What will 2019 bring?

As 2018 comes to an end let’s look ahead and get a sneak peek at 2019. As per usual the start of our New Year will begin in that beautiful city by the bay for the annual J P Morgan Healthcare Conference. Anyone who has attended JPM knows this conference is a must attend for anyone and everyone in healthcare. This year JPM will be ending and CES will be beginning so it possible we’ll head from SFO to LAS to take a gander at all the new way cool whiz bang toys.

Speaking of toys 2019 will be another good year for CGM as it continues to become the standard for glucose measurement. BGM will continue its slow move towards obscurity.

When it comes to the coolest toys in the toy chest 2019 could be a big year as Tandem could launch the Control IQ system with the TypeZero algorithm while at the same time Medtronic could be dealing with whatever punishment the FDA hands down once their investigation is completed. The Control IQ will give the 670G a serious run for Medtronic’s money, but it will be up to Tandem to get the system on level formulary with 670G.

In the medicine cabinet 2019 could well go down as the year GLP-1 therapy goes mainstream in a big way with the oral version of semaglutide from Novo Nordisk and the exenatide micropump from Intracia both coming to market. It will be interesting to see how Novo handles the dosing instructions for their drug which could limit its initial uptake. However, we do believe just the approval of either new GLP-1 will help the entire market.

In many respects the CGM market and GLP-1 markets are on similar paths. Both continue to grow, both are benefiting from greater patient/physician awareness, both have room to grow and both markets are large enough for multiple winners. We have not reached full blown commodization as we have in the insulin markets, which in 2019 will only continue with further price reductions.

The one saving grace for insulin in 2019 could be the introduction of Tyler. Lilly, Novo and Sanofi understand with insulin prices under continued assault they must come up with new options to make insulin therapy more patient friendly. This is perhaps the most misunderstood aspect of Tyler in that it will make life easier for all involved. The real question is who will come up with the most patient friendly system.

Sticking with insulin for just a moment 2019 will not see a resolution of the “high” out of pocket cost of insulin issue. The issue will get attention but the basic problem here is no one can agree on just what affordable means. Everyone is busy pointing fingers, but few have come up with any workable solutions. Frankly we could care less about why the problem was created we just wish someone anyone would offer something other than blame.

Another area which will get lots of attention are the way cool whiz bang cloud enabled systems that offer coaching, systems which have garnered lots of hype but only a mere handful of patients. First, we should clarify something as we are not opposed to these systems as education works, there are thousands of studies that prove that. What we can’t understand is the business model or put simply how will these companies make money. Having watched these systems evolve over the years the nearest we can tell is these companies will go 100% at risk getting paid only if they produce better patient outcomes.

The one big issue with the pay for performance business model is it requires huge amounts of capital. A company like OnDuo with Google and Sanofi behind it might be able to afford this but for smaller players like Livongo and OneDrop this model poses some issues. Our guess and we think it’s a really good guess what Livongo and OneDrop are hoping for is that as Apple, Facebook and Amazon dive deeper into diabetes they will become the shortest distance between two points. Time will tell but one thing is becoming clear snarky Alexa is on her way to become a virtual CDE.

The reality is diabetes management is continuing its transformation. Thanks to quality CGM systems from Dexcom and Abbott and sophisticated insulin dosing algorithms the day is coming when it will be easier to be an insulin using patient than a patient who’s on orals alone. Whether patients will have access to this technology is open to debate but there is no question this technology is paradigm shifting for every insulin patient no matter how they administer their insulin.

The same paradigm shift is beginning with increasing uptake of GLP-1 therapy. The oral version of semaglutide may have some issues but its expected approval along with the Intracia exenatide micropump will expand this market even further. As we predicted years ago when Byetta first came onto the market GLP-1 therapy will grow as delivery systems improve – they have, and primary care physicians start adopting GLP-1 therapy – they have.

So, let’s have it 2019 looks to be another wacky year.