David Panzirer is fed up with the healthcare system in America, and he has an idea for a fix -- specific to people with diabetes.

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This D-Dad with two T1D children (Morgan, diagnosed with type 1 diabetes in 2007 at six years old; and Caroline, diagnosed 1.5 years ago and now aged 15) sees widespread access and use of CGM (continuous glucose monitoring) technology as the key to a new standard of care. He’s so passionate about that belief that he’s envisioned a “Diabetes Geek Squad” that would in some ways function like the popular tech support program offered by retail chain Best Buy. But in this version, it would be an entity that primary care physicians could refer their insulin-using patients to for help getting started and using the latest diabetes devices.

It’s a simple idea at the core: the Diabetes Geek Squad would teach both patients and primary care physicians about the various CGMs on the market, broker CGM prescriptions in some cases, send a CGM system directly to a patient’s home, walk the patient through how to apply the sensor and use the app, and help them with data interpretation.

Now, after two years of brainstorming, market research, and assessments, the program is making its way towards a reality.

Not surprisingly, this initiative is backed by The Leona M. and Harry B. Helmsley Charitable Trust -- the $6 billion fund that Panzirer is a trustee for -- given that he is Leona Helmsley’s grandson. Through the years he's helped fund many different diabetes programs as part of the Trust’s mission to support global health initiatives. Alongside Panzirer in this initiative is Sean Sullivan, who serves as Program Officer for Type 1 Diabetes at the Helmsley Trust. We recently talked with both about their vision and the program’s current status.

 

CGM as the Future of Diabetes Care

If Panzirer is right and CGM is the future of diabetes care, replacing fingerstick tests much like fingerstick tests once replaced urine strips, two of the largest obstacles to widespread usage are location and access. The question has always lingered over our healthcare system: why are the most effective and up-to-date tools, like CGM, often treated as "a luxury item" by our healthcare system, that remain painfully out of reach of so many?

“What has become very clear to us, is that right now geography absolutely plays a role in what your outcome is going to be with diabetes, as well as your access to specialty care and devices like CGMs," Panzirer says, noting that stats show more than 90% of CGM Rxs currently come from specialty clinics. “If you live in rural America, you're not getting access to the best care unless you advocate for it.”

This access issue is what Panzirer and Sullivan hope to address, because they only see it getting worse in the near future.

“We have a tsunami of insulin-using type 2s that are coming down the pike over the next decade or so, and I would argue that our healthcare system is ill-equipped to deal with this. Primary care physicians don't know how to titrate insulin. Sometimes they don't want to prescribe insulin," Panzirer says. "I just think that if we don't do something drastically different, our healthcare system is going to collapse. Maybe that's dramatic, but that's what I believe. I also believe that your geography shouldn't dictate your health outcomes.”

Enter the Geek Squad as a way to combat these issues of exclusivity and access.

 

A "Diabetes Geek Squad" to the Rescue

“We were kicking around a bunch of ideas and came up with a Geek Squad-type concept,” Panzirer said. “We think it should be able to do a number of things similar to what Best Buy's Geek Squad does, and it’s our goal that the Geek Squad – it'll be called something else, but everyone understands what we're talking about right now when we use the term  'Geek Squad' – will teach people about all the different CGMs out there and give primary care physicians, as well as people living in rural America, a place to refer their patients to.

The diabetes Geek Squad will actually take shape as a virtual specialty clinic. Primary care physicians will be able to refer their patients to here for help setting up and using their CGMs. And patients who are going it more on their own could also reach out to the Geek Squad for help and support via phone on web connections. Ultimately, the vision is to move beyond just support, and become a more fully-integrated virtual clinic that includes clinicians capable of writing prescriptions and fighting the lack of access to CGM systems in rural America.

“The person with diabetes, regardless of where they live, can receive the same quality care that someone hopes for at a specialty clinic,” Panzirer says. “The facts are simple: CGM reduces severe events by about 40 percent, as well as reducing A1Cs.”

“We’re not trying to be cool or hip, we’re trying to change healthcare,” he added.

He envisions this working simply: if a patient came in to the Geek Squad and said “I want a CGM,” the clinician would do everything from there – writing the Rx, dealing with the insurance company, having the CGM manufacturer ship the product to the patient’s home, and then teaching that patient virtually how to put on and use the device.

Panzirer sees the program as a win-win for all the involved parties: PWDs who don’t already have access to this tech or to local clinics staffed with CDEs and endos will get access to a higher level quality care. Doctors will be able to help more patients, more efficiently. Payers get better outcomes that cost the system less money. And the CGM manufacturers get to tap rural America, a market they're not yet penetrating sufficiently.

Panzirer says they have spoken to the big CGM makers -- Dexcom, Medtronic and Abbott -- and all have expressed willingness to have a conversation about how the Geek Squad concept could expand the use of their products.

 

Testing the "Geek Squad" with Patients

A small-scale pilot study is already underway, that involves roughly 30 people and is focused on working out the logistics as opposed to measuring its efficacy. This pilot study is being conducted through the Jaeb Center for Health Research, a independent non-profit that coordinates multi-center clinical trials and epidemiologic research. Cecelia Health (formerly Fit4D) has also been subcontracted to deliver the virtual clinic services in the study.

Importantly, Cecelia Health has an army of certified diabetes educators (CDEs) on staff, which Panzirer says is a critical factor because they are on the front lines of diabetes care, and really this concept can’t work without them. While details are being hammered out, Cecilia Health doesn’t yet have the Rx-writing capability they would need. That will be added soon, along with an algorithm for decision-support and mental health treatment options, for what Panzirer describes as “a more robust virtual clinic.”

The protocol for the pilot study was co-written and reviewed by a health insurance company, because Panzirer says they wanted that payer perspective included in the process -- the key to assuring that payers will be willing to cover this type of service going forward.

This first small-scale study will last only three months, meaning people will only be on the CGM for that amount of time, so it won't be able to fully evaluate primary outcomes and "adherence" over time. But next up will be a much larger ~200-person study planned for late 2019 or early 2020, where the focus will move from logistics to analyzing meaningful treatment outcomes.

After the larger study, assuming all the necessary components for script writing and mental health support have been added, the idea would be that Cecilia Health could commercialize the concept.

 

Combating "White Coat Syndrome"

Of course, there are still challenges and hurdles in getting this off the ground.

Perhaps the biggest impediment is the “white coat syndrome,” a push-back by patients that still happens, particularly in rural communities, against medical advice or care that does not come from a traditional doctor.

“It turns out, at least from the preliminary market research we’ve seen, that (patients) want the blessing of the primary care physician,” Panzirer says. “That means we have to go in, appeal to, teach, and train the primary care physician about CGM, trying to get them to realize this is the best thing they can do for people with diabetes. That's probably the toughest piece.”

Other basic questions remain, as well:

  • logistics of getting prescriptions to patients
  • convincing insurance (i.e. payers) to cover the services
  • navigating issues across state lines 

The hope, Panzirer and Sullivan say, is to solve those issues during the first two studies. The model has clear benefits and incentives for all the players involved, they believe.

“I think the problem with a lot of diabetes is that we are victims of listening to the vocal minority,” Panzirer says. “We don't really get the voice of the large amount of people who are living in rural America. They've been listening to ‘A cure's coming in five years!’ for 20 years now. Maybe they even tried one of the first CGMs. Let's face it, those things sucked. They hurt, they weren't accurate. These devices are ready for prime time now and in my opinion, they really hold the keys to being able to get better outcomes for people living with diabetes.”

Here's to hoping a new Geek Squad can help change the game!