toys and those that do rarely play with them all that much.

It’s a well-known fact that non-insulin using patients have yet to embrace CGM. These patients are still using old fashioned finger stick monitors, which now of course send readings to the cloud. That’s great until you consider that when they aren’t used or used sparingly there is no data to analyze or not enough data to analyze.

So just how will a virtual doctor visit or coach help these patients more effectively manage their diabetes? Just what will the doctor say during this virtual visit that is more impactful than a face to face visit? What exactly can a coach do? Even if the coach delivers coaching via a text message who is ultimately responsible for following the coach’s instructions?

Think of it this way, during the Bulls championship run – six titles in seven years – our Zen master of a coach drew up plays but without that guy MJ – the greatest player in the game – being the incredible player he was it’s unlikely we’d be watching the Last Dance on ESPN. Yep Phil was an incredible coach but had the players not executed on his instructions we wouldn’t look back at these Bulls teams as some of the greatest ever.

We know that everyone who does not have diabetes and sees all this way cool whiz bang technology believes that diabetes management is complex but thanks to all this whiz bang way cool technology is becoming easier. When in reality for the largest group of patient’s diabetes management is pretty simple and involves one pretty simple task. No it’s not checking their glucose levels on a regular basis. Nor is its regular exercise or eating properly. Yes, these tasks certainly will help but by far the biggest single task these patients can do to achieve better outcomes is to take their meds.

Think about that for just a moment. Think about it in the context of all the way cool toys in the toy chest or all the apps/coaches available. All the patient really needs to do is take their meds. Just ask any physician, endocrinologist, diabetologist, nurse practitioner or anyone who understands diabetes. Ask them if they could pick one thing to change about their patients, one thing that increases the chances of the patient achieving better outcomes, one thing that is simple and easy to do what would it be.

Hands down it would be the patient taking their meds. Sure they would love it if the patient did more than that but that one simple painless task is paramount above all others.

Now someone has to explain how does telemedicine or digital health help with that. How does telemedicine or digital health go from telling the patient what to do to making sure the patient does it. Damn we hate to be redundant but as Momma Kliff used to say sometimes you need to beat people over the head with a baseball bat before they get it, but the easiest part of telemedicine or digital health is telling the patient what to do. The most difficult part, the part that has never be solved and likely will not be solved even with increased use of telemedicine or digital health is getting the patient to actually perform the tasks even a simple painless task like taking their meds.

Listen by comparison insulin using or patients following GLP-1 therapy have it easy. These patients may have more to worry about than patients on orals alone, but they are also the ones who tend to play with all the toys in the toy chest. Heck GLP-1 patients have it easiest of all as all they need to do is take their med once a week. No daily regimen of taking pills just one relatively painless injection once every week.

We’ve said it many times and will say it again with all the toys now available it’s easier than ever to be an insulin using patient. Insulin using patients are embracing these toys and the results are proof that when played with the toys work. Just go to Facebook and look at the many post from patients using the Control IQ from Tandem. Frankly the results are astonishing. Or look at the many posts from patients using the Dexcom G6 or Libre who have noted how this technology has changed their lives.

Once Tyler gets here, we suspect we will see similar posts. The fact is insulin using patients are the major beneficiaries of all this way cool whiz bang technology provided of course they have access to it. For this group telemedicine and digital health works. The problem is this group is not large enough and given the continued improvement in technology this group will no longer need telemedicine or digital health as the system will do 99% of the heavy lifting.

We won’t say that insulin using patients won’t have to think about their diabetes management. What we will say is thanks to systems like the Control IQ they do a lot less thinking about it.

This has always been our issue with any of the coaching platforms. It’s not that they don’t work per se. It’s they are targeting the wrong group of patients. Even worse this target group thanks to technology will discover they really don’t need coaching or need it only on rare occasions. Yet the largest group of patients the ones who need the help the most are largely ignored by these platforms.

When we first started writing Diabetic Investor over 20 years ago whiz bang way cool technology was conventional glucose monitors that didn’t require codes or insulin pumps that had a bolus calculator. Back then smart insulin pumps, CGM, GLP-1 ‘s were in their infancy. Back then patients were not attached to their smartphones, patients went to their doctor’s office and talked with coaches over something called a land line. Heck back then those who used the internet did so with a dial-up connection.Back then disease management was all the rage. It was the magic potion that would forever transform diabetes management.

Fast forward to 2020 and all this way cool whiz bang technology, all the new drugs in the medicine cabinet. Think how easy it is for a patient to see their doctor, something that they can do using their other way cool whiz bang attached device, their smartphone. This same smartphone allows them to receive text messages from their diabetes coach. Heck it has replaced something my generation thought was way cool and very whiz bang, a personal computer.

Yet the same problem that existed when AOL was the most popular web platform, when we used floppy disks to add a program to our PC and waited patiently for our PC to connect to something called the world wide web via a dial-up connection still exists today when we have wireless connectivity on a device we hold in our hands, a device that has become part of our everyday lives.

Yes, we have seen incredible advancements in technology and will continue to see them. However when it comes to diabetes and getting the largest group of patients to manage their diabetes more effectively it comes down to one simple task that no amount of technology has ever been able to change. We’re delighted that telemedicine and digital health thanks to the coronavirus are now being embraced only problem is this embrace even if it becomes passionate likely won’t change the results.