Memorandum

Livongo to roll out medication incentives program and voice-/cellular-enabled blood pressure monitor in 2019 – October 30, 2018

Executive Highlights
  • In 2019, Livongo will release a medication incentives program: members who check blood glucose or blood pressure with a minimum frequency will have their co-pays waived at the pharmacy for diabetes medications (and eventually hypertension medications). We love this idea! Livongo told us medication coverage is determined for each client/partner individually, so it’s unclear which medications are frequently included (e.g., insulin? GLP-1s? SGLT-2s?) and what the minimum frequency is for blood glucose checking.

  • Livongo will also launch a cellular-enabled blood pressure monitor with two-way voice capability in 2019. Users will be able to provide contextual information around their blood pressure reading through speech, and the monitor will give tailored insights and recommendations on how to keep blood pressure readings in range (e.g., “try this deep breathing exercise”).

  • Newly-announced data partner MediSafe offers a manual logging app that reminds patients when it is time to take their medications and tracks overall medication-taking behavior (doses, timing, etc.). This input will be a nice addition to Livongo’s existing data partnerships with the likes of Abbott and Lilly.

  • Livongo now has >100,000 users, up from >75,000 in April. The company boasts >600 clients, mostly self-insured employers.

This morning, Livongo announced two new products that will roll out in 2019: (i) pharmacy co-pay waivers for meeting self-monitoring behavior thresholds; and (ii) a voice- and cellular-enabled blood pressure monitoring system.

These products come in tandem with the company’s newly announce “category of technologies and capabilities, Applied Health Signals,” which aims to aggregate data and deploy actionable insight and support in a timely manner – “Applied Health Signals” and the underlying “AI+AI” (Aggregate, Interpret, Apply, and Iterate) whitepaper can be downloaded here. We note there are a lot of buzzwords here and we look forward to better understanding what the actual messages/insights are. Read more below from our call with the Chief Product Officer Amar Kendale.

Notably, Livongo now has >100,000 users and >600 clients, up from >75,000 users in April.

Medication Incentives Program

  • Through this program, eligible Livongo members who check blood glucose or blood pressure a minimum number of times in a given month can have their co-pays automatically waived at the pharmacy. For example, a patient can receive blood pressure medication for free for checking blood pressure once a week. We’re not sure what the BGM frequency target is. The program was developed in close consultation with payers and PBMs, many of which plan to eliminate eligible members’ co-pays completely for diabetes drugs initially, with those for hypertension on the roadmap. We’re not sure if more expensive branded diabetes medications are covered, such as insulin, GLP-1s, and SGLT-2s; presumably doing this for generics like metformin is easy. Livongo will also use the clinical, pharmacy, behavioral, and biometric data it collects to flag opportunities for pharmacists or healthcare providers to optimize medication – this could take the form of moving a patient from a branded to a generic to save cost, consolidating prescriptions, (de-)intensifying medication doses, or even suggesting a medication home delivery program. This model is a clear win-win-win for all parties involved: Livongo can aggregate more data from more people to better tailor insights and interventions, thereby driving better outcomes; payers could see greater medication and self-monitoring adherence from their beneficiaries; and members will benefit financially when they meet the minimum threshold for testing.

    • At launch, blood glucose and blood pressure testing thresholds for earning waived co-pays – a “minimum dose of Livongo” – will be uniform across Livongo’s population. However, Chief Product Officer Mr. Amar Kendale told us that the company will eventually head in the direction of personalized testing goals. We love this approach and hope it motivates a wide spectrum of people, especially those who are less engaged – could it move the needle on those not taking their meds and not getting enough data? In the worst case, there is risk of a positive feedback loop where already-healthy people are the only ones rewarded – e.g., those who were already checking BG sufficiently (and likely taking their medications) would earn co-pay waivers and continue to take their medications. With gamification in its relative infancy in the clinical diabetes sphere, we hope to hear frequent reporting of outcomes from Livongo and other companies’ (notably Medtronic with Inner Circle for 670G and Guardian Connect CGM) experiments with incentives.

Voice- and Cellular-Enabled Blood Pressure Monitor

  • Livongo has built voice technology directly into its cellular-enabled blood pressure monitor, enabling two-way voice communication. Mr. Kendale noted that the voice modality is “quickly gathering momentum across Livongo’s member base, and especially among seniors,” who may have more difficulty making out words on the monitor’s display. The device allows users to provide context around a given reading (e.g., pre- or post-meal) and returns feedback and in-the-moment nudges. If a blood pressure reading comes back out of range, the device may say, “We noticed that your blood pressure is elevated. We recommend that you perform a deep breathing exercise. Would you like us to send you an email/text that connects you to this service?” (Livongo takes note of and acts through the user’s communication preferences). Nice! It may also give specific, individualized comments such as “try eating less red meat” or “try walking after a meal.” If the reading is in-range, the monitor would likely give other tips on sustaining good health, such as “It looks like it’s time to refill your medications. Would you like a link to our pharmacist’s phone number?” We love the convenience here and the holistic focus – not just pattern recognition but thinking about stress and pharmacy hassles. We’re hoping this approach also praises patients for positive trends (Bright Spots!) in either engagement or blood pressure. Mr. Kendale emphasized that the feedback is hyper-personalized down to the recommended action and how likely the member is to follow through with it.

  • Livongo’s hypertension product was fully released onto the market just last month; notably, Omada and Welldoc are also moving in the direction of hypertension management. We heard early information and metrics on Livongo’s offering from Mr. Kendale during a center stage session at Health 2.0.

  • Mr. Kendale chuckled and responded, “Stay tuned,” when we asked if we may one day see a voice-enabled Livongo blood glucose meter. To our knowledge, only Prodigy makes a voice-enabled meter on the market (it only speaks, doesn’t “listen”), and One Drop integrates with Amazon Alexa and Siri, but Livongo’s would be the first to our knowledge to have two-way voice built in to the cellular meter.

Data Partners

  • CMO Dr. Jennifer Schneider said in the press release that Livongo aggregates health data from >20 partners, including new partner MediSafe. MediSafe’s patient-facing app focuses on manually logging meds, reminds users when it is time to take medications, gives helpful notes like “take with food,” allows caregivers to be alerted when doses are missed, and lets the user send monthly medication progress reports to providers. On the backend, it keeps track of medication-taking behavior for the patient, provider, and in this case Livongo. The app has 4.5 million registered users worldwide, with 4.6/5 stars from ~170,000 reviewers on Google Play and 4.7/5 stars from ~17,000 reviewers on the App Store – very impressive. We’re not entirely sure how the integration works logistically, but we imagine Livongo coaches or the app recommends that members download the MediSafe app and then shuttles medication information over to Livongo via an API or some kind of cloud sharing. Having this critical data related to which members are successfully taking doses and when could greatly inform future interventions.

  • Livongo’s existing data partners include Abbott (FreeStyle Libre Pro) and Lilly (real-world research on outcomes of diabetes interventions). Livongo also pulls in medical and pharmacy claims data, Fitbit exercise data, as well as information from Apple Health and Google Fit. Moving forward, the company says that it is (i) developing an “Applied Health Signals marketplace” through which it can offer third-party applications, perhaps like Voluntis or Glytec insulin titration (both partnerships are already in place); (ii) aggregating new data from partner devices and APIs; (iii) collecting new data inputs such as that related to transportation, weather, behavioral health, and respiratory conditions; and (iv) building out new application modalities like smart speaker integrations.

Close Concerns’ Questions

Q: What medications are typically covered in the copay program? What are the BP/BGM thresholds for qualifying for the program? How much could these financial incentives further drive outcomes, especially if the copays are high (i.e., a big discount with Livongo)?

Q: How challenging is the business model with copay incentives and who compensates whom – e.g., does Livongo pay the PBM? Pharma? The insurance company? What kind of deals have been struck and what are the terms?

Q: How much uptake will Livongo’s cellular blood pressure monitoring see? Will the combination with BGM offer synergy for driving outcomes in type 2? How much additional data could this give Livongo to drive outcomes?

Q: What are the coolest examples of Livongo’s new actionable insights and data aggregation? Where does Livongo stand relative to its competitors on this?

Q: Will we see more diabetes technology companies venturing into medication incentives/management, especially for type 2s not on insulin? Will we see this in CGM?

 

 

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