Teladoc Health lost $13.7 billion in 2022, mostly from a write-off related to the plummeting value of Livongo. This experience should serve as a massive lesson to the rest of the healthcare business community. The health solution graveyard is littered with answers to problems that make sense, but fail to produce the promised results. The Teledoc-Livongo merger is just the latest example. Livongo is a company that promises to improve clinical and financial outcomes in type 2 diabetes by supplying materials to test glucose levels and diabetic coaching.
It is very difficult to find objective analysis of Livongo’s results. Most of the analysis of this failure functions on the business issues like difference in company culture and I find very litttle on the impact on clinical and financial outcomes. There is this:
“Now, more than two years after the merger was completed, a seasoned healthcare lawyer declared that he too had his doubts from right from the start about this union.
“Teladoc was never able to effectively drive its members into chronic care because those nurse practitioners in the Teladoc model were not being incentivized to find the chronic conditions and to cross sell,” said Eric Klein, partner of Sheppard Mullin’s national healthcare practice, in a recent interview. “The employers also didn’t create those incentives. If the employers had created those incentives for employees to go ahead and utilize the Livongo services, then that might have worked as well. But they didn’t do that.”
But there is another reason Livongo valuations are plunging because self-insured employers are not realizing the promised outcomes. I turned to Al Lewis (Quizzify) for some insight on this issue, and he did not disappoint.
Livongo bases its claims about clinical and financial improvements on a study. Al’s comments on this study are definitely worth your time. “By way of background, this study was conducted by Livongo’s employees, along with employees of its partnered diabetes supply company (Eli Lilly), which also funded the study. So there couldn’t possibly have been any conflict of interest, right? Right?
It was published in something called the Journal of Medical Economics (JME). And no, I hadn’t heard of this publication either. Turns out it’s an “open-access” journal offering “accelerated publication,” where you pay to publish. The Impact Factor is 1.9.
Not familiar with Impact Factors? Those measure the influence of a publication. For instance, the New England Journal of Medicine tallies a 70.8. How hard is it to only get a 1.9?
Livongo provides unlimited glucose testing along with coaching services to target a hemoglobin A1c of 6.5. Simply targeting lower glucose using any medication approved for that purpose does not work. That has been proven by a landmark study involving 10,000 patients, sponsored by the NIH, and reported in the New England Journal of Medicine (with the impact factor of 70.8.) Aggressive glucose lowering in this well-designed controlled trial killed more people. It did not lower the risk of heart attack and stroke.
The lesson here: It is not just lowering the sugar that matters. It is how you lower the sugar. Another controlled study in the New England Journal of Medicine showed a dramatic impact of optimal medical therapy (OMT) in patients with type 2 diabetes and chronic kidney disease compared with patients in usual care. The OMT patients had one fourth as many heart attacks, on fifth as many strokes and one sixth as many patients on dialysis. Patients on OMT lived 8 years longer free of heart attacks and strokes. After 21 years of follow-up, there was a 70 percent reduction in hospitalizations for congestive heart failure. Optimal medical therapy involves aggressive targets for blood pressure, glucose and cholesterol and a protocol that specifies ACE inhibitors like lisinopril or ARBs like losartan, calcium channel blockers like amlodipine and a thiazide diuretic for high blood pressure, along with metformin for type 2 diabetes. OMT patients with known vascular disease or chronic kidney disease receive aspirin and support to stop smoking. Successful management of type 2 diabetes that improves clinical and financial outcomes requires a comprehensive solution that addresses global risk.
Delivering optimal medical therapy requires substantial changes in the systems of care. “Teladoc was never able to effectively drive its members into chronic care because those nurse practitioners in the Teladoc model were not being incentivized to find the chronic conditions and to cross sell.” If your diabetes solution merely tests sugar and provides coaching it will fall short of the potential changes that can be realized. There are many solutions that make sense, but most of them don’t work. Most efforts to improve glucose levels, blood pressure, and cholesterol management fail to move the numbers. There is evidence around that too. “The one approach that has proven to be effective is using specially trained nurses or pharmacists, under appropriate supervision, with authority to make medication changes without consulting the physician as long as the changes fell within approved treatment algorithms.”
Don’t be taken in. Improving chronic disease management requires a comprehensive solution. I am working with others to provide just that solution at Congruity Health.
We begin with your data. We go to your third party administrator and our platform identifies all patients with diabetes or related conditions like chronic kidney disease and heart artery disease that can be treated with one team using a similar protocol. We provide that list to our nurse coaches. Then we identify all patients with gaps in care like a blood pressure that is too high, a test that has not been done, or failure to appear for a follow-up visit. We provide a list of these gaps to our nurse coaches to close. We work with nurse practitioners and primary care docs who can write the prescriptions to close those gaps. Our platform follows the changes in clinical and financial outcomes and we provide feedback every three months to continuously improve results. Our data function is utterly transparent. If we are engaged with a self-insured employer, the data we generate is your data and you have a dashboard that allows you to see your clinical and financial outcomes at anytime.
Just know this. Improving diabetes care is like a stool. If there is a missing leg, it will dump you in the floor. Let us help you help your employees. Patients with diabetes can learn a lot by subscribing to this content.
Unsurprisingly shocking! American legacy medicine, I call it a "American Legacy Late-stage-sickness-seeking-profittering Kabuki Dance Theatre," or as Professor Lustig describes, "Fifty-year Wild Goose Chase," must be replaced.
Incidentally, what we have discovered is concurrent with the current understanding of the metabolic origins of most chronic illnesses. We provide the objective and quantitative physiological measurements missing in the conventional legacy work. We prove Professor Lustig's point perfectly; he doesn't know that yet. But he will!
https://youtu.be/odZlKkGkOVI
Also, read his book "Metabolical." I am reading it. What we have discovered is not just coincidence; this is our destiny.
I declare the metabolic origin of all diseases will be our focus to help the missing information gap. The critical information we deliver will change the world through fundamental lifestyle metabolic optimization medicine.
Joseph T. Shen, Recovered Physician, Developer of The World's first BioCybernetic Computational Systems Physiology Technology Platform
All true commentary Bill. The biggest takeaway for me relates to the fact that Livongo, like historic wellness snap on plans, was a point solution that was never integrated into a patient’s own PCP or specialist. They operated on their own without coordinating care. Further, they rarely, if ever, integrated their utilization into the employer’s data/analytics to either show or not show ROI. Livongo isn’t the only point solution that has tried to sell direct to employer without any sort of coordination or accountability. It is a failed model. That realization was made clear in their own earnings call.