Memorandum

Livongo adds Abbott’s FreeStyle Libre Pro to its coaching platform for people with diabetes – September 5, 2018

Executive Highlights

  • Livongo announced today that it will offer Abbott’s 14-day, blinded FreeStyle Libre Pro professional CGM to its members with diabetes, where “appropriate and prescribed.” Members will receive their Ambulatory Glucose Profile (AGP) and can request to share it with their HCPs. Livongo CDEs will also have access to their patients’ AGPs.

  • Livongo management shared via email that FreeStyle Libre Pro will be initially provided at select onsite clinics associated with certain Livongo employer clients. It’s therefore likely to be a slow and limited launch, available at first only to very large employers. Livongo will collaborate with these onsite clinicians to recommend candidates for CGM. From the press release and our email correspondence with Livongo management, the FreeStyle Libre Pro will be made available only to patients with diabetes, excluding those with prediabetes enrolled in the Livongo DPP powered by Retrofit. It’s possible, however, that such an expansion is in the pipeline.

  • Per Livongo management, FreeStyle Libre Pro will be offered both through members’ own health plans and as part of a Livongo bundle. We’re unsure how an option is selected and to what extent either might impact out-of-pocket patient expenditures. See below for a full list of questions we’ve sent Livongo, with several dedicated to reimbursement and pricing. We’ve since updated this piece with the company’s response, although a few questions remain.

  • This exciting news represents a potential first step towards Livongo becoming a curator for an assortment of devices, therapies, and services, not to mention a clear move to compete with offerings like Glooko. Livongo joins Onduo as the only digital coaching offering prepared to jump into the realm of CGM prescription and reimbursement (Onduo’s virtual clinic provides the Dexcom G5 to certain eligible patients). It’s very encouraging to see a growing focus on bringing sensors and coaching to people with diabetes, and we look forward to seeing how Livongo continues to expand and push the field forward.

    Livongo announced today a non-exclusive partnership to provide Abbott’s 14-day, blinded FreeStyle Libre Pro professional CGM to its members with diabetes, where “appropriate and prescribed.” Per the press release, members will receive their Ambulatory Glucose Profile (AGP) and can request to share it with their HCPs. Livongo CDEs will also have access to their patients’ AGPs; we can’t begin to imagine how excited these coaches will be to have a more complete picture of their members’ 24/7 glucose! Livongo CDEs will receive the same instructions and support as do other healthcare providers applying the FreeStyle Libre Pro. Notably, Abbott Diabetes Care SVP Mr. Jared Watkin was quoted in the Livongo press release, a very positive sign indicating that Livongo likely has the support of and access to Abbott’s technical teams, as well as underscoring Abbott’s enthusiasm for this partnership (and probably more to come).  

    Livongo management shared via email that FreeStyle Libre Pro will be initially offered at select onsite clinics associated with certain Livongo employer clients (of which Livongo had >350 in April). To us, this makes it sound as if the roll out of Libre Pro in Livongo offerings will at first be slow and limited to very large employers (i.e., those with onsite clinics). Livongo will identify CGM candidates using real-time data in collaboration with these onsite clinicians, who will then prescribe Libre Pro. Livongo has not, to our knowledge, released the criteria to be used for this selection process (A1c? Hypoglycemia? Medications? SMBG frequency? Payer coverage?). From the press release and subsequent follow-up with Livongo management, the FreeStyle Libre Pro will be reserved only for patients with diabetes, excluding Livongo’s members with prediabetes enrolled in the Livongo DPP powered by Retrofit (though use in the DPP could well be on the roadmap).

    Per Livongo management, FreeStyle Libre Pro will be offered both through members’ own health plans and as part of a Livongo bundle. It’s unclear how an option is selected, whether the bundle will only be offered in Livongo’s direct-to-consumer subscription model, and what impact both approaches will have on out-of-pocket patient expenditures. This dual approach raises several questions: Will Livongo/Abbott be paid for outcomes based off of CGM data (i.e., improvements in AGPs at six months relative to baseline)? Will Livongo receive any reimbursement for the FreeStyle Libre Pro if it is offered entirely through the members’ own health plan, or simply receive its data? How might the new Livongo bundle with the FreeStyle Libre Pro be priced? In the bundle, will Abbott grant Livongo a discount on FreeStyle Libre Pro systems? 

    Adding professional CGM may represent a first step towards Livongo becoming a curator for an assortment of devices, therapies, and services, as it means that the company is now willing and prepared to interact with HCPs to orchestrate prescribing activity. The implication is that we may soon see Livongo striving to interface with the healthcare system to recommend prescription of connected pens, pumps, AID systems, other sensors, and possibly various medications. Livongo could also eventually build an internal team of doctors to prescribe tools and therapies absent traditional healthcare routes.

    With this announcement, Livongo positions itself on the leading edge of a wave that began with cellular/Bluetooth BGMs, then added remote coaching, and is now incorporating continuous glucose data. Although the digital diabetes coaching space is growing increasingly crowded, Livongo is the only offering in addition to Onduo that is involved in the prescription and reimbursement of CGM. As a reminder, the ~$496 million Sanofi-Verily joint venture Onduo announced the limited launched of its virtual clinic for people with type 2 diabetes in February and provides certain eligible patients with a Dexcom G5 at no additional cost. Similar to Livongo’s inclusion of FreeStyle Libre Pro, it’s not clear how Onduo will determine who receives CGM or how long patients will wear CGM. Still, it’s very encouraging to see a growing focus on bringing sensors and coaching to people with diabetes in innovative ways. Onduo and Livongo are likely turning up the pressure for competitors like Glooko, One Drop, and mySugr, which incorporate CGM data, but refrain from becoming involved with the process of acquiring CGM.

    • Per the press release, a healthcare professional must apply the FreeStyle Libre Pro sensor to the Livongo member’s arm, suggesting that the device will not be shipped directly to patients, but rather to participating clinics. Indeed, Livongo management confirmed that Abbott will ship the FreeStyle Libre Pro sensor directly to clinics for Livongo users. Although in this initial rollout clinicians will start FreeStyle Libre Pros with a reader, the remote coaching of Livongo plus the FreeStyle Libre Pro’s ease of use also opens the low-friction possibility for members to receive a sensor in the mail and then send it back to Livongo to harvest the data. Might Livongo eventually consider moving towards this more direct approach?

    • Professional CGM data could be immensely valuable for identifying population-level insights. While the press release notes that CGM data will be made available to patients, coaches, and (if requested) providers, it will be interesting to see whether participating health systems and insurance plans, not to mention Livongo partners (such as Lilly) will also be provided with the data. Livongo management emphasized that Livongo will not share data unless authorized to do so by Livongo members.

      • While we would love to see real-time, personal CGM eventually included in Livongo’s platform for certain patients, we think there are so many valuable insights that can be enabled by professional CGM. In fact, a particularly compelling oral presentation at ADA found an interim intervention technique (IIT) using the FreeStyle Libre Pro in India to drive significant patient outcomes after just one session of wear. Moreover, Livongo members who use the FreeStyle Libre Pro will hopefully recognize the benefits of CGM and may be more willing to discuss transitioning to a personal CGM with their provider.

    • Livongo is making increasing strides to become a more device agnostic platform, while also expanding into holistic chronic disease management. In addition to offering its own cellular-enabled BGM, last September Livongo acquired Diabeto, a startup offering a small, plug-in device that provides Bluetooth connectivity to over 40 non-connected BGMs, immediately making Livongo’s service more attractive to patients who want to stick with their current meter. Moreover, Livongo has leapt into diabetes prevention with its new Livongo DPP powered by Retrofit, launched a hypertension service in January, and has plans to develop a program for dyslipidemia by the end of 2018.

    Close Concerns Questions

    What are the financial terms of Livongo’s agreement with Abbott? Will Livongo or Abbott be paid for outcomes?

    How (if at all) will Livongo be reimbursed for situations in which the FreeStyle Libre Pro is provided through the Livongo members’ own health plan? How will Livongo price bundles in which the FreeStyle Libre Pro is included?

    Who will have access to FreeStyle Libre Pro data in addition to patients, coaches, and providers? Will participating health plans and systems have access? Will Abbott have access? Will other Livongo partners (e.g., Lilly) have access? [Livongo will only share data if authorized to do so by Livongo members.]

    What criteria will Livongo use in selecting candidates for the FreeStyle Libre Pro? Will Livongo eventually include the FreeStyle Libre Pro as an option for those with prediabetes?

    How frequently will Livongo members be able to use the FreeStyle Libre Pro?

    How large will the initial launch be? How quickly might it expand?

    Might this move be a first step towards eventually offering the real-time, consumer FreeStyle Libre to Livongo members?

    Might Livongo add additional CGMs - professional or personal - in the future?

     

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