
The Sad State of Diabetes Technology in 2012 - dennisgorelik
http://www.hanselman.com/blog/TheSadStateOfDiabetesTechnologyIn2012.aspx
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johnnyg
The CPAP industry is as bad or worse. Here are the drivers I see:

1\. FDA -> Medicare -> Private Insurance. They set the reimbursement codes and
what each code will pay. On the internet, you throw up a website and the
_customer_ decides if your approach has value. With a pay per code system,
anything outside of the sanctioned approach is either puts you at legal risk
("you aren't allowed to do this, it is not sanctioned") or financial risk
("thanks for the better way, but it disrupts money flow X in the system, so
we're not giving you a reimbursement code").

2\. The "Insurance is better" customer bias. The average consumer of
healthcare expects to show up, slap their insurance card down and receive
treatment. This abstracts them from being the direct payment entity of the
services they provide. If you piss off the patient but provide the service to
code, then the insurance company will pay. If you please the customer but go
outside the payment structure, the insurance will not pay. Businesses get
paid.

3\. Regulatory and bureaucratic haze. Go to a CPAP trade show some time, it is
a different world. No one is focused on improving technology and services for
the CPAP user. They want to get together and lobby to prevent reimbursement
cuts. They want to make sure the business they run stays good with the new
regulations and can survive the next wave of audits. They do not shop machines
to find what works for the patients, they have too many other stakeholders to
please: referring physicians, insurance payors, what their front lines people
have experience setting up. They are an extension of a giant that has far more
control and say about their own business than they do. They fight back or buck
the trend, they are literally audited out of business or worse.

4\. Talent Deficit. There are very few places to innovate and if you find a
line and do it, you have to fight the system hating you for doing it on top of
the normal startup pains. It takes very special people to want to walk that
road with you. For the bigs in the industry, mfgs and large insurance based
sellers of equipment, their HR departments are hiring for technical positions
based on resume check boxes and history with microsoft. The products they put
out are heavily windows, heavily compliant, fearful of making waves with any
stake holder. You can't build a better one and win because you won't get paid
and don't have a network to leverage. People who could come in and really make
bold moves get on the ground, see the reality and leave to do something
easier.

~~~
Aaronontheweb
"2. The "Insurance is better" customer bias. The average consumer of
healthcare expects to show up, slap their insurance card down and receive
treatment. This abstracts them from being the direct payment entity of the
services they provide. If you piss off the patient but provide the service to
code, then the insurance company will pay. If you please the customer but go
outside the payment structure, the insurance will not pay. Businesses get
paid."

THIS. Combine this with the fact that most consumers receive insurance through
their employer (and expect this too) further abstracts them from being the
payment entity.

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pimeys
I've had Diabetes since I was eleven years old. For the last seventeen years.
To be in good health, every day I have to:

* Measure my blood sugar at least six times a day

* Take at least six shots of insulin

* Always think what I eat. How many grams of carbohydrates is in the stuff I put into my mouth.

* I have to be very careful with alcohol. I've once woken up by an emergency crew while having a hangover. Never again. (Weed is much better though.)

* I have lots of small annoyances which require medical care every now and then.

* Influenza is a catastrophe - it will take ages and my blood glucose is not going normal easily.

Try to forget any of these, and _bam_ your general health is at risk. It's not
so easy all the time to be fully with your body and take care of yourself.

What I would love is a bloodless way of measuring my glucose, a way to get the
results to my iPhone and a way to calculate the amount of carbohydrates I have
in front of me. No, a database of different foods is not enough. I have to do
it 4-5 times a day, remember.

When you have to do something many times a day for the rest of your life, it
should be as easy as possible.

~~~
shanselman
Have you thought about a pump (no shots, more accuracy) and a DexCom CGM (only
finger stick a few times a day, pretty accurate). I complain in the post but I
will say this, of you're serious about staying alive, you MUST get an Insulin
Pump.

~~~
pimeys
I've always thought the pump is not for me. It seems to be pretty big and you
always have to carry around it with you. My life is still pretty fast paced
and sometimes that kind of machinery is just an annoyance to get along with.
The shots are not the problem, the everyday need of full control of your life
is.

~~~
shanselman
It's smaller than the phone you already carry around. It's mathmatically and
demonstrably superior to shots. They have integrated CGMs now. Ask around, the
folks with the fastest paced lives (diabetic Olympians, marathoners, world
travelers, etc) ALL have pumps.

Unless you have a 6% HA1C on shots, get a pump and live decades longer.

~~~
LocalPCGuy
My wife is Type 1, and was on the pump but went off of it after about a year.
Says she feels in more control without it, and that it gave her a false sense
of "security." And she has had better results since, and more stable sugars.

I don't know, obviously, not being diabetic myself, but I will say she went on
the pump really soon after being diagnosed and didn't really have a chance to
establish a routine first, and that probably played a large part in her doing
better on shots right now. I've been encouraging her to start thinking about
using the pump again, as I do feel that, used correctly, as I believe it is a
better method, but she has to do what she feels works best for her.

Being a developer myself, the idea that she has to use a custom cable and
custom software to manage the data she has in her meter drives me a bit nuts.
But the meter industry is, IMO, full of companies that don't really want to
help users, they just want to get rich off of diabetics. I know thats a bit
cynical, and I'm sure there are companies that sincerely care as well, but
it's how I often feel about the meter industry.

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MrFoof
>Now I wait 5 seconds but we still have blood sugar strips with +-20% accuracy

This is the part that still both sickens and baffles me. I had onset at about
20, despite not looking like a typical diabetic (5-foot-8, 140lbs). 11-years
ago, my endocrinologist made sure to drill into my head this margin of error,
and that the margin of error was highest in situations where I would be
hypoglycemic or suffering from an insulin reaction. As a diabetic himself (and
for the record, having a diabetic endocrinologist is the best thing you can
hope for), he was all too aware and frustrated with the limitations.

Now, a few days ago it was pointed out that the margin of error for test
strips in a medical facility is much lower. The one thing I've been waiting
for is to get that level of accuracy. If there's one thing I want, it's that.
More than anything. I couldn't give a rat's ass about anything else.

Getting that number consistent could've sped up the timeline in which it took
to get my blood sugar levels to be consistent. I'm not terribly methodical,
but at the end of the day my endocrinologist doesn't complain when my HA1C
results are consistently between 6.2 and 6.6, and have been for the past 6
years, despite relying only on subcutaneous injections(1) and continued
dietary changes and experimentation. However, I bet I could keep it at 6 on
the nose -- while "cheating" a bit more -- if I knew that a reading was nearly
dead-nuts on every time.

(1) Not a fan of pumps. My mother was and still is on TPN. After seeing the
joys of dealing with infections, I prefer the very rare dermatitis.

~~~
ssorc
A major reason why the accuracy on blood sugar strips is +/- 20% is because
that is all that the standard (ISO 15197:2003) requires:

* Within ±0.83 mmol/L of lab results at concentrations of under 4.2 mmol/L

* Within ±20% of lab results at 4.2 mmol/L or more

Companies are juggling cost, reliability and performance/accuracy, with the
first two generally winning in the marketplace as key selling points.

Some devices offer significantly better accuracy than 20%, depending on the
market that you are in (not all are for sale in USA, IIRC).

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ck2
The industry will never let you get off strips because the strips cost a penny
or two to make but sell for $1 each.

So they make millions off insurance for the strips at the expense of society
and the people who cannot get insurance.

If they ever invented a $100 device that doesn't need strips they would
completely destroy the crazy profit they have.

The article didn't mention the Contour USB which is completely digital but of
course still needs strips.

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joeconway
This is a very well articulated representation of the frustration I feel as a
technically minded T1 diabetic. Thank you. I dream of the day when both my
meter and insulin pen transmit data in an open format over bluetooth. It is
clear that any steps that can make the monitoring and analysis of diabetic
care more transparent to users will genuinely save lives.

For anyone who is disinclined to get a pump, I highly recommend the Bayer
Contour USB. I've had it for a week and it is _leagues_ better than anything
else I've used. I was so thrilled when I discovered that with it I could
simply access my readings as an SQLite DB rather than the hell of trying to
communicate with and parse the data from anything from Lifescan over a bloody
3.5mm serial port.

~~~
dennisgorelik
If sugar level meter and insulin pen start transmitting data in an open format
- would non-technical diabetics be able to use it?

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brudgers
> _"I've been diabetic for almost two decades"_

I'd say that is more compelling evidence that the state of technology is good.
Lack of bluetooth may be somewhat inconvenient, but it is not life
threatening...and the lack of bluetooth is less inconvenient than dialysis
several times a week.

I'm not unsympathetic toward the author's medical condition, but proprietary
interfaces are even part and parcel of devices as successful as the iPhone,
and it's hard to see a strong medical case for adding bluetooth to a medical
device...sometimes hardwiring is just a better solution for life critical
applications.

~~~
shanselman
Sure, I hear what you saying but even a crappy diabetic on shots live two
decades. The tech hasn't kept me alive, diet and excercise has. Saying the
current state of tech must be good because I'm alive doesn't hold, I'm afraid.

I'm concerned with quality of life and convenience. As the other commenter
said, if it's something you are doing 10 times a day, thousands of times a
year, you want it to be convenient.

Diabetes wears on you. It's the incessant nature of it that hurts.

~~~
brudgers
I look at the devices and think of the HP12B calculator or 37 Signals.
Sometimes, a piece of hardware is just suitable for its purpose. Sometimes,
less features is better design. Its a small step down a slippery slope between
adding Bluetooth and requiring it to access device features.

There's a legitimate philosophy behind not treating medical devices as
electronic gadgets.

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bdfh42
Fair point: If you want to disrupt an industry which is entrenched by the
legal/regulatory system - you have to find ways around it.

Think education, health, law ...

Any more?

In fact from the list of the oldest professions only the "oldest" is free from
regulation (only, for the most part, suffering from prohibition).

~~~
wissler
There's no really good way around it other than by changing the attitudes of
the culture. At present, people generally like their nanny state and want more
of it, not less. So we'll all suffer the consequences in the meantime.

~~~
roguecoder
You would also have to change the culture of business. As long as companies
are out to make money instead of contribute value the force of the state will
be employed to keep snake oil off the market.

------
chrisennis
As an entrepreneur (and engineer) who has built two healthcare companies, I
believe we'll get to a point where the speed at which innovation moves in
other sectors will start to take foot in healthcare. But like everything in
the space, it takes time. Sometimes too much time.

~~~
ippisl
What changes you think will happen to make healthcare innovation go faster?
And how can we help push those changes ?

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crisnoble
My doctor visit routine goes like this: Nurse asks for my password to login
into mymedtronic.com to "download my data" this costs me 20 dollars. Nurse
gets access to special healthcare only charts, you know ones that are actually
somewhat useful and prints them. My doctor looks at the prints and stuffs them
into my file, rubs my feet and tells me to keep up the exercise. That was a 50
dollar foot massage. I don't want to think what that would cost without
insurance.

~~~
DanBC
Your doctor is looking for lesions - diabetic foot kills a large number of
people. The ones that don't die have a leg amputated.

~~~
crisnoble
I know that is what he is doing, what I don't know is if that was worth my
time or money. I am nimble enough to see lesions for myself and smart enough
to see a doc if I get one.

But that was not my main concern...

The worst thing is that instead of using the the data in combination with all
their patients to form some sort of massive dataset that could help
everyone... they print a chart for my file.

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glennos
Keep an eye on the guys at mySugr. I've had a few interesting chats where
they've told me about the issues you come up against in the medical industry.
They're diabetics, they get it and they're working around (and through!) it to
make a really usable and useful diabetes app. It's German only at the moment,
but check it out at <http://www.mysugr.com/>.

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akandiah
I can't believe that no one has suggested the use of RFIDs to measure blood-
sugar levels! These guys already have a product that's under testing:
<http://www.positiveidcorp.com/products_glucochip.html>

The only trouble with things going inside the body is the need to get FDA
approval and the vigorous testing that goes along with that.

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rlvesco7
I'd like to see the Pebble watch serve as a way to view blood sugar levels and
send commands to an insulin pump ... at one point I thought about setting up a
kick starter project for this, but all the issues with bluetooth seemed
daunting. Thank you to Scott for making these issues heard.

~~~
gonzo
there are almost no issues with Bluetooth LE. Pebble supports it, the new
MetaWatch supports it, iPhone 4S and many new Android phones support it...

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jostmey
I would have hoped that we would have a gene therapy to treat diabetes at this
point in time. But alas, the medical industry has stagnated under the weight
of bureaucracy and an overall decline of investment as investors demand the
same kinds of ROIs as those seen in the dot-com sector.

------
Cochise
<http://www.echotx.com/symphony-tcgm-system.shtml> Wireless cgm and non-
invasive. Passing every clinical trial with excellent accuracy too. "Coming
soon" though.

------
earnon
The industry will never come up with a cure because there's more money in
chronic treatments.

At the same time, why do we even need diabetes technology? Just go on a low-
carb diet. My grandma was borderline diabetic a year ago. She was getting very
worried, so I was finally able to convince her to try it and now her test
results are great.

Even if you're a type I diabetic, this will manage your symptoms although it
won't cure you. Check out "Good Calories Bad Calories" by Gary Taubes.

~~~
nopassrecover
I'm not sure low-carb is necessarily effective for people with serious insulin
dysregulation. I'm pretty sure for Type 1 in particular, avoiding carbs is
insufficient (you also require insulin injections). Personal bias: Dad has
diabetes, caused by pancreatitis, and although minimising carbs led to some
weight loss (not that he is/was overweight), it has no impact on his blood
sugar.

~~~
Shorel
Yes, type 1 is a different beast.

The latests theories point to gluten to cause a leaky gut, that causes complex
foreign molecules to enter the bloodstream, and as some molecules are similar
to our own, this causes the immune system to attack some cells in our body.
The cells in the pancreas that make insulin are one of these.

The bad news is that if you have Type 1, you can't be cured, and need insulin
for life.

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verra
Treatment = profit while cure stops all income.

