Anyone watching the Twitter feed for the Advanced Technologies and Treatments for Diabetes 2018 conference can’t fail to have noticed that, once again, the answer to the question that wasn’t being asked was “Time in Range” (TIR). You may even have seen the tweet below:
This makes the bold assumption that in 10 or 15 years from now, globally, the T1D population will have access to tools that allow Hba1C to have been deprecated.
What needs to be achieved in order for this to happen?
In a world, where many people with T1D die due to a lack of access to insulin, they would need to be able to afford a form of continuous monitoring and have the ability to store that data somewhere and observe it. Oddly, given the infrastructures in many parts of the world, the latter part of that is probably the easiest to overcome, indeed, with the open source tools provided as NightScout it would be remarkably easy to provide a way to store and capture this data.
The elephant that’s been in the room throughout the discussion on Time in Range is access to the technologies and treatments. For it’s all very well to be able to store data for free, but one, you have to be alive to capture the data and two, you need to have some way of capturing it. Setting aside point one here, the key issue in this discussion is point number two.
How big an issue? Well let’s dig into it shall we?
First up is this tweet from Adam Brown at ATTD, and important to note, the response.
Those are both scary numbers, and both demonstrate very clearly where the issue lies. To put that in context of the 400,000 or so UK Type 1s, it would mean that something like 10,000 of us have CGM (and for the purposes of this discussion, that covers Dexcom, Medtronic, Eversense and Libre), and based on the survey we did last year, more than 50% of those will be Libre.
What’s even more disturbing is the number in the response. In the US, this person would be paying $580 a month to use CGM. That’s £416 at the time of writing. Even using the Dexcom G5 system without a receiver and according to the manufacturer’s specifications, in the UK, we pay (without any discounts) £266 a month. Neither of these numbers is great and shows a damning indictment of this person’s insurance.
So, we’re at £266 per month in the UK if used in accordance with the manufacturer’s instructions. And bearing in mind that the UK is a member of the G7, making it one of the richest countries in the world, that £266 per month is still a significant proportion of the median income.
How much? According to the Office of National Statistics, in its Annual Survey of Hours and Earnings, the median weekly wage in the UK is £550. That’s £2,383 per month before tax. Taking 20% as the average tax rate at this level, you’re talking about a take home pay of £1,900. Putting that £266 into context, it amounts to 14% of the median wage. What about Libre? When funded personally, that would be roughly £100 per month. That’s still 5.25% of the median.
To put that in context, wages are spent, on average, as shown below:
Bearing in mind that these are averages and not median numbers, at £61.54 a week, Dexcom would account for 11% of an average weekly wage while Libre would be 4.5%. It’s also worth bearing in mind that the numbers shown do not include various taxes and interest.
It’s therefore relatively easy to assess that for a majority of the population, CGM in whatever form, is shown to be relatively expensive on a personal payment basis, and out of the reach of the majority.
So what about getting the National Health Service to pay for it? Well, as Partha says in his blog after being at Vienna, just for those with Hypoglycaemia unawareness (where Flash is not appropriate), that’s a cost of £150m a year. He puts that in the context that the total additional budget received for Diabetes interventions across T1 and T2 was £42m. In order to fund Time in Range then, either the individual has to pony up, or the healthcare service, in whatever form it takes, has to do the same thing. And to do so involves taking the money from one service or luxury and giving it to another.
If Time in Range is truly to replace the Hba1C as a measure of long term management of Glucose, as it stands at the moment, someone is going to get very rich. For now then, that’s the elephant in the room.
How can Time in Range become the gold standard?
The NHS has form in relation to self monitoring. Whilst blood glucose testing was expensive in the eighties, it didn’t offer it, until the prices came down. Likewise, it has negotiated the cost of the Libre down to par with the most expensive blood glucose testing strips. Even with that, you still need glucose testing for various reasons, so guidance is required as to who qualifies, and CCGs are still reticent to allow prescription.
It’s very simple really. Just like Insulin, CGM is too expensive. But while insulin saves lives, CGM, in most cases, doesn’t. And in addition, various “interesting” regulatory requirements for the use of CGM make it something that some people don’t want to use, and of course there will always be those who can’t.
Given that sensing technology is the key to the technological solutions coming forth, right now, that cost is a significant blocker, not only to Time in Range, but also to the uptake of Artificial Pancreas systems.
And that’s really where we sit. In order for the discussion at ATTD to move into the mainstream, the technology has to come down in price. What does this mean for manufacturers? It means that they need to change their view.
Instead of selling their products as “Gucci”, they need to be “Gap”. We get that it’s not cheap to develop the products, but if, instead of having a consumer base of 3% of the global T1D population, you had 40% of the population, that £266 per month could become a lot lower. And that’s when we’re talking something big.
If it cost significantly less than self monitoring of blood glucose with test strips, it would be much easier for insurers and healthcare systems to offer.
Like all these things, that’s where it needs to start. The trick is how that’s made to happen. Over to you, Dexcom, Medtronic, Eversense, Abbott and the start-ups. What are you doing to make this uptake happen?