This is not easy

This is not easy

Two things are becoming apparent now that Apple’s secret effort to move into the glucose monitoring is no longer a secret. First, everyone just assumes that Apple will be successful and second Dexcom (NASDAQ: DXCM) share price has been declining. As per usual conventional wisdom is wrong on both accounts. These past few days we have attempted to bring some much-needed clarity to the hurdles Apple faces and by default have outlined why we see Dexcom having the better option. Still because they are Apple the Apple pickers just assume that this Apple pie will taste delicious.

Now before we go any further allow us to make some assumptions of our own. That Apple will succeed where everyone else has failed and develop a non-invasive continuous glucose monitor. We say continuous because that’s what Apple CEO Tim Cook stated about the device he was seen wearing. Let’s further assume that while we aren’t sure this will be an FDA approved device, that Apple can get it approved. Finally, we don’t have to assume this point but it should be noted that Apple already has a distribution network in place to sell this device. Based on what we know we don’t see Apple using any of the conventional distribution networks commonly used in glucose monitoring.

Ok with that out of the way the first question is why would a patient buy the device. Now here too we will make some assumptions primarily that Apple will target non-insulin using patients. This as we have been noting is where the money is as it is by far the largest percentage of patients with diabetes. Perhaps we should rephrase this question and ask; “What is the value proposition for the patient? What will they get out of using this way cool whiz bang toy?

We hate to point out the obvious but when it comes to anything Apple, many obvious things get overlooked because they are Apple. This entire conversation is based on the premise that patients will come to the orchard and pick Apple’s. That this entire model falls apart if there is no demand for this way cool whiz bang toy. Patients must have some reason to buy the damn thing otherwise all this talk is just that talk.

Apple pickers will use the same argument that’s always used when non-invasive is involved. Apple’s will be picked because patients will no longer have to prick their finger, there would be no “pain” associated with testing. As we noted many times this is a flawed belief as the reason these patients fail to test is the test result is meaningless to them, it’s carries no value. Even when their physician tells them they should be testing they don’t. Even when their CDE, assuming they have a CDE, tells them they don’t.

Even worse when these patients do test and are diligent about recording their results, the data becomes meaningless as their physician does not use this data preferring instead to use HbA1c results when it comes to judging the success or failure of the patient’s treatment regimen. Now we don’t blame the physician here as they are not paid to analyze this data and frankly don’t have the time. Primary care physicians (PCP) who treat 80% of all patients make their money by seeing patients they do not make money from analyzing glucose data.

Now just in case anyone in the orchard believes that patients will be proactive, that they will take the time to analyze the data or read the reports generated by the app that will come with the way cool whiz bang toy, think again. Even if the patient wanted to change their therapy regimen they can’t without first seeing their physician. This not only costs the patient money but also costs them time, as we are not aware of too many PCP’s who will simply change a patient’s script without seeing them and with patients with diabetes this visit will surly include an HbA1c test which also can cost the patient.

We hate to be redundant but when it comes to non-insulin using patients they only make changes in their therapy regimen when its recommended by their physicians most of these patients are NOT proactive.

Another fact, yes, those pesky facts again, let’s say a patient does use the way cool whiz bang toy. Let’s also assume they are well educated in diabetes management, which most aren’t. That they are proactive about their diabetes management, which most aren’t. Since they cannot change their therapy regimen without seeing their physician what options are left to them. Sure, they can change their diet or begin exercising but that’s about it and let’s be honest here their physician has already told them to change their diet and exercise.

The truth is most patients who do use this way cool whiz bang toy will stop using it after the coolness factor wears off. Why do we say this? Experience. Allow us to use a real-life example. Back in the day when we had time to play golf one of our golfing buddies was diagnosed with diabetes. Knowing what I did for a living he asked some questions and asked what meter he should use. My advice was simple it really didn’t matter which meter he used as long as he used it.

The next time we played I asked how it was going and how many times he was testing. Being a new patient he was fairly diligent about testing in the first few weeks after being diagnosed but this wore off over time. When I asked why he wasn’t testing much his answer was simple no matter what the number was he took the same pills at the same time. Simply put the test results were meaningless so why do it. Other patients have shared similar experiences basically saying that nothing they were doing changed because of the test result so why do it.

We have long contended that average testing frequency for non-insulin patients would not increase if test strips were given away for free or if there was no “pain” associated with testing. That until this number was of value to the patient, forget about it. The Apple way cool whiz bang toy does not change this no matter what the Apple pickers think.

About the only way this could work would be to blind the data from the patient and do all the analytics for the physician. Still even if this happened and if it does this isn’t cheap, the patient still has to take the medication, they need to be compliant. As it stands today the non-insulin using patient has no incentive to get their diabetes under control. They won’t save money or time.

For the past 20 years or so we’ve seen millions spent on this quest for non-invasive glucose monitoring. We’ve seen disease management morph into interconnected diabetes management (IDM). We hear the talk that if only patients who don’t use insulin would test everything would be great. That if getting this data was painless millions of patients would use such a device.

The fact is this even if this way cool whiz bang toy worked and was given away for free it wouldn’t make a damn bit of difference for patients who do not use insulin. We’ve said it before and we’ll say it again because its true you can give these patients the how to, but you cannot give them the want to. They need a reason to manage their diabetes better something tangible.

As Momma Kliff used to say; “Just because I have experience and seen this before doesn’t mean you to listen.”