Onduo launches its virtual clinic for type 2 diabetes at no cost for BCBS members in GA, SC, and AR; Includes app, coaching, unlimited BGM supplies – February 1, 2018

Onduo, the ~$496 million joint venture between Sanofi and Google’s Verily, recently updated its website (without the fanfare of a press release) to mark the initial launch phase of its “virtual diabetes clinic.” The Onduo for Diabetes app, glucose monitoring supplies, and coaching are available at no cost to South Carolina, Arkansas, and Georgia BCBS beneficiaries with type 2 diabetes (as announced in November 2017 and confirmed yesterday by Verily via email).

Based on Onduo’s updated homepage, How it Works, FAQ, and app store listings (Google Play; App Store preview), we’ve got a better picture of what the program entails – read on for specifics, screenshots, what we know about payers and partners, competitive landscape implications, and our questions. If we hear back from the company, we’ll update this piece.

The launch means Onduo hit its ATTD 2017 timeline to reveal a product in about a year, and also easily meets the debut September 2016 plan to launch a product in ~2-3 years. Great to see this highly anticipated program moving on time, given the bold mission to redefine diabetes care delivery. This pilot is definitely a big deal for both JV partners – it’s a major bet on technology and new business models for Sanofi’s pressured diabetes business (3Q17 sales dropped 14%), and it’s Verily’s first commercialization in diabetes.

Welcome Kit – BGM, Strips, Lancets, CGM for Eligible Patients

All program participants receive a complimentary, beautifully-designed Welcome Kit three-to-five days following registration. Included in the kit are Telecare cellular-enabled BGM (now owned by BioTelemetry), an A1c test kit, lancets, and glucose strips. According to the FAQ, patients can choose to use the new BGM or continue with their existing BGM, though we imagine Onduo would favor the Telcare meter with built-in cellular for more passive upload and no manual entry hassle. Unlimited refills of supplies can be ordered for free through the app, similar to the approach mySugr, One Drop, and Livongo have taken. Certain patients may also be eligible to receive a Dexcom G5 CGM at no additional cost. It’s not clear how Onduo will determine who receives CGM or how long they will wear it – hopefully type 2 participants who have sporadic glucose excursions, don’t check frequently, are on insulin or sulfonylureas, or are switching medications would be at the top of the list. We also expect that, in patients who meet the criteria, CGM won’t necessarily be used all of the time, but intermittently – we’d guess Onduo will deploy CGM vs. BGM as it sees fit in different patients, optimizing outcomes/costs (in line with its risk-based contracting). How to most effectively use CGM, particularly in people with type 2 diabetes not on insulin, is still an area with very little data, and we hope Onduo’s program will yield insights.

• We were particularly impressed with the sleek, user-friendly packaging of the Welcome Kit and Dexcom-branded CGM (screenshots below). These “Googley” design details are absolutely critical in creating delightful experiences for the consumer in order to elevate the chances of activation, the first step toward sustained engagement. It reminds us of what One Drop has done with the packaging for its Chrome BGM/Premium program – very user-friendly – and with the “halo” of a large, very notable company like Verily/Alphabet.

• In the future, we wonder if a simple, disposable blinded professional CGM such as FreeStyle Libre Pro would be included in the Welcome Kit, giving the Onduo care team a strong baseline impression of the person’s glycemic trends in addition to an A1c test. We imagine this would not be allowed by the Dexcom contract but we are not sure. It seems like for many, a professional product to start might be useful to assess diabetes management changed needed (if any) and direction/plans.   

Onduo app, including photo-based meal logging overlaid with glucose data

The Onduo app (“Onduo for Diabetes”; Google Play; App Store preview) leverages data streamed from connected BGM and/or CGM to provide patients with glucose trends following meals (photo logging). A chat interface allows for coach communication. Google Play shows that there have been 100-500 installs so far, but no reviews have yet been posted. In a visibility win for Onduo/Sanofi, the app’s registered developer is actually “Google, Inc.” – whoa.

• We were excited to see that the app includes photo logging for meals – nearly identical to one of our favorite but no-longer-available apps, Meal Memory. Notably, Dexcom hired Meal Memory creator Doug Kantor last year, hopefully meaning the brilliance of photo logging overlaid with CGM data will resurface in some Dexcom product – we aren’t sure if they “purchased” the company. This feature allows users to visualize the glycemic effect of a meal by pairing a photo of the consumed food with the subsequent glucose data (either BGM or CGM trace); the text specifies glucose level before the meal, peak glucose level after the meal, and the change. We are big fans of this approach to food logging, as the capture is fast, intuitive, provides arguably more value than text input, and doesn’t require searching through databases of food and selecting amounts. Though computer vision to recognize what’s on a plate is still lacking (e.g., Calorie Mama AI, LoseIt!), a simple photo capture of the meal paired with glucose data could provide a lot of value for a patient and a coach. Onduo also provides segmented glucose trends: In addition to viewing daily and weekly data, patients can tap on “Insights” and sort their glucose data by meal (e.g. breakfast, lunch, dinner, snack, drink) – the approach harkens a bit to Medtronic/IBM Sugar.IQ’s Glycemic Assist feature. In doing so, users can view how specific food choices impact their glucose levels, photo included!
• Notably, outside of nutrition, the app allows users to communicate with their care team (including sending photos of the meals), inputting exercise (manually or Apple Health), and sharing data with their providers. The App Store description notes integration with Apple Health to import activity data and retrospective glucose data (implying the Dexcom CGM integration is actually a three-hour delayed Apple Health integration). The description also says that the app supports family sharing, such that up to six family members can use the app (presumably to remotely monitor their loved one). We’re not sure if the app can import insulin dose data from Apple Health, but this is an obvious area of expansion for decision support as more smart pens/caps come out – especially given Onduo’s partners Glytec and Voluntis. We’re also not sure if there are feature set differences for Apple and Android customers, as the Google description omits the information about activity, retrospective CGM data, and family sharing.

Onduo Care Team

Each participant is assigned a Care Lead, who can be reached by text and phone (see screenshot above), and has access to a team of lifestyle specialists and CDEs. Care Leads are not necessarily CDEs, and are likely paired with participants based on their biggest areas of need. For example, one Lead featured on the front page is a counselor and exercise scientist, while another is a registered dietician, certified personal trainer, and group fitness instructor. The one featured care specialist is a pharmacist and CDE, though we’re not clear if Onduo’s experts will adjust medications. Few details about the nature and periodicity of coaching interactions were shared, but the FAQ section says that “the Onduo Care Team supplements your current treatment plan and makes sure you have the support you need between doctor visits. You'll get up-to-date personal health information and answers to your questions from our own team of health coaches. You can continue to see your current doctor throughout the year, but Onduo's program can function as your day-to-day support. A key part of Onduo's program is empowering our members to use learnings and tools to build stronger communication with their doctors.” The text messages in the above make it seem like interactions are fairly frequent – “Great job logging your breakfast this morning. Let’s explore some ideas to lower your post-breakfast glucose.” Presumably much of this could be automated; we wonder how Onduo’s personal coaching touch will compare to mySugr, One Drop, Livongo, and Virta.

• How will Onduo communicate and interface with patients’ current HCPs? The nature of the interaction between the Care Team and the traditional health system seems to be one-sided: Onduo receives data from members, their connected devices, and “the healthcare system” (EHRs?), but as we understand it, the only way healthcare providers can receive data generated through Onduo is if the patient chooses to share it. We’d imagine most patients would choose to share data with their HCP, though if not, it does create potential silos between the traditional delivery system and Onduo’s virtual clinic.
• In November, Voluntis and Glytec announced plans to integrate with Onduo in type 2 diabetes pilots beginning in early 2018. Voluntis brings Insulia, its patient-facing, FDA-cleared basal insulin dose titration app, and Glytec offers Glucommander Outpatient, its provider-facing insulin dose titration platform for basal, basal-bolus, and basal combinations. We’re not certain how Onduo intends to deploy these apps: Will they be used in this initial launch phase? Do they integrate directly into the Onduo for Diabetes app, or will they run separately from the Onduo app? Will every insulin-using participant have access to one app or the other? How will Onduo decide who should be assigned which? In both cases, will the Onduo care team or the patient’s own provider configure/use the insulin titration feature?

Participating Payers and New Onduo Partners (AADE, Amwell, Mytonomy)

To qualify for Onduo, patients must have type 2 diabetes, be at least 18 years of age, and be a member of Blue Cross Blue Shield (BCBS) in Arkansas, Georgia, or South Carolina. The company hits its goal of initiating the pilot in 1Q18. Onduo also announced plans in November to begin several pilots in early 2018 “with select US providers and payers,” so it’s likely the company has arranged for reimbursement from plans beyond BCBS in the near future. Onduo is clearly interested in expanding reimbursement – the website includes a pitch to health plans, highlighting value-based contracts. Interested users can enroll here by entering their insurance information.

In addition to previously-disclosed partners Dexcom, Telcare, Voluntis, and Glytec, the Onduo website lists three new-to-us partners: AADE, Amwell, and Mytonomy. Amwell is a telehealth service accessible online and via an app, with coverage for over 80 million people on major plans including UnitedHealthcare, Cigna, Aetna, BCBS, and more. Mytonomy – where former AADE President Dr. Deb Greenwood serves as Chief Digital Research Officer – delivers “micro-learning content” to patients with step-by-step videos, in addition to a provider-facing dashboard with both individual- and population-level statistics. AADE and other diabetes experts have been tapped to ensure that Onduo’s program follows the standards of leading diabetes professionals. We’re not sure if/how Amwell and Mytonomy will be integrated in this initial launch, as there was no mention of them beyond their inclusion in Onduo’s list of partners. AADE and Dexcom were the only partners listed on the front page

• Onduo has not yet announced a connected pen/pump to capture insulin dose data – might such a partnership be in the works? Might an internally-developed technology surface soon? As far as partners go, Common Sensing is a likely candidate, as Sanofi has invested in the Cambridge-based company and is currently involved in a pilot with Innovation Health (Aetna/Inova), Common Sensing, and One Drop. While we’re not sure how enriched the initial Onduo patient cohort is for insulin users, eventually incorporating insulin dose capture seems like a no-brainer, as it could help solidify dose titration and add further context to the photo meal logging feature.

How Does Onduo Fit into the Connected Care/Coaching Competitive Landscape?

Onduo enters a growing landscape of related diabetes care/coaching offerings: Livongo, mySugr, One Drop, Virta, Medtronic’s Turning Point Program Dexcom/UHC, and Glooko. The former three companies all offer unlimited strips, a connected BGM, and some form of coaching, while Virta boasts a “full-stack clinic” (MDs in house) that pairs a ketogenic diet with coaching and medication management. The most directly related program is Medtronic’s under-the-radar Turning Point program, which shared very encouraging data at ATTD 2017 (2% A1c reduction from a 10.1% baseline) – it includes a Bluetooth-enabled BGM, a patient mobile app, a one-on-one health coach, clinical decision support for PCPs, and as-needed iPro2 professional CGM to help patients with uncontrolled diabetes. On the CGM side, Dexcom/UHC’s soon-to-begin 10,000-patient CGM+coaching pilot is definitely in line with Onduo’s approach, which will be interesting to follow from a product choice perspective – how will payers choose between a direct CGM deal with Dexcom vs. contracting with Onduo? Glooko can arguably be grouped in here too – it has a partnership with Fit4D for diabetes coaching and population tracking, though it is not providing the actual glucose monitoring supplies. In short, there is no shortage of competition in this area, an outstanding trend in our view - these connected diabetes management programs should help add clinical value beyond just providing a device, sell a more seamlessly integrated “all-in” package, ease supply reordering, provide support between appointments, and hopefully align incentives in the system (outcomes-based, shared savings, at-risk contracts). 

• At this stage, most companies in this area are pursuing B2B2C models, even if they have a B2C offering. Relative to the companies above, Onduo is newer on this scene, but has major resource advantages: (i) Google’s big data capabilities, consumer experience, and global reach; (ii) Sanofi’s global reach, pharma background, and payer influence; and (iii) ~$496 million in funding! Onduo could really take this connected care/coaching business model and drive payer adoption, assuming it shows outcomes and scalability in these early pilots go.
• How will this connected care market evolve in 2018? Many seeds have now been planted and studies seem to be getting underway – which program(s) can drive the strongest outcomes/costs? With 30 million Americans with diabetes and 84 million with prediabetes (a segment Onduo would be smart to explore), there is room for many companies to be successful. What will be more interesting to watch, in our opinion, is the exchange between all these companies and healthcare system – they are taking some ownership over patients, especially during those gaps in care between traditional care interactions.

Onduo’s Impressive Advisory Board

In perusing Onduo’s Our Team page, we came across a powerhouse list of advisors. It features expertise across the board, from primary care, endocrinology, government, insurance, pharmaceuticals, digital medicine, value-based care, industry, growth-oriented human capital, and more.

• Dr. Robert Gabbay (Chief Medical Officer, SVP, Joslin Diabetes Center). Dr. Gabbay is an extremely respected care provider and thinker in diabetes. We’ve recently covered his talks on value-based care at AADE and outcomes beyond A1c at a diaTribe-hosted meeting in July and have a great deal of respect for the Joslin system’s approach.
• Dr. Sachin Jain (President/CEO, CareMore Health System). Dr. Jain is an extremely highly regarded young leader well known for his Forbes writing and his stint as a senior advisor to the administrator at CMS. He also briefly served as deputy director of the Center for Medicare and Medicaid Innovation. He then served as Merck’s global Chief Medical Information and Innovation Officer from 2012-2015, surely a transformative experience understanding one of the world’s leading healthcare companies, before joining CareMore, an integrated health plan and delivery system headquartered in Los Angeles.
• Mr. Don Jones (Chief Digital Officer, Scripps Translational Science Institute). An mHealth visionary who works closely with digital health guru Dr. Eric Topol and previously led Qualcomm's Wireless Health Global Strategy and Business Development and founded its healthcare division.
• Dr. David Judge (Chief Medical Officer, Beth Israel Deaconess HealthCare). Previously Medical Director at Bulfinch Medical Group and MGH’s Ambulatory Practice of the Future.
• Dr. Samuel Nussbaum (Professor of Clinical Medicine, Washington University School of Medicine). Previously led the Clinical Endocrine Group at MGH, served as an executive at BJC HealthCare, and was Chief Medical Officer for Anthem for 15 years.
• Rachel Pacheco (Chief People Officer, Oxeon Partners). Ms. Pacheco is also President of Oxeon’s Organizational Design Business. Oxeon is a healthcare recruiting firm, also utilized by Omada Health.
• Brian Zelickson (CEO, United Skin Specialists). Dermatologist who has co-founded over eight companies and holds 15 US patents.

Close Concerns’ Questions

Q: What other insurance plans will come online in 2018, if any?

Q: How large is this initial launch? Is it <500 patients? How quickly will it expand?

Q: Does this initial launch include the Voluntis and Glytec basal insulin titration? Are Mytonomy and Amwell (education and telehealth, respectively) included?

Q: How many Care Leads and coaches are currently employed at Onduo? How many patients can each coach take care of?

Q: What is the extent of Onduo’s coaching interactions? How frequently do they happen? How automated are there? How will Onduo’s personal coaches compare to what mySugr, One Drop, Livongo, Virta, Medtronic, and Dexcom/UHC are doing?

Q: How does Onduo decide who gets CGM? How will CGM be used (i.e., full-time vs. intermittent)? How will other software and education be curated?

Q: How does Onduo work with a payer over time – does Onduo take care of a patient indefinitely, or only for a certain period of time? Once outcomes are achieved, does a patient graduate from the Onduo platform or remain in a maintenance state?

Q: Is Onduo paid 100% based on outcomes, shared savings, or is there a per-member-per-month component to cover overhead, etc.? How does the business model compare to what mySugr, One Drop, Livongo, Virta, and Medtronic (Turning Point) are doing?

Q: Is there any interaction between Onduo’s initial launch phase and Verily’s Project Baseline diabetes study, since they sound very similar?

Q: How will providers feel about Onduo taking over some patient care? How do payers feel about it?

Q: Does Onduo have plans to incorporate insulin dose capture?

Q: Is this the future of diabetes care – diabetes companies taking on more and more patient care? If so, what else needs to happen? Will companies start hiring MDs and moving into medication management?

--by Maeve Serino, Brian Levine, Adam Brown, and, Kelly Close