What happens in the real world!

To help everyone gain a better appreciation as to the road Livongo must travel to profitable, allow us today to walk you through the daily life of an average patient. As we keep stating the key for Livongo is not signing deals, the key is enrolling patients and keeping them enrolled this is how they make money.

While we know that Livongo wants to help all patients no matter what their therapy regimen, their true target their core customer is a non-intensively managed patient with Type 2 diabetes. Patients who treat their diabetes with oral medications or orals plus insulin. We do not believe intensively managed patients need the services Livongo provides for several reasons. Most notably is the increasing usage of sensor augmented insulin delivery system. Systems which do the heavy lifting for the patient therefore eliminating the need for coaching.

Even when intensively managed patients are eliminated from the mix the non-intensively managed patient population is a huge target market. They are however also the most difficult group of patients to engage with their diabetes management. There are many reasons for this, but they boil down to the fact these patients have a chronic disease they did not want in the first place, a chronic disease they do not understand, and which requires some work to manage properly.

That being said programs such as what Livongo offers can when used as designed assist the patient helping them more effectively navigate their diabetes management. Yet the system is predicated on the premise that the patient will use the tools provide by Livongo, in this case a conventional finger stick glucose monitor which also serves as a communication conduit between the patient and the Livongo coaches. The system is also predicated on the premise that the patient will accept and follow the assistance offered by the Livongo coaches.

It seems like a no brainer until you look at the lives these people lead. Lives which are not centered around their diabetes management. To these patients their diabetes management is just one more thing they must do each and every day. One more thing they would rather not be doing at all. This is one reason non-intensively managed patients are the lest frequent testers of their glucose levels. This is problem number one for Livongo getting these patients who don’t test regularly to test regularly. Without data there is nothing to analyze.

Let’s say that Livongo somehow magically does something that no one else in diabetes history has been able to do, get non-intensively managed patients to test their glucose levels on a regular basis. The next step is to get these people take their meds as prescribed. We’ve said it before and we’ll say it again ask any physician, primary care or specialist, the biggest issue standing between these patients and better outcomes is therapy adherence. So problem number two for Livongo is the second most difficult problem in diabetes history that again no one has solved, getting patients adherent with their therapy.

Every other aspect of the patient’s diabetes involves changing the patient’s behavior which per numerous studies does not work over the long term. Livongo can tell the patient to exercise more, quit smoking, eat a healthier diet, etc. They can give the patient the how to manage their diabetes management better they cannot however make the patient want to manage their diabetes better. Again we’ve said it before giving the how to is easy.

Now put all this into the context of an average day for a non-intensively managed patient. Besides worrying about getting to work, getting the kids off to school, paying bills and dealing with all the other things everyone else does the patient with diabetes has additional responsibilities. The first of which is taking their meds. This seems like a simple task, but numerous studies have proven that it’s not as easy as it seems. Keep in mind that the majority of these patients are not just taking one pill but multiple medications and not all of which are for their diabetes. Multiple medications taking multiple times each day.

It’s not as if these patients get up each day take on pill and are on their marry way. The majority must remember to bring their meds with when they go to work and take them when they are supposed to. Why do you think there are multiple apps which are designed just to remind patients to take their pills? Why do you think physicians are embracing long-acting once weekly GLP-1’s such as Trulicity? Think about this just for a moment one shot once a week or multiple pills multiple times per day which is easier for the patient?

Next to get their data the patient must test their glucose. Again this seems easy enough, but this means the patient must carry around with them their meter, lancing device and test strips. Just as they must remember to take their meds with each day, they must also remember to take their glucose testing equipment each day. Again why do think continuous glucose monitoring systems usage is increasing. What’s easier inserting your sensor once every 10 days or every two weeks or testing multiple times per day each and every day.

Are we done yet? Not by a long shot. On top of remembering their pills and testing supplies the patient has the additional responsibility of eating right, exercising, etc.

Yet Livongo adds one more responsibility, dealing with all the messages they are sending. These are not like text messages from a family member or friend. These are messages telling them what to do and how to do it. Yes, they are well intentioned, but they add to their daily responsibilities. Worse and it’s difficult for someone who does not have diabetes to understand this, but these messages are just one more reminder they have diabetes. Keep in mind the one thing these patients want more than anything is something they cannot have. What they want more than anything is not to have diabetes in the first place.

But let’s say that Livongo can overcome all of these obstacles, what does the patient get for all this work. Will they “feel” better? Maybe. Will they save time? No. Will they save money? No. Are their daily lives easier? Debatable. One of the most impactful studies we ever read came out of the University of Chicago over 15 years ago. The study noted that patients would rather sacrifice years off their life expectancy than do all things they need to do to manage their diabetes properly. Think about that just for a moment.

Yes poorly controlled diabetes does result in many severe complications, blindness and amputations are just two of them. However most patients even if they are aware this don’t think about them. Complications are something that happen to the other guy. Worse there is no guarantee that even if they do everything, they are supposed to do they will avoid these complications. Patients are not motivated by the possibility they may avoid complications that may or may not happen years down the road. Patients are motivated by the here and now.

Perhaps the easiest way to think about this is think about every person you know who has been on a diet lost weight only to gain it back. Does behavior change work? Yes. Is behavior change sustainable? Debatable.

We view this from a much different perceptive than almost everyone else. Livongo is pushing information to the patient. Livongo assumes the patient will be receptive and will respond to this information. They like many others believe the patients wants to manage their diabetes more effectively that the patient wants to achieve better outcomes.

We on the other hand understand the daily burden of diabetes management. The psychological toll it can take on a patient and the patient’s family. We understand human nature and don’t live in an ivory tower which seems to think technology can solve every problem. But most of all we understand that people respond better to things they can see, touch or feel. They might think about the long-term consequences of poor diabetes management, but it does not motivate them to change their behavior.

This is one reason Livongo always talks about short term results just assuming these short-term results will translate into long term success. As we have seen with weight loss or smoking cessation short term results don’t always translate into long term sustainability. They might be able to get people into the program but we’re skeptical they will keep them in the system.

When you strip away all the whiz bang and way cool this all comes down to one simple pesky fact, in that these patients want their diabetes management to be simple and easy and it’s not simple and easy. The reality is diabetes is more than a math problem and there are no quick fixes. This is a major reason why so many patients do the best they can and let the chips fall where they may.