OVERVIEW
On February 19th, we spoke with a board certified physician assistant specializing in endocrinology and diabetes management at a large, multi-specialty practice in the Midwest. We came away from the discussion with a greater appreciation for 1) the impact that COVID-19 has had on diabetics and the medical professionals that care for these patients, 2) the potential role Senseonics’ (SENS) Eversense can play in helping patients manage the disease, and 3) the importance of patient engagement/coaching.
TAKEAWAYS
- In its current state - 3-month use and 2 calibrations per-day - the Eversense is a good option for about 5-7% of our contact's patients. A switch to 6(+) months could double or triple that penetration rate.
- DXCM still has the best sensor and is the best option for Type-1 diabetics, but the FreeStyle Libre 2 is a very close second and preferred option for Type-2 insulin-dependent patients. Where SENS has an opportunity is with diabetics in labor-intensive roles and where the tradeoff of being able to take it off vs. still calibrate is appreciated.
- Live coaching is valuable and works - feedback was positive on Livongo's impact on patients, albeit for a small percentage of our contact's CGM users (supports the large addressable market opportunity - i.e., that the market is under-penetrated).
CALL NOTES
Background info: Our contact sees between 40 and 60 patients per week, on average (~40% are using a CGM). The clinic is a larger regional one and employs >500 physicians and other advanced practitioners, such as our contact, across dozens of specialties. The inbound volume is mostly referrals from primary care practices (PCPs), and most of her patients with CGMs use the Dexcom (DXCM) G6 or Abbott's FreeStyle Libre. About 10% have an Eversense implanted.
- 15% of her patients are T-1 diabetics, about 10-15% are T-2, and then the remainder are T-2 insulin-dependent. About 7-10% of patients have a Tandem (TNDM) pump.
What's the typical Eversense patient like?
- The patient wants something longer-term than a 14-day G6 or Libre. One group of patients is in the 20-40-yo range with labor-intensive jobs. The G6 or Libre can be knocked off. Also, some more active patients like the concept because of sweating it off, not being easy to swim or wash, etc.
- With Eversense, they don't worry because you can take the transmitter off leaving just the sensor in the arm. I have some patients on their 4th or 5th one, and one patient asks for it to stay in the same spot (have done it 3x, moving it slightly forward or backward with no trouble). I usually switch arms though.
- Beyond labor-intensive jobs or athletes, there's a smaller group like one of my patients in her 50s - she just didn't want a thing on her body that needed to be changed.
- It's mostly T-2 insulin-dependent patients. T-1 is the lowest percentage.
There are 3 codes for insertion and explant - what can you tell us about billing for it?
- There's no disincentive. I haven't had trouble at all. For two patients, insurance paid for the sensor but not my time to implant it, which was odd. But the patients were covered.
What was your initial impression [of Eversense], and how has it changed?
- It sounded interesting at first (got certified toward the end of 2019). It's positive overall. The “free/naked shower” attraction is real - it's really nice to not have a device to work around in the shower. It’s under the skin. That's a big thing for some patients.
- It might look bad, but the Eversense procedure is NOT a big deal. It’s very superficial - under the subcutaneous layer. Most patients heal within a week.
- 3 months isn’t a big deal - one of the major reasons patients are not interested is because there are calibrations (every 12 hours). The G6 and FreeStyle don't require calibrations.
Calibration and "only" 3 months - any other pushback?
- It's a tradeoff. These patients checked their blood sugar 6x a day and that goes to 2x. But then other patients are tired of it all. With Eversense, you have to calibrate or the meter won’t read... it makes sure you’re calibrating.
- The 3-month switch and calibration are the two major things. We're waiting on the 6-month one - just not sure when that's coming.
If those were removed, where could it go? What % of T-2 insulin-dependent or T-1s?
- I think up to 20%, at least. There are a lot of patients that see the value and want to go on vacation, swim, etc. In its current form, the max is probably 5-7%, broadly speaking. (Our impression is that her current mix is slightly higher because of advertising and awareness that she is certified as an Eversense provider.)
- DXCM has too good of a sensor to lose out (and no calibrations) - but 6 months w/ the Eversense would be big.
- I argue that T-2s with insulin should use a CGM - they still have the risk of getting low and the monitors prevent any hypoglycemic syncope events.
Have you seen a clinical benefit - are A1Cs better? Other benefits?
- Every Eversense patient of mine saw an A1C reduction in the first three months. There are big clinical benefits.
- I wore a G6 and FreeStyle for a while - it's very helpful to know what spikes your blood sugar (Tom agreed, having tried the G6 himself).
- T-1s - one of mine said, "It's like having my own gas gauge."
COVID-19 - what has it meant for your patients? We hear about the deferral of care leading to issues in other specialties like oncology. Is the same true for diabetes?
- Yes. Poorly controlled A1C. We dropped off in April and May - almost no patients.
- We started telehealth, which we didn't have before. Some patients still ask for virtual visits (more on this below).
- With all diabetics after that drop - the majority (~60%) have worse control of their A1C.
- The schedule has been pushed way back - before COVID, we could see a new patient in 3-4 weeks, now it's 6 weeks or more. Follow-ups are pushed out to 3 months. We don't think it's going to get back to normal until well into 2022.
- A lot of my T-2s are 60+ and they were afraid to come in. We're catching up. I won't see new patients via telemedicine - only follow-ups.
What is the natural limit?
- We're scheduled to see 23 patients this Monday - of those, 3 are new. It's about 10% new patients per week - we had to cut down last year. I only see new patients on Mon and Wed, and we flexed staffing to start this year.
- 10-hour days on Mondays - 7am to 6pm (hour of downtime) so we added 3 patients. I get asked to work in 3-4 new ones. I need 40 minutes for a new patient, but just 15 min for established.
- In-person checks - the main thing is the foot exam. Yes, we download CGM data and draw blood, sometimes I check the injection sites for scar tissue or to make sure they are injecting.
Are any of your patients enrolled in virtual services like Livongo’s or DarioHealth’s through work?
- I have a few patients that use Livongo but not many. Maybe 5% that I'm aware of.
- For the ones I know of, there is better [A1C] control with them - I think it's the support. One example is a patient that had an A1C of 8.5 and after six months she came back and it had dropped to the 7% range... no medication changes or anything, just Livongo helped through her work.
- The majority of patients welcome more support, motivation, encouragement, etc. One of my patients said, "It's like having a nurse in my pocket."
- Yes, I've heard of Gluco but it's not live coaching... patients have to initiate the process (not ideal).
What are your thoughts about telemedicine? Are you looking forward to getting back to in-person care?
- I do want to get back to in-person care. Telemedicine is great for nursing home patients and follow-up - e.g., every other visit via telemedicine. However, I don't want to see any new patients via telehealth and I'm down to about 2 virtual visits per week.
- We use Doximity and I chart it after.
- My colleagues are down too - it's interesting, we will offer a telehealth visit to patients that call in and can't be seen before they hang up. The majority of my patients turn down the offer.
What are your thoughts on the FreeStyle Libre 2?
- I have at least two dozen on it and the data is just as good plus the alarms for hypoglycemia awareness - and it's cheaper.
- 90% of my T-1s use a Dexcom, and then it was a 60/40 split with T-2s - that's now about 50/50.
- How to pick?
- I do prefer to have my T-1s on the G6 and T-2s on the FreeStyle. It's just the nature of diabetes and needing the bells and whistles. Insurance is less of a factor, but does influence the decision sometimes.
- It's odd that Medicare switched to the G6 from the FreeStyle - it's more expensive, that didn't make a lot of sense.
- The G6 is still the best.
What about CGMs for pre-diabetics?
- The view that if you put a CGM on them and avoid progression w/ a generally non-compliant population... well, those programs don’t work. I never considered this. And insurance won't cover it. Patients won't understand the ins-and-outs of it.
- Yes, DXCM and ABT would be thrilled to put millions of CGMs on people.
What’s the trend with Eversense?
- There were no new patients for a while. Even established patients - I had one where it was five months before I got to take an old one out.
- Now, new patients are OK again - it started toward the end of last year. I get asked about it often, and since there's no pain, swelling, infections to report, it's a good option. It's picking up a bit - I have another one next week.
Please reach out to with any feedback or inquiries, questions or topics for future field checks, or requests for underlying data. We mean it - if you've got an idea or want us to "check" something, within our reach, of course, we can likely do it.
Thomas Tobin
Managing Director
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