OVERVIEW
We spoke with a practice administrator and board certified physician assistant who specializes in endocrinology and diabetes management at a new endocrinology practice on the West Coast last month. Similar to our prior Field Check, we came away from the discussion with a greater appreciation for the importance of in-person visits for diabetes care (and generally), the return of in-person care and pent up demand, and app-based coaching services Livongo and Dario, as well as the potential role Senseonics’ ($SENS) Eversense continuous glucose monitor (CGM) can play in helping patients manage the disease in the future. However, there were some noteworthy differences of opinion and incremental points to consider in thinking through the market opportunity for SENS, as well as the role of telemedicine (virtual visits).
TAKEAWAYS
- In its current state - 90-day use and 2 calibrations per day - Eversense was a good option for 3-5% of our contact's patients (lower than the range noted in our previous field notes (published 2/26) by 200 bps).
- An improvement to 180 days without iCGM capability wouldn't move the needle much; however, adding iCGM - integrated continuous glucose monitoring - at any point with a sensor that lasts 6+ months would make the Eversense "a very competitive option" vs. either the G6 or FreeStyle Libre 2, in our contact's opinion. It will be difficult for SENS [and/or Ascensia] to win over this PA-C and other practitioners that are pro-pumps without iCGM capability (this risk is partially mitigated by "pumpers" being a small, albeit growing, percentage of the market).
- There's an underappreciated issue with coaching services like what Livongo and DarioHealth offer: doctors and PA-Cs are "possessive" and may be wary of someone they don't know working with/guiding their patients. On the other side of that, our contact thinks telemedicine is very helpful for follow-ups and works well with diabetic patients. Seeing patients in person once a quarter is a norm, but it could go to once a year for many patients.
- It sounds like Medtronic (MDT) has made some progress w/ its algorithm and MiniMed, but it's still a "temperamental" system.
CALL NOTES
Background info: Our contact is a type 1 diabetic and board certified physician assistant specializing in diabetes. Prior to starting a practice with an endocrinologist within a larger multi-specialty group in 4Q20 (present volume is ~20 patients per week and growing), work experience included managing upward of 20 patients per day at one of the largest endocrinology/metabolic practices in California.
- The endocrinologist is "not as comfortable w/ all the tech" so our contact sees ~85% of the practice's diabetic patients, including all the type 1s (~40% of the total). Of the remaining ~60%, 70% are on insulin.
- All patients on insulin get the option of being on a pump (it is strongly suggested) - all are on a CGM unless refused.
- A LSD% of patients say, "No" to the pump, mostly because they don't appreciate the benefits.
How do you choose a CGM for your patients?
- If patients come in on multiple daily injections, I'll suggest the FreeStyle Libre 2 first because it's usually covered and is under the pharmacy benefit - the cost is lower, access is better. If I put someone on the G6 right away, they are locked in for 6 months and can only choose between the Tandem or Omnipod pumps (MiniMed isn't an option). If they start on the Libre, they aren't locked in and can choose. After an initial period w/ CGM, I try to put them on a pump.
- I try to see the new patients every couple of weeks, review positives and negatives, then choose.
- Which are the best? Omnipod and Tandem w/ ControlIQ are both really good. The G6 is a great CGM. The MiniMed 770 and Medtronic CGM follow.
- Eversense is a good option for patients, but I hope it gets iCGM to work with pumps. Until then, it'll be challenging to incorporate it as much into the new practice. We don't use standalone CGM normally. I don't force patients to be on pumps, but hybrid closed-loop therapy has benefits. I think it's a no-brainer for anyone on more than just basal insulin. 90%+ of patients on pump therapy is high but I spend a lot of time with patients discussing the options, quality of life, whether you need to check/interact w/ the device(s), etc.
- There are other factors to consider - diabetics often suffer from depression, anxiety (incl. social anxiety), eating disorders - whether type 1 or type 2, checking blood sugar + taking insulin in public can impact people differently.
- Diabetes care is "Whole Person" care. Food and stress influence blood sugar - choices patients make impact their blood sugar for 4 hours (note, we continue to hear stories evolving from Primary Care to other specialties about the importance of Whole Person care).
Is Tandem's t:slim X2 insulin pump with Control-IQ top-of-the-line/life-changing? How does it compare to the others?
- I think Medtronic's algorithm is better, but Tandem's ease of use is better. From what I've seen, MiniMed control is better if used properly, but it's temperamental.
- The algo for MDT auto-adjusts every 5 min based on glucose vs. Tandem, which is predictive (i.e., what will it be in 30 minutes). 30 minutes may not be long enough to prevent something from happening because insulin is slow. If a patient's blood sugar is up, it would still go high, same on the way down - it'd still go low.
- For the CGMs - Libre 2 and G6 - I think Dexcom is better. The Libre is still not approved to be used with pumps - it's the vitamin C issue (readings may not be accurate). Whether I think it's significant or not doesn't matter - the FDA does. People do complain relatively more (not quantified) about the accuracy of the Libre even though the 2 was shown to be more accurate (published data). In real life, patients complain.
- Overall, the G6 is easier to use and the app is great.
What do you think about Senseonics' Eversense? If it were iCGM compatible, where would you rank it?
- If it were 1-year wear plus iCGM, it would mean a lot. There would be no issue/problem getting utilization. The 3-month window is OK for most patients for a couple of/few times - it's worth trying with athletic patients or people that don't want to wear a CGM or be on a pump ((e.g., a college student can put it on overnight). But people get tired of it. 6 months would be better.
- I never did more than two on the same patient (implant, then two explant/implants subsequently). It was only used in about 3-5% of my patients at my prior practice. My patients usually go to a pump (and G6).
Can you tell us about the procedure with the Eversense?
- It doesn’t hurt. The worst part is the lidocaine. I've used it personally (3x). The insertion is super easy - it's the removal that can be challenging from a time perspective.
- Depending on the patient, extraction is the one thing that I worried/worry about. Fibrotic tissue can grow around the sensor or it can move. I've spent up to 45 minutes digging for a sensor in a patient's arm.
- We can use ultrasound to help, but it's still challenging, especially for obese patients.
- How's reimbursement with it?
- Payers were good with it. They've been less aggressive lately. Compared to pre-COVID-19, they are much less aggressive.
- Less pushback on the >4 glucose checks per day. The FreeStyle Libre 2 - I think the max is $75/mo. Overall, there's less friction with insurers. We see a lot of MediCal & Medicaid patients now, and they get the best care w/ 100% coverage. We must jump through more hoops, but it's full coverage.
- It's the middle-class people with BCBS that pay a lot because of deductibles, copays, etc.
Where does Eversense use go if they get the 6-month label later this year and reduce the # of calibrations? From 3%-5% to what?
- For me, iCGM is the most important thing. Most type 1 diabetics don't care about the fingers ticking/calibration. It's so much better now than years ago (10x - 15x sticks per day). Once or twice a day is not a big deal, but if you present someone with two options, one with and one w/ out finger sticks, they'll choose none.
- If they get a few things right with Eversense, it can be really competitive [with G6 and Libre 2], but I'm not using it with new patients until iCGM.
- It's all about presentation. If someone explains it to a patient that likes the idea of being able to remove it when they want, wants to swim, no phone, etc. It's patient-specific, but we guide people.
- Also, vibratory alerts and adhesive issues are reasons that Eversense is a good option. It's just a hard sell in its current state.
What are your thoughts on telemedicine/virtual visits and coaching services like Livongo and DarioHealth?
- We actually see all patients in the office now, but I'm seeing a lot of my old patients via telemedicine. It's not because they don't want to come in, they don't want to commute.
- I think diabetes lends itself well to telemedicine - we really don’t need to see patients in the office.
- We like seeing patients in the office every so often, but I think an all virtual diabetes clinic would be totally acceptable/effective.
- It's easier to build a relationship and connect with a new patient face-to-face. There are plenty of studies showing that patients feel like they receive better care if you physically touch them, speak with them from a standing vs. sitting position, etc. It's all about gaining trust. It takes longer to establish rapport w/ telemedicine.
- Outside of that, it's pretty equal to make adjustments to a regimen, evaluate/discuss data, etc. I think there's a right mix with a minimum of one annual in-person visit. It could be anywhere from 2 - 4 in-person after that per year, but it depends on the patients, access to tech, etc.
- I use doxy.me, which is really easy. It has a waiting room, uses my last name, and is fluid - I code/capture the visit in NextGen, which isn't the best EMR.
- Livongo is a good thing if used properly and in-between visits. Same with Dario, but I'm very protective of my patients. I worry that someone is telling them the wrong thing, especially if there's little or no visibility (current state). I am a bit wary of the coaches - "How are you a coach? What's your philosophy?" I'd like to know and have more visibility.
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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