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Post by joeypotsandpans on Jan 9, 2018 15:22:04 GMT -5
I originally was going to post this on the thread about the sales and marketing individual who accepted a position at the other company but think it is more appropriate here.
From what I understand there have been a fair amount that have come over from DEXCOM that are now in the sales and marketing area, what I was told is that they (the hires that came from DEXCOM) see MNKD the same as DEXCOM was 5 yrs. ago and know that this is the way the treatment will be heading. They are also very committed and understand the educational aspect of the new paradigm with physicians as well as patients. Now with the availability of the lesser expensive Libre which is much more conducive to real time monitoring for T2's it will help significantly with each T2 individual's situation ie., the differences in metabolism, other medications they are taking, etc.
It isn't like there is a uniform dosing/titration that covers everyone, each T2 requires different regimens depending on where they are on the spectrum of disease progression...for example, Spiro only requires 4u at mealtime and a 4u correction dose when snacking and that is enough to keep him in range...I on the other hand require 8-12u at mealtime with a 4u correction dose depending on carbs at mealtime. I suspect this (lack of understanding by the physicians regarding same) along with the insurance issues were the biggest culprits regarding the drop off in refills. With the ability to constantly monitor this will help tremendously with the learning curve they will continue to go through with the shift towards real time management of the disease.
I can definitely envision a joint marketing endeavor between MNKD and Abbott and/or DEXCOM at some point as it would be akin to the wireless carriers model with the various phones they market in packages IMO.
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Post by dreamboatcruise on Jan 9, 2018 16:30:36 GMT -5
I originally was going to post this on the thread about the sales and marketing individual who accepted a position at the other company but think it is more appropriate here. From what I understand there have been a fair amount that have come over from DEXCOM that are now in the sales and marketing area, what I was told is that they (the hires that came from DEXCOM) see MNKD the same as DEXCOM was 5 yrs. ago and know that this is the way the treatment will be heading. They are also very committed and understand the educational aspect of the new paradigm with physicians as well as patients. Now with the availability of the lesser expensive Libre which is much more conducive to real time monitoring for T2's it will help significantly with each T2 individual's situation ie., the differences in metabolism, other medications they are taking, etc. It isn't like there is a uniform dosing/titration that covers everyone, each T2 requires different regimens depending on where they are on the spectrum of disease progression...for example, Spiro only requires 4u at mealtime and a 4u correction dose when snacking and that is enough to keep him in range...I on the other hand require 8-12u at mealtime with a 4u correction dose depending on carbs at mealtime. I suspect this (lack of understanding by the physicians regarding same) along with the insurance issues were the biggest culprits regarding the drop off in refills. With the ability to constantly monitor this will help tremendously with the learning curve they will continue to go through with the shift towards real time management of the disease. I can definitely envision a joint marketing endeavor between MNKD and Abbott and/or DEXCOM at some point as it would be akin to the wireless carriers model with the various phones they market in packages IMO. A big contributor to Minimed winning the pump market was their focus on patients and education. Certainly see echos of that in MNKD now. Wouldn't have thought it would be as much of an uphill battle as creating an entirely new market for pumps, but glad to see/hear MNKD is hiring the right people. Think you are spot on regarding individualization of dosing, which is made more complicated by doctors' relative lack of experience with Afrezza. CGM's will certainly help. Hopefully supplying at least temporary use of CGMs will become much more common for T2s, where use is currently almost non existent. I don't quite see the part about joint marketing coming to reality. Would likely be great for MNKD, but I don't see the CGM manufacturers thinking picking sides regarding insulin is a good marketing strategy. I don't even think the cellular carriers would be doing the joint marketing with Apple if not for Apple paying the tab. Or computer manufacturers having done joint "Intel Inside" marketing if not for Intel footing the bill. Obviously MNKD can't throw money at large joint marketing advertising campaign. We might be able to afford the advertising to OneDrop users (does anyone doubt MNKD paid for that), but MNKD can't afford to help subsidies a big national push with the likes of Dexcom or Abbot.
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Post by Deleted on Jan 9, 2018 17:12:04 GMT -5
I originally was going to post this on the thread about the sales and marketing individual who accepted a position at the other company but think it is more appropriate here. From what I understand there have been a fair amount that have come over from DEXCOM that are now in the sales and marketing area, what I was told is that they (the hires that came from DEXCOM) see MNKD the same as DEXCOM was 5 yrs. ago and know that this is the way the treatment will be heading. They are also very committed and understand the educational aspect of the new paradigm with physicians as well as patients. Now with the availability of the lesser expensive Libre which is much more conducive to real time monitoring for T2's it will help significantly with each T2 individual's situation ie., the differences in metabolism, other medications they are taking, etc. It isn't like there is a uniform dosing/titration that covers everyone, each T2 requires different regimens depending on where they are on the spectrum of disease progression...for example, Spiro only requires 4u at mealtime and a 4u correction dose when snacking and that is enough to keep him in range...I on the other hand require 8-12u at mealtime with a 4u correction dose depending on carbs at mealtime. I suspect this (lack of understanding by the physicians regarding same) along with the insurance issues were the biggest culprits regarding the drop off in refills. With the ability to constantly monitor this will help tremendously with the learning curve they will continue to go through with the shift towards real time management of the disease. I can definitely envision a joint marketing endeavor between MNKD and Abbott and/or DEXCOM at some point as it would be akin to the wireless carriers model with the various phones they market in packages IMO. A big contributor to Minimed winning the pump market was their focus on patients and education. Certainly see echos of that in MNKD now. Wouldn't have thought it would be as much of an uphill battle as creating an entirely new market for pumps, but glad to see/hear MNKD is hiring the right people. Think you are spot on regarding individualization of dosing, which is made more complicated by doctors' relative lack of experience with Afrezza. CGM's will certainly help. Hopefully supplying at least temporary use of CGMs will become much more common for T2s, where use is currently almost non existent. I don't quite see the part about joint marketing coming to reality. Would likely be great for MNKD, but I don't see the CGM manufacturers thinking picking sides regarding insulin is a good marketing strategy. I don't even think the cellular carriers would be doing the joint marketing with Apple if not for Apple paying the tab. Or computer manufacturers having done joint "Intel Inside" marketing if not for Intel footing the bill. Obviously MNKD can't throw money at large joint marketing advertising campaign. We might be able to afford the advertising to OneDrop users (does anyone doubt MNKD paid for that), but MNKD can't afford to help subsidies a big national push with the likes of Dexcom or Abbot. Keep in mind healthcare is switching from fee for service to fee for outcome. CGMs alone don't produce good patient outcomes. They can show time in range or out of range or % of time in range. Now if I work for ACME CGM company and I want to charge more for my stuff, if I can find a product that consistently helps patients control blood glucose levels better, it might be in my best interest to partner and bundle my products to attempt to get max reimbursement for better patient outcomes. ABT and DXCM won't want to be pigeon holed with MNKD and alienate Novo of LLY but all of this stuff is about to under go a revolution and fee for service will go the way of the buggy whip. Time in range as Mike C has pointed out is the new A1C. Elimination of the peaks and valleys in blood glucose levels improves long term patient health and reduces long term health complications. Remember the DCCT study validated this in a big way several decades ago.
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Post by dreamboatcruise on Jan 9, 2018 17:28:00 GMT -5
@scotta ... do you have some info on what fraction of diabetes patients are currently on some form of fee for outcome. That certainly would be encouraging if the shift is meaningful. Though there would also be the question of what "outcome" they are measuring. If it is only A1c, and they are using ADA type guideline, that is still suboptimal and not being measured in a way that would most encourage use of Afrezza. I still don't believe CGM companies would be interested in marketing in such a way that might imply their product is mainly useful only with one particular insulin, especially when it is an insulin that hardly any patients are aware of. Realistically speaking how long do you think it will be before ADA adopts time in range for their treatment guidelines? And majority of patients covered by insurance that pays for this outcome... and thus necessarily pays for CGMs for both T1 and T2 patients? Will be great when it does happen, but change in healthcare seems to come very slowly. The great push to make healthcare records electronic and easily transportable started 20 years ago and yet I still have to get my PCP to take a paper copy of a lab report from my folder and fax it to a specialist (yes many health organizations have made progress but it's been very slow)
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Post by spiro on Jan 9, 2018 18:23:25 GMT -5
Afrezza is a game changer from the first day that it is used properly by a diabetic. Of course Spiro and joeypotsandpans had an advantage on other new users, because we were participants on this board and knew exactly what we had to do to start getting control of our diabetes. Using Afrezza properly is such a no-brainer that it is truly frightening that so many doctors appear incapable or unwilling to figure it out. As Joey mentioned, Spiro usually takes 4 units with his average meal. If the meal is larger than usual, he will take 8 units. When Spiro snacks during the day, he will take a 4 unit dose after every snack. Spiro will puff 20 -24 units of Afrezza per day. Ok, Spiro lied, on his cruise, he puffed up to 42 units a day. But that was the cruise ships fault. Spiro's last blood test on November 6, indicated an A1c of 6.1, his lowest since starting Afrezza. But this is not the whole story, Spiro's other wacko blood chemistry has remained in the normal zone for almost 2 consecutive years now. Could this be just one of the fringe benefits of blood glucose control? Spiro's doctor certainly thinks so.
Spiro here, Just trying to help Make Diabetics Great Again. oh, maybe Spiro should have said Healthy Again.
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Post by Deleted on Jan 9, 2018 18:26:07 GMT -5
@scotta ... do you have some info on what fraction of diabetes patients are currently on some form of fee for outcome. That certainly would be encouraging if the shift is meaningful. Though there would also be the question of what "outcome" they are measuring. If it is only A1c, and they are using ADA type guideline, that is still suboptimal and not being measured in a way that would most encourage use of Afrezza. I still don't believe CGM companies would be interested in marketing in such a way that might imply their product is mainly useful only with one particular insulin, especially when it is an insulin that hardly any patients are aware of. Realistically speaking how long do you think it will be before ADA adopts time in range for their treatment guidelines? And majority of patients covered by insurance that pays for this outcome... and thus necessarily pays for CGMs for both T1 and T2 patients? Will be great when it does happen, but change in healthcare seems to come very slowly. The great push to make healthcare records electronic and easily transportable started 20 years ago and yet I still have to get my PCP to take a paper copy of a lab report from my folder and fax it to a specialist (yes many health organizations have made progress but it's been very slow) Good Question re: fee for outcomes. My dartboard guess is as of right now, very few but its going to ramp. Most diabetes are poorly controlled and CGMs would demonstrate how glaringly poor the entire population is doing in terms of time in range. Its the big swings in blood glucose levels that cause the most long term damage and as such, the expensive treatments associated with the debilitation outcomes of poor control, ie laser treatments for retinopathy, wounds that cannot heal and subsequent amputation, CV issues. With all the crazy stuff floating around these days, try this one on for size. Amazon is getting into the Rx business. They are also going to have their own PBM (run I believe on an existing outsourced platform but dont quote me for sure on that one). Amazon has already proved it can run their business successfully on a much lower margin than competitors so even if the PBM ran at 1/4 the profit that the big guys do, Amazon would probably still make money or still stay in the game so they could dominate the space. You realize you don't need a prescription to buy insulin. You do need an Rx to get your insurance company to pay for insulin. Amazon has a pretty good web services operation. They could figure out how to collect and aggregate CGM data. What happens if they can get paid a fee for good outcomes and have a system and tools to produce unprecedented results? The cost of the Rx products is chump change compared to the savings insurance companies reap from a massive patient population that has a poorly controlled disease whose costs could bankrupt the US healthcare system. All speculation on my part but given our nations debt, aging population, pension fund liabilities, poor wage growth... you get the idea, what we have now in our healthcare system and other aspects of our country is simply not sustainable.
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Post by dreamboatcruise on Jan 9, 2018 20:44:51 GMT -5
@scotta ... do you have some info on what fraction of diabetes patients are currently on some form of fee for outcome. That certainly would be encouraging if the shift is meaningful. Though there would also be the question of what "outcome" they are measuring. If it is only A1c, and they are using ADA type guideline, that is still suboptimal and not being measured in a way that would most encourage use of Afrezza. I still don't believe CGM companies would be interested in marketing in such a way that might imply their product is mainly useful only with one particular insulin, especially when it is an insulin that hardly any patients are aware of. Realistically speaking how long do you think it will be before ADA adopts time in range for their treatment guidelines? And majority of patients covered by insurance that pays for this outcome... and thus necessarily pays for CGMs for both T1 and T2 patients? Will be great when it does happen, but change in healthcare seems to come very slowly. The great push to make healthcare records electronic and easily transportable started 20 years ago and yet I still have to get my PCP to take a paper copy of a lab report from my folder and fax it to a specialist (yes many health organizations have made progress but it's been very slow) Good Question re: fee for outcomes. My dartboard guess is as of right now, very few but its going to ramp. Most diabetes are poorly controlled and CGMs would demonstrate how glaringly poor the entire population is doing in terms of time in range. Its the big swings in blood glucose levels that cause the most long term damage and as such, the expensive treatments associated with the debilitation outcomes of poor control, ie laser treatments for retinopathy, wounds that cannot heal and subsequent amputation, CV issues. With all the crazy stuff floating around these days, try this one on for size. Amazon is getting into the Rx business. They are also going to have their own PBM (run I believe on an existing outsourced platform but dont quote me for sure on that one). Amazon has already proved it can run their business successfully on a much lower margin than competitors so even if the PBM ran at 1/4 the profit that the big guys do, Amazon would probably still make money or still stay in the game so they could dominate the space. You realize you don't need a prescription to buy insulin. You do need an Rx to get your insurance company to pay for insulin. Amazon has a pretty good web services operation. They could figure out how to collect and aggregate CGM data. What happens if they can get paid a fee for good outcomes and have a system and tools to produce unprecedented results? The cost of the Rx products is chump change compared to the savings insurance companies reap from a massive patient population that has a poorly controlled disease whose costs could bankrupt the US healthcare system. All speculation on my part but given our nations debt, aging population, pension fund liabilities, poor wage growth... you get the idea, what we have now in our healthcare system and other aspects of our country is simply not sustainable. You do need a prescription to buy Afrezza. Reports to the contrary are not accurate. What you say about diabetes complications is certainly true, and even well known throughout the healthcare profession. Problem is that most payers don't have that long a term view. I have a group of friends in healthcare management. Even an organization like Kaiser that is known for being "evidence based" doesn't take a long term view of the cost/benefit... I've been told this. Payers realize that they may not have a patient as their member 5 years down the road after paying more now to keep them healthy. Additionally, in all industries execs are rewarded for short term results, not long term... myopic business planning is rampant in companies everywhere. Thinking about what will save money 10 years down the road simply isn't what exec are incentivized to do. It is true enough that better preventive (and more aggressive diabetes) care would save American consumers and taxpayers huge amounts of money, but the system isn't currently set up where the players actually have incentive to do so. Currently it's actually the opposite. Insurers are required to spend a certain percentage on the actual care, which caps the percentage profit they can make. The way to increase profit when the percentage is capped is to increase the health expenses so that overall premiums go up. It would be nice to think some course correction is coming, but alas, I'd be surprised if things really change in our current atmosphere of dysfunctional politics. BTW, collecting CGM data is pretty trivial from a technology standpoint (if not HIPAA) and is in fact is already a reality. Dexcom, and I presume Abbot, already have the technology built in to upload CGM data. I know Amazon has been rumored to be thinking about PBM business (actually has obtained pharmacy licenses in some states, and already sells drugs in Japan), but it appears big insurers may now be questioning bringing PBMs in house (or the functionally equiv CVS-Aetna merger). Maybe that merger leaves more opportunity for Amazon as an independent PBM, but also perhaps means that the dominance of independent PBMs has peaked and now declining. I'd be hesitant to even guess how all of that may shake out... though it really is the profit incentives that would need to change or else it's just possibly more efficient competitor doing the same thing as the existing ones.
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Post by Deleted on Jan 10, 2018 7:22:38 GMT -5
DBC, your post has much validity in the current environment. I don't think the current environment is going to last. The DXCM relationship with Verily gives Dex the first $1B in data proceeds and as I understand it, Verily views that amount as pocket change because the upside value of the data is so massive. Assuming they (Verily) acts in their own self interest, I would suspect they would take these big amounts of data, redact patient identifiers and make the information well known to the right entities to demonstrate who does and does not produce proper outcomes. Once this happens, it puts pressure on all interested parties to measure patient compliance in a new manner (not A1c). There are some people with diabetes who no matter what they do, struggle to control glucose levels and these people have been dealt a very very challenging hand. For many PWD, diet and exercise would make a monumental difference to their health, quality of life and cost reductions for their healthcare. As previously stated, the financial trajectory we are on is not sustainable and diabetes, due to prevalence and massive costs due to health complications can bankrupt the healthcare system. Its going to change and some entrenched entities will not benefit financially from the changes, as such, they will not go willingly.
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Post by akemp3000 on Jan 10, 2018 8:43:52 GMT -5
I agree the current environment is not going to last. This is an excellent thread describing the giant paradigm shift that's currently underway. A close relative with a doctorate specializing in drug interaction for geriatrics explains the entire current system for diabetes management is ALL based on the (antiquated) A1c measurement. That's all they've had to go on until now. This means FDA testing, protocols, insurance, incentives, relationships, and basically the entire system of diabetes management all sit on a foundation that is just now starting to crumble. 2018 should be a big year that the new players drive the shift to time-in-range management. Every step in this direction will be good for the future of Afrezza. The current players who profit immensely off the old system aren't going away easily but new data plus the new economic environment now favors takeovers and mergers that should accelerate the shift.
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Post by spiro on Jan 10, 2018 12:02:03 GMT -5
Spiro thinks that one of problems that MNKD has, relates to the very high number of brain dead doctors that Afrezza reps have to deal with. A diabetic friend of Spiro's questioned his doctor about his A1c being over 8. His doctor replied, that wasn't too bad for a type 2 diabetic and that most of his diabetic patients had an A1c higher than that. BTW, Spiro's friend is 73 years ago, doesn't own a computer and is stubborn as a mule. He loves his doctor and has total faith in him.
Spiro here
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Post by boca1girl on Jan 10, 2018 13:43:47 GMT -5
Having the tech savvy kids on Afrezza is going to be the game changer. The pediatric trails can’t finish soon enough. Hopefully excellent trial progress will prompt an early positive conclusion and approval.
Kids adopted social media then the old farts finally came around. I think a similar scenario will play out for Afrezza.
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Post by sportsrancho on Jan 10, 2018 14:12:03 GMT -5
Spiro thinks that one of problems that MNKD has, relates to the very high number of brain dead doctors that Afrezza reps have to deal with.
Exactly! And that’s where Vdex comes, they are like having a “Personal Trainer” for your diabetes. That your insurance pays for. Afrezza First:-)
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Post by dreamboatcruise on Jan 10, 2018 14:13:57 GMT -5
DBC, your post has much validity in the current environment. I don't think the current environment is going to last. The DXCM relationship with Verily gives Dex the first $1B in data proceeds and as I understand it, Verily views that amount as pocket change because the upside value of the data is so massive. Assuming they (Verily) acts in their own self interest, I would suspect they would take these big amounts of data, redact patient identifiers and make the information well known to the right entities to demonstrate who does and does not produce proper outcomes. Once this happens, it puts pressure on all interested parties to measure patient compliance in a new manner (not A1c). There are some people with diabetes who no matter what they do, struggle to control glucose levels and these people have been dealt a very very challenging hand. For many PWD, diet and exercise would make a monumental difference to their health, quality of life and cost reductions for their healthcare. As previously stated, the financial trajectory we are on is not sustainable and diabetes, due to prevalence and massive costs due to health complications can bankrupt the healthcare system. Its going to change and some entrenched entities will not benefit financially from the changes, as such, they will not go willingly. Can you provide a link to the info about this data sharing arrangement with regard to the $1B. I've read a lot about the cooperation in development of miniturized sensors but seen nothing about this $1B arrangement. Due to HIPAA a patient would absolutely have to consent to have data used in a particular way or shared with a third party. Does Dexcom currently seek consent to share data with Verily? and do patients typically do that? As for figuring out "what works" you have to consider that a Dexcom often isn't aware of everything that effects a person with diabetes. It isn't tracking caloric intake, activity level, other medications (sometimes not even insulin), etc. Personally I think the companies working on artificial pancreas are where the figuring out "what works" is occurring, as they are actually using metabolic modeling. Perhaps Verily is working on that sort of thing but figuring out how bodies metabolize sugars is not very similar to figuring out that if you searched for Prada shoes you might respond to an advert for a Jag. There might be some uses for "big data" analysis in healthcare, but figuring out how to dose insulin isn't one of them.
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Post by dreamboatcruise on Jan 10, 2018 14:19:55 GMT -5
I agree the current environment is not going to last. This is an excellent thread describing the giant paradigm shift that's currently underway. A close relative with a doctorate specializing in drug interaction for geriatrics explains the entire current system for diabetes management is ALL based on the (antiquated) A1c measurement. That's all they've had to go on until now. This means FDA testing, protocols, insurance, incentives, relationships, and basically the entire system of diabetes management all sit on a foundation that is just now starting to crumble. 2018 should be a big year that the new players drive the shift to time-in-range management. Every step in this direction will be good for the future of Afrezza. The current players who profit immensely off the old system aren't going away easily but new data plus the new economic environment now favors takeovers and mergers that should accelerate the shift. Seems like things will not change until ADA changes their guidelines (which are used by most practitioners) to add time in range or fully replace A1c. Another change would be when FDA starts requiring clinical trials for diabetes drugs to include measure of time in range. I don't think there is any indication of either of these yet being in the works. It may be overestimating the speed at which medicine changes to assume these will happen within 2018. It certainly is good the discussions are happening, but the real tipping point won't come without institutional changes such as the two I mention. spiro... totally agree. Too many docs remain on cruise control, doing what they feel comfortable with.
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Post by dreamboatcruise on Jan 10, 2018 16:26:01 GMT -5
All this talk of Dexcom here sent their stock shooting up today
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