Scott Benner 5/6/22 Scott Benner 5/6/22

#677 Defining Diabetes: Hypo and Hyper

Scott and Jenny Smith define diabetes terms

Scott and Jenny Smith define diabetes terms In this Defining Diabetes episode, Scott and Jenny explain Hyper and Hypo.

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DISCLAIMER: This text is the output of AI based transcribing from an audio recording. Although the transcription is largely accurate, in some cases it is incomplete or inaccurate due to inaudible passages or transcription errors and should not be treated as an authoritative record. Nothing that you read here constitutes advice medical or otherwise. Always consult with a healthcare professional before making changes to a healthcare plan.

Scott Benner 0:00
Hello friends and welcome to episode 677. It's a short one, but it's good

Hello, everybody on this episode of The Juicebox Podcast, Jenny Smith and I will be defining hyper and hypo as it relates to all things, not just diabetes. Please remember, while you're listening that nothing you'll hear on the Juicebox Podcast should be considered advice, medical or otherwise, always consult a physician. Before making any changes to your health care plan, or becoming bold with insulin. I'm going to just ask you the briefest of favors. If you are a US citizen who has type one diabetes, or is the caregiver of someone with type one diabetes, please go to T one D exchange.org. Forward slash juicebox. When you get there, join the registry take the survey takes fewer than 10 minutes, I would consider it a personal favor T one D exchange.org. Forward slash juicebox. If you're enjoying the Juicebox Podcast, please share it with someone who you think might also enjoy it. If you're loving the defining diabetes series. There are so many of them to choose from right there in your podcast player, where diabetes pro tip.com. This episode of The Juicebox Podcast is sponsored by us med. US med is a place where you get diabetes supplies, and they do it. Well they do it better. They offer you better service and better care than you're accustomed to getting. All you need to do to get a free benefits check is to go to us med.com forward slash juice box or call 888-721-1514 Hi, Jenny. Hi, Scott. How are you?

Jennifer Smith, CDE 2:05
I'm fine. How are you today?

Scott Benner 2:07
Good. Have you seen the little animations of you and I talking on Instagram and and Tiktok yet?

Jennifer Smith, CDE 2:14
I have I saw when you originally showed me what was going to be there but I have not seen recently. Because I have to admit I'm not a tic tac, or Instagrammer.

Scott Benner 2:26
So the person making the videos Maggie, who is a great young artist whose sister has type one diabetes. She has now added what I'm gonna call googly eyes to us. So while we're talking now the eyeballs move around inside of the eyes. Oh no, I'm absolutely like enamored by it. So

Jennifer Smith, CDE 2:43
I'm sure that if I showed it to my boys, they would probably think it was the coolest thing in the world to see

Scott Benner 2:47
your voice coming out of a cartoon. Yeah. Oh, yeah. All right. Well, you should check it out. I don't think you should get on Tik Tok because I have to tell you, it really is a time suck. Like it is it is the scrolling. Like I got it just to put this stuff, you know, for the for the podcast app. And then I'm like scrolling and I'm like, oh my god, I can see how people get lost in this. It's fascinating. So

Jennifer Smith, CDE 3:06
yes, I have stay away. I have more things that I need to do then.

Scott Benner 3:11
Yeah. If you're not on Tik Tok, you're doing okay. I think I was hoping today that we could define something that I mean, in all honesty, I had skipped over we I'd made a list and thought this isn't necessary. But it is. So we're going to do it. I want to define hypo and hyper just those words, and then we'll attach them to diabetes, and a couple of other things. So you know, everybody understands, again, Isabel helping me with the Facebook page, she said, I know this seems basic, but you really could use an episode on what hyper and hypothyroidism is people ask especially new newly diagnosed people, we don't have anywhere to send them. So here we are. Great. Awesome. Okay, so let's start like super simple, right? We're just going to use the dictionary. Hypo is a noun, and it means

Jennifer Smith, CDE 4:11
under or beneath a level of where you want to be. Right? And, yes, I mean, hypo hypoglycemia, hypo thyroid, hypo, many other medical terms that come along with hypo, it is like, it's low, right? It's under where a level of comfort would be.

Scott Benner 4:35
I also should have said and this is going to be a good indication to all of you that I stopped paying attention to my English teacher in about seventh grade, but it actually can be used as a verb as well, but we mostly think of it as a prefix, under beneath down less than normal, in a lower state of oxidation, for example, in a low and usually the lowest position in a series of compounds. So glycemia You know, I didn't think of this but darn it. Let's define. Let's define glycemia for a minute. Why not? I don't even think glycemia is a word, right? It is the presence of glucose in the blood. Now I'm learning. Yes. All right, like this podcast, okay? Jenny, then you

Jennifer Smith, CDE 5:21
can then you can put them together low presence of glucose in the blood. Yeah. Jenny, I hypoglycemia.

Scott Benner 5:29
I was gonna say I would listen to this podcast. Okay, so glycaemia the presence of glucose in the blood. So hypo, beneath normal, less than normal, presence of glycine, of glucose in the blood, and then hyper, which, if you've anyone's ever had a hyper kid, you know, this won't sound crazy, highly excited, extremely active, excessively excessive. That is or exists in a space of more than three dimensions that one doesn't really like It's like hyperspace. Oh, yeah, I really should have paid attention in school. This is all very interesting. I feel like an idiot. Okay, so but excessive, is where we're going to ride on this. So hyperglycemia excessive presence of glucose in the blood. That's it. Now, why somebody couldn't just call it high blood sugar and low blood sugar. You know, smart people, doctors, they fancy.

Jennifer Smith, CDE 6:25
Right? Well, and they're just medical terms, right? I mean, hyper and hypo, even in the sense of other medical conditions that carry that same prefix, if you will. They're just a medical term, rather than saying high and low blood sugar or high and low blood glucose even I also think, just glucose and sugar, right? I mean, when you say, my blood sugar is this, some people say my blood glucose is this, it's just another word for the same thing.

Scott Benner 6:54
Do you have a preference? Personally, when you write it out? And you know, someone else is gonna say it? Do you think blood glucose or blood sugar? How do you write it out?

Jennifer Smith, CDE 7:02
I abbreviate the G, because that's my quick way to type up something.

Scott Benner 7:08
After writing blogs, for so long, I did the same thing. But in the beginning, I had this like this blood sugar sound. I don't know. Like, I like this is not sound, I don't know, appropriate or something like that. But I don't think of it now. It's however it comes off my fingers when I'm typing. Like when I'm talking to somebody, I don't think of it one way I don't care. I

Jennifer Smith, CDE 7:28
guess if you, if I think about when I write about it, when I'm writing more professionally, I use the term blood glucose. And when I'm writing more from just a general kind of public, I typically use blood sugar. Okay, not that people don't know what glucose is, especially within the diabetes realm. I just think that blood sugar is often more what we say. Yeah. And so it's more readable. I don't know if that makes sense.

Scott Benner 8:02
Yeah, I think it just makes it feel more affable, honestly, just sure available to people. As an example, and we're not going to turn this into a third grade English lesson, but hypothyroidism is a condition in which the thyroid gland doesn't produce enough thyroid hormone. So back to hypo, low last, etc. Hyperthyroidism, the overproduction of a hormone by the butterfly shaped gland and the neck called the thyroid. Excessive too much. I just pulled up a couple of other words to make the point that it's not always about. It's not always about medicine. Hyperbole, as an example, is an exaggerated statement. We're claimed not meant to be taken literally hyper hyper. Right? Is the prefix. My, my last thought is just to get away away and Jenny used to be a nurse. Right, Jenny? What is hypo perfusion?

Jennifer Smith, CDE 8:56
Good to correct you I wasn't a nurse, or I'm not a dietician.

Scott Benner 9:01
Sorry. It's the same thing.

Jennifer Smith, CDE 9:05
Oh, well, you know, if I had thought that when I was going to school, then I probably would have ended up being a nurse. But yeah, so that different,

Scott Benner 9:15
I make a suggestion. Sure. We'll have to add CDE to the defining diabetes series.

Jennifer Smith, CDE 9:23
That would be great because you can have many credentials that precede CDE, which is actually not CDE even anymore. It's now c d c e s certified diabetes care and education specialists to make it even more complicated than it ever was.

Scott Benner 9:40
Have you given over to that yet? Because you you said you were gonna fight it in the big guy

Jennifer Smith, CDE 9:44
in credentialing just in terms of my signature and the way that I you know, put, again, sort of publications and that kind of stuff out I do. But I still call myself a CDE because I that's just like, what I've been long term.

Scott Benner 9:59
I have to Say I like these. Oh my gosh, I've gotten too hot tea and it doesn't matter. Oh no. I'm just gonna start drinking scalding water. When I'm recording from Elon just, I'll drip a little lemon in it and pour down my throat. I was gonna say I like the free flowing pneus of our conversations, because my just miss speaking for a second, immediately made my brain go, Hey, why are we not defining this stuff for people? Because people all the time, say, who just see today? I don't know, I saw the lady. You don't I mean, like, the doctor is the doctor, an endocrinologist? I don't know, what's the woman I don't know. Like, like, you know, she writes the prescriptions. It seems like she's got a medical degree.

Jennifer Smith, CDE 10:37
That's I saw these people. And they told me to do this. And I don't necessarily know what they are, you know, in fact, in terms of like that defining of even clinicians, many endo offices now sort of transition often on between, you see the Endo, you see the nurse practitioner or you see the Endo, or you see the PA, a physician's assistant, right, and you go back and forth. So it's not every three or four months, you're seeing the same Endo, you may see them only twice a year and in between, you actually follow up with the nurse practitioner, the physician's assistant, because that's the time that they have.

Scott Benner 11:13
So my brain like, I know, you have a firm background in nutrition. Like I understand all that. And I guess my brain just was like, well, she's the CDE she must have had to have been a nurse in the middle of it. And now so Okay, so we have more stuff anyway. Just

Jennifer Smith, CDE 11:27
remember things in nursing school that I was like, Yeah, I don't want to do that. I don't want to ever ever do that to a person. So no, I'm not going to be a nurse.

Scott Benner 11:37
Well, then just for fun.

Jennifer Smith, CDE 11:38
I I very much appreciate the nurses who do and can do those types of things. But I That's not me. I can do blood. You could bleed all over me. I could do wounds, weird looking gashes.

Scott Benner 11:51
Where's the line pee?

Jennifer Smith, CDE 11:53
Oh, the line is mucus. Oh,

Scott Benner 11:57
I wish you could have saw the face Jenny just made we should make it a poster. I just sideways or tongue came out or one of her eyes went one way she's like,

Jennifer Smith, CDE 12:05
yes. No, I was I was an ICU dietitian. So I did like tube feedings and IV nutrition and all that kind of stuff. And I would have to move away when they were doing like suctioning of patients and stuff. I like the noises and not for you. Not for me. Nope. My Oh, come back. Thank you. My wife

Scott Benner 12:27
is like three clinicals away from being an RN. And I mistakenly got her pregnant before she could finish off. So I do remember that she never got back to it. But she even said that. She thought by the time if she would have finished she's like, I don't think I could have like actually helped people. Like it just was Yeah, her vibe. And it wasn't about the people. It was more about the that stuff. Okay, but anyway, just for shits and giggles Do you know what hyper perfusion is? Now that I brought it up? Because if not, I gotta tell people.

Jennifer Smith, CDE 12:57
What and why? I'm curious actually. Why?

Scott Benner 13:00
Because it had the word hypo in it. And I thought I wonder if anyone just randomly know what this is? Oh,

Jennifer Smith, CDE 13:05
well, it has to do with like blood flow. It's hyper. Hyper is more and hypo is a reduction in the amount of blood flow.

Scott Benner 13:15
This is why you're listening to the podcast because Jenny knows stuff about stuff she doesn't know about. Hypo fusion has nothing to do with diabetes, but it describes a reduced amount of blood flow. There you go. You can't trust somebody who knows stuff. They're not supposed to know who you're supposed to trust.

Jennifer Smith, CDE 13:29
Correct. There you go. Well, thank

Scott Benner 13:31
you so much for doing this. I

Jennifer Smith, CDE 13:32
really You're welcome. Absolutely.

Scott Benner 13:36
That was good. That was hilarious. Actually. It's always fun. Good time. All right. hyperperfusion. I'm getting rid of tabs on my

Jennifer Smith, CDE 13:43
Yeah. Are we stalled for a second? I need to I think I forgot my orange link in my kitchen. And I need to go grab it because my loop is red right now. We'll be right back.

Scott Benner 13:54
No problem. While Jenny's off getting her orange link. I'm going to tell you about today's sponsor, US med

just the other day, I had Omni pod send Arden's prescription for Omni pod five over to us med. All of this happened without problems. That's what we want. Right? Nice and easy access to our supplies. US med offers that with their white glove treatment. US med accepts Medicare nationwide and over 800 private insurers. They carry everything from insulin pumps and diabetes testing supplies to the latest CGM, like FreeStyle Libre two and the Dexcom G six. US met always provides 90 days worth of supplies with that fast free shipping that I've been telling you about. If you want better service and better care than you've been accustomed to getting with your other suppliers, check out us med. They've helped over 1 million diabetes customers since 1996 are the number one rated distributor index com customer satisfaction surveys, the number one specialty distributor for Omnipod dash, the number one distributor for FreeStyle Libre, and the number one fastest growing tandem distributor nationwide. US med get your free benefits check right now. Us med.com Ford slash juice box or call 888-721-1514. There are links to us Med and all of the sponsors in the podcast player shownotes that you're listening in right now. Or at juicebox podcast.com. And don't forget to take that T one D exchange survey AT T one D exchange.org. Forward slash Juicebox. Podcast support T one D exchange, you're helping people with type one diabetes, and you're supporting the Juicebox Podcast, keep the show free and plentiful by supporting the sponsors.

on next week's defining diabetes, Jenny and I will be defining all of the different types of diabetes. And there are more than you think. To find a list of all of the defining diabetes episodes, go to Juicebox Podcast type one diabetes on Facebook, it's a private group for people who listen to this podcast. And right there at the top of the page. You click on a little tab called where the is it God, I can never remember the name of this. I'm going to curse. I'm going to curse. I don't want to curse just trying to finish this ad and I'm done for the week when I get this done. Like I actually get a day off tomorrow. I mean, I still have to record but I don't have to edit and I just want to tell you the name of this. Featured, you go to the Juicebox Podcast type one diabetes, it's a private Facebook group. Almost 25,000 people in it. They use insulin, they chat with each other, they help each other. And under the featured tab at the top. There's lists of episodes in different series, including the defining diabetes episodes. So if I didn't sound too crazy, just then maybe you'll go check them out. I just didn't want to curse. That's the end of my week and I had knee surgery. I'm feeling okay, but I'm not supposed to be sitting here right now. I'm supposed to have my flights. This is not your problem. Just go find that. Just go find it. It's Juicebox Podcast type one diabetes. It's a private group answer a couple questions you get right in. It really is a magical place. I'm not kidding

you. Thank you so much for listening. I'll be back very soon with another episode of The Juicebox Podcast.

#676 Dexcom G7 is Getting Close

Jake Leach Executive Vice President and Chief Technology Officer at Dexcom is back to talk G7.

You can always listen to the Juicebox Podcast here but the cool kids use: Apple Podcasts/iOS - Spotify - Amazon Music - Google Play/Android - iHeart Radio - Radio Public, Amazon Alexa or wherever they get audio.

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Scott Benner 0:00
Hello friends, and welcome to episode 676 of the Juicebox Podcast.

Today on the Juicebox Podcast, I don't know why I'm talking like this. Let me start over again. On this episode of The Juicebox Podcast, I'll be speaking with Jake leech. Jake is, you know from Dexcom. He's been on the show a bunch of times. And he's here today to talk about g7. It's a short episode, but it's full of good information. If you're looking forward to the Dexcom g7, you're going to like what comes next. While you're listening today, please remember that nothing you hear on the Juicebox Podcast should be considered advice, medical or otherwise, always consult a physician before making any changes to your healthcare plan, or becoming bold with insulin. If you are a US resident who has type one diabetes, or is the caregiver of someone with type one, your answers to simple questions are valuable. Go take the survey AT T one D exchange.org. Forward slash juice box in fewer than 10 minutes, you will help people living with type one diabetes while you're supporting the Juicebox Podcast.

This episode of The Juicebox Podcast is sponsored by us Med, get your diabetes supplies from us med find out more and get your free benefits check by going to us med.com forward slash juicebox. Or you can call I love reading the phone number. It brings me back to my childhood when I watched television, I was who my parents were the television. And then the ad was nevertheless ready. 888-721-1514 That's 88721514 Call now. That is how every ad when I was a kid ended? Was that the phone number that they said call now. Anyway, if you call that number, or you go to the link, you can get a free benefits check and get started with us, man. I'll tell you more about them later. I actually just switched over Arden's on the pods to us med.

Jake Leach 2:25
We're working on getting g7 approved, sorry about being late. It's not a stupid excuse. That's literally what I was on the phone talking about. That it's approved, don't take that as long as the record is more of like three questions. All

Scott Benner 2:42
right, hold on a second, I can't get my light to come on. So I'm going to be in the dark. But I'll still be see if I can throw a secondary light on. No worries. Let's see. Hey, how are you? Good, man. How you doing? I'm on okay. So is that really what you were doing? You weren't just like in the bathroom? And you couldn't get here on time? What was that? No,

Jake Leach 3:08
no, literally, I was I was on the phone with our team, we're, you know, back and forth with the FDA, they ask a question and you answer it, then they want some more clarification you answered. And I mean, it really comes down to there's just so much in these filings that they you know, they can't possibly read all 38,000 pages. So they just kind of pick areas that they want to spend some time with. So we ended up helping point them to the right places. And so it's very, it's really interactive. It's great. And very thorough, but it takes a little time.

Scott Benner 3:36
Yeah. Does the integration with algorithms change your submission? Or is that on the pump person side?

Jake Leach 3:42
That's on the pump side. Yes, the pump side, they basically once we get G seven approved as an IC GM, then they quickly do their submission. They've a little bit of validation work they have to do on their side to show that they have compatibility with the new G seven system. But it's all of this is based on the work that FDA has done to do the I CGM and the AI Controller it really facilitates quicker approvals. If if they wouldn't have done that, it almost likely wouldn't, you'd have to run a new study with every generation of technology instead of trying to make them more compatible. So it's pretty it was good forward thinking on the FDA has purposely set it up. So yeah, each of those pump companies will have a submission right after we achieve seven approved that they'll have to go through to get the g7 approved for use with their automated insulin delivery systems.

Scott Benner 4:31
Do you think that I'm going to ask you to speculate Do you think that's something they have ready to go and they're just waiting for you to get your Okay, so they can submit theirs? Or is it a process that like starts at day one when you

Jake Leach 4:40
know No, there are both both of them in tandem and insulet are already working on g7 integration. I've already seen prototypes working of their systems so they you know, they're not ready to like file it right away. They might be by the time we get to seven approval we'll see you know, because you know, probably a little More review time on D seven. So we'll see. Hopefully, I mean, they're moving as fast as they can. We're supporting them in every way to help them move as fast as possible. But there will be some time where people will stay on G six, if they're on those systems before they can move to G seven. What was I'm going to jump around a little bit here. Do you mind? No, I'm no problem, man.

Scott Benner 5:19
Good to see you got approval overseas already? Yeah,

Jake Leach 5:24
we got to see Mark last last month. And you know, we'd like to move fast. So we already moved into a limited launch. So g7 is in the hands of customers in the UK right now. That the recent attd show that just is wrapping up in Europe, they, we had a number of clinicians that have used the product as well as some of their customers. And they shared a little bit feedback, feedbacks been great. No surprises. Everyone loves the smaller size, easy use new app, the grace period, the 30 minutes start up, the more configurable alerts. For convenience, there's just there's a whole lot in g7. So pretty, everyone's pretty happy with it. We're happy with how it's going. We do these limited launches just to test, you know about the product, but also just our systems technical support, make sure we know how to support this, the last thing you'd want to do is go big and then have an issue that while it's fit, correctable it's kind of hard to correct when you're hurt. Yeah. At the scale we're at. So you want to get it going a little bit slower at first,

Scott Benner 6:23
was that the first time that that's happened that you've gotten something moving overseas before in the US on a new products?

Jake Leach 6:30
No, it's you know, there's been lots of different reasons over time where this has happened. I'll give you one example is g4 actually was approved first in Europe, with the Animus pump of all things right. So that was actually a previously approved version. So that was, you know, then we ended up redesigning some of the GE for for a product, he made it g4 Platinum, and then launched it. This one was just the case here is that the clinical trial that we had to run for the FDA is a little bit larger and takes longer than we the one that is required for the regulatory agencies in Europe. So we purposefully ran two separate trials, we wanted to get the product out as fast as we could. So we ran a trial for Europe. And we ran a separate trial for the US. And we submitted the European submission while we were still running the US trial.

Scott Benner 7:21
Okay. Can I flow through some questions real quick? I think they're going to be kind of kind of quick ones? No, of course. Excellent. I have these are from people who listened to the podcast who want to know what they want to know. I'll, I'll start with, they're wondering if the new form factor of G seven cuts down on compression lows. I've asked you guys this question in the past? And the answer has been We hope so. But I was wondering if you have any more data? Yeah, we don't, I don't have anything valid validated to say, you know, if

Jake Leach 7:51
you place the sensors in the exact same spot, and you lay on it in a, you know, statistical format, does it reduce compression, those, I don't have that, but what we have seen is that with the size of g7, it can be worn, you know, in slightly different locations on the particular the arm, where you can kind of move it around that because the sensor probes shorter, it's also more comfortable in the arm. So people have found like they can wear a little bit lower and there are a little bit higher. So we have seen people that they experienced professional have figured out how to move it around a bit so that they don't don't have it, but they still can happen on g7. But from a statistically significant perspective, I don't have an exact answer. Is it less, but it's certainly more comfortable to wear? Because it's so much thinner.

Scott Benner 8:36
Yeah. Hey, you just mentioned the sensor probe, does it go on in on a different angle than the G six?

Jake Leach 8:42
It does? Yeah, it goes straight in. It's a 90 degree angle versus the 45 degree angle. And what we were able to develop sensor technology within our electrodes that allow us to have a shorter sensor probe. So the depth is actually slightly shallower than G seven or G six. So G seven shallower than G six. And it's also less sensor probe under the skin because it's straight in versus that 45 degree angle.

Scott Benner 9:04
Oh, no kidding. So the G six is it? Am I ready? Test my memories at 13 millimeters? Yes, yes, exactly. I can't believe this is how long I've been doing this chicken. Bird right off the top of my head. What about the g7? Is it? Do you know the measurements? six millimeters? six millimeters? Oh, that's amazing. Oh, cool. Is the change in size going to impact the cost at all? I think what people are asking. Moreover, as do you see yourself as a competitor with libre or a different? Are you in a different space than they are?

Jake Leach 9:38
Well, actually, Scott, that is a very good question. So we're definitely looking at a portfolio of products. So in Europe, we've launched a new product called Dexcom one which is going to be in same the same markets as our G seven product as well. Usually six but we'll be replacing G six with G seven. The ideas There's certain in certain countries, people have access to GS six, but they may not. There's some people that don't have access to G six. So for example, right now, it's some countries categorize if you're at higher risk, meaning maybe a pediatric whose parents are taking care of their diabetes management or someone who's hypoglycemic and aware, they absolutely have to have alerts and alarms. Those folks have access to G six, there's a large population of people that don't have access to G six, they have access to other technologies. And so what we did was with Dexcom, one, we brought in the product, it's doesn't have all the same functionality as G six. It's a simpler product, but it still has alerts and alarms, it's still all based on the same accuracy, same hardware platform with a new mobile application, the whole purpose of that product is to help grow our business internationally and give more people access to Dexcom CGM. And so that product, you know, just over the past year, we've we've opened up over a million new people who have access to Dexcom that have never had it before around the globe. So that and then we're kind of just starting with that we've launched in a few countries with Dexcom. One, and we plan to launch in quite a few more. But, you know, getting back to that question around cost, you know, g7 is not intended to be more expensive, or at a higher out of pocket for people, it's, you know, part of people's cost of the product is have their insurance coverage. But you know, there's 30% of our customers don't pay anything. And you know, the other 30% pay quite a low copay, I think it's less than 30 $60 per month. So it's, you know, g7, one of the things about launching it is there's some coverage that we have to get for the product to ensure people can transition from G six to G seven, or get coverage for D seven. So there's some steps we take once we get FDA approval.

Scott Benner 11:51
So for people who are out of pocket, though, will there be an increase from cheese?

Jake Leach 11:55
I don't believe so. Yeah, I'm not. I mean, I'm not deep into the pricing discussions, but I don't expect it we don't have any expectation that we're increasing price for QBO. Customers,

Scott Benner 12:06
okay, great. When, eventually, one day when on the pod five and control, like you are compatible with G seven, and they're through FDA and everything, this is a big, I know this isn't really a question for you. But I got asked so many times, today, I'm going to bring it up anyway. If someone set up with GE six on one of those systems, and they move to G seven is it going to just be as simple as going into a setting and telling it I'm using the G seven now not the G six

Jake Leach 12:33
there, you know, each each, the architecture, these systems are a little bit unique, right? Each one is, you know, the Omni pod has the algorithm on on top of the disposable, you can look at control IQ, it's built in to the pump. And so you take control IQ for an example, when you want to upgrade to G seven, there'll be a firmware update that's required on the pump. Similar to my expectations be similar going from Basal IQ to control IQ, and they did the you could do the update is going to be something similar to that is what I would expect. And, you know, with Omnipod, it's likely a new firmware version on the pod, right that can communicate with G seven. So I think it's gonna be you know, the whole point is it's very easy for customers to do it. It's not like you have to get a whole new system. It just you know, it's about making these systems upgradeable. That's the whole point of trying to be able to keep up with the innovation that's going on in you know, sensors AI D they're all on slightly different timelines, but you want them to come together. So Right. That's why the FDA is approach with a CGM was such a good approach

Scott Benner 13:37
of let's see, oh, people want to know about overlaying session time. So we'll with g7, will there be a possibility of putting on a new one while you're still wearing an old one?

Jake Leach 13:47
There? There is completely you can do that if you want. With the 30 Minute startup time, though, it's it's not quite the same challenge that you're trying to solve for. Because right now, you know, I get feedback from customers that the two hours that they don't have the CGM data while it's doing its warm up at the initial beginning session is a terrible time because you know that the ID systems are not working or they're not getting that data, they're flying blind. So you do have a 30 minute startup with G seven, G seven starts the sensor session immediately upon insertion automatically you don't have to do anything so it just starts Okay. And you get into 30 minutes later I get data. Literally you get data Yeah, accurate, reliable data.

Scott Benner 14:35
US med is a place where you can get your diabetes supplies, they offer you white glove treatment. US med is a number of things. I'm gonna rattle them off for you right now ready, the number one distributor for FreeStyle Libre systems nationwide. They are the number one specialty distributor for Omnipod dash, the number one fastest growing tandem distributor nationwide, the number one rated distributor index com customer status faction surveys. How about that? They have served over 1 million people with diabetes since 1996. They always provide 90 days worth of supplies and they have fast and free shipping. That's right us med carries everything from insulin pumps and diabetes testing supplies to the latest and CGM, like FreeStyle Libre two, and the Dexcom G six. Here's a little personal information for you that you really have no business knowing, but I will tell you anyway, I just had Arden's prescription for Omni pod five, sent to us Med, they accept Medicare nationwide, and over 800 private insurers, you should check out us Med and find out why they have an A plus rating with the Better Business Bureau. How do you do this? Well, you can do it with a link us med.com forward slash juice box or by calling this special number just for Juicebox Podcast listeners. That number is 888721151 for us med wants you to get your diabetes supplies, they want you to have a better experience than the one you might be having now with whatever company is sending you your supplies, switch to us Smith. But also remind you to go to T one D exchange.org. Forward slash juice box and fill out the survey. And lastly, that the links to us med T one D exchange and all the sponsors are available in the podcast player that you're listening in right now. Like go in there. There's like shownotes, they're right in there, or they're available at juicebox podcast.com. Super important. When you click on the links, you're supporting the podcast if you love the podcast, if you love how much content there is, and that it's free for you. Supporting the sponsors and sharing the show with others are the two quickest way is to keeping it going.

Is there is there any kind of wonkiness in the first 24 hours like some people see what G six

Jake Leach 17:03
the all, you know, my experience with CGM technology over you know, last 20 years is that always the first day, and there's more a little more variability in that day at times some people experience it more than others, some people, you know, experience once in a while. And it really just comes from the form of kind of wound response from inserting a sensory of a brand new sensory insertion site. There's a whole lot that's actually going on from a physiology perspective. And so that does create variability in the first day. And so the performance is still really good. But yeah, you can have some of that, you know, signals that generally they run a little lower sometimes, you know, that give you a bit of a dip in the sensor signal. But still still accurate and reliable, but not, you know, not perfect. It's clearly the meds on the later days are better than the initial days.

Scott Benner 17:58
Things I think we know already were times 10 days.

Jake Leach 18:00
It's actually 10 and a half days. Okay, there's a there's a new feature called grace period. And

Scott Benner 18:07
we talked about that before. I have not spoken anything about it yet. No. So yes,

Jake Leach 18:11
we have this new new feature on G seven that was basically designed based on feedback from customers saying, you know, when the sensor stops showing data exactly 10 days after I insert it, it's not always the most convenient time to change my sensor. So sometimes I have to stop my sensor session earlier to replace the sensor, because you want to do what's convenient. So the the 10 and a half day we're on g7. The grace period, which is 12 hours is basically once you get to your 10 days from sensor insertion time, so let's say you did at four o'clock in the afternoon 10 days later at four o'clock in the afternoon and it's saying hey, we're going to time your sensor off we actually want you seven extend it we notify you saying hey, your sensors expired, but you have another 12 hours to find a time that's convenient for you to replace your sensor.

Scott Benner 18:56
Wow. Do you have anything that will make my daughter actually pay attention to that message when it pops up and says a little arm that'll come out of it and like knock around their house or something like that? I say change your sensor art and what happened? I don't know. It told me something earlier but I didn't read it. That was great. Thank you

Jake Leach 19:17
every time you go every Yeah, we're trying.

Scott Benner 19:21
I know you guys have been doing I know that you've been doing testing on adhesives because listeners of the podcast through T one D exchange have gotten opportunities to be in trials for but have you got any? Any results from that yet? Or people are asking a lot about adhesives. We have

Jake Leach 19:38
Yes. So a couple couple things on adhesive. So G seven has a new adhesive. It's different than G six. It looks similar, but it doesn't have some of the compounds that we've identified that can be irritants for some people. So the within the adhesive of G six we've through those tests that we were really happy that people were supporting those trials and participating in them, and wearing all the different types of patches, because it really did help us learn about some of the compounds that can cause irritation. They're not identified as irritants, but they ultimately can become them for certain people. So g7 doesn't have those in it. And actually, with G six, we've been working on a version of the patch that doesn't have those same compounds in it, a little bit of its proprietary between us and our patch supplier. But we basically are very focused on ensuring that we have as little irritation as possible, while still sensitive, having sensors last you know, that he here to the body, it's kind of like this little bit of a balancing act at work. But we've learned quite a bit over the last year and a half with those studies. So appreciate everyone participating in those that can and people will see it in the products, which is seven in particular, did it become more easy? Because the product is smaller? Does the adhesive not need to be as strong because it's not holding on as much weight? Or did that not? No, it was just it's just basically using some different types of adhesives and not including the same ingredients. And also some of the manufacturing processes we use are different with G seven that also helped enable using some different adhesives, they literally if you look at it, you can't tell the difference. But the g7 adhesive is, is strong. It's not less strong than G six. You're right, though it's quite a bit smaller, which is nice. Yeah. And then also with every g7, we supply the over patch for use if folks want to it's automatically placed in the box. And so you'd have to call for that separate

Scott Benner 21:39
burners, DME, durable medical, pharmacy, Medicare, how is that all going to be covered?

Jake Leach 21:48
So generally, for GCC, so you're basically asking me when we transition to g7? Yeah, well, there's a basic Yeah, the it's a bit of a, it's a bit of a process, the DME and Medicare usually moves a little faster than all of the pharmacy contracting. So you would expect that DME coverage would come quite quickly upon FDA approval, and then the pharmacy contracts will work their way over time. But we are working on programs to ensure that customers can get G seven as fast as they can. So more to come there. But it does, it does take a little bit of time to get the G seven into everybody's systems in the pharmacy and available for every all the patients that have G six today.

Scott Benner 22:29
Okay, well, G seven, show any improvement over sensor errors and not lasting 10 days for people.

Jake Leach 22:36
Yeah, it's, it's similar. It's similar in terms of g six. But what we have seen is that, and I know a lot of customers do wear G six in their arms. But we are seeing with G seven quite good sensor longevity when worn in the arm. And so if you look at the clinical trial results that we've published, we get better performance in the arm that we do the abdomen, the abdomen, still very good performance, but the arm is better. And so we we've we've kind of known that, or we thought that that was the case for quite a while, but we'd never run enough large clinical validation study work to really prove it. But with the g7 studies that we ran for approvals, they were quite large, you know, hundreds and hundreds of customers or patients subjects in the study, and both pediatrics and adults. And that we saw in both cases the arm performance was it was more accurate and lasted longer in the arm.

Scott Benner 23:30
Interesting. Are you expanding the approved places? Or is it still the same as before?

Jake Leach 23:34
No are no g7 Our intent is to get an arm indication to get definitely it'll be indicated for use in the arm.

Scott Benner 23:40
I often only wear scars on her hips. So I'll be interested, I wonder if the size change would maybe get her to move it to her arm. That'd be great.

Jake Leach 23:50
It's it's it is quite convenient. With the size and it's one of the things like it's kind of obvious, but when you actually experience a product, you You do understand how much smaller it is and basically forget you're wearing it is really quite different than my LG six experience. Okay, excellent.

Scott Benner 24:07
Smartphones at launch, are you adding any, are there going to be the same ones that people get for G six.

Jake Leach 24:12
So we so we're basically the way we approach smartphones is we're always working on whatever the latest available phones are. And so with Apple, you know, always takes us a little bit a little bit of time to get all of the validations and testing approved and you know, through the system. So you often get a little warning that says we're still in the middle of testing this GPU kit. Okay, and you can continue to use it. But we are still in the formal validation phase. So won't be any different with G seven Apple will we're working on the latest phones and iOS is there. Same with Android, right? The Samsung models are are the ones that we support the most number of phones, but we you know we are internally working on programs where we do want to support more handsets. We think about it as we go global right? We're During this global business in the US and outside the US and you know, there's a lot of different handsets out there. And so we're working on ways to be able to support more. And for us, it's really just about can we enhance our efficiency in the testing that we do to validate, we have to validate every single phone to ensure that the Bluetooth performance meets the requirements, because the alerts and alarms of our products are so important. And if the Bluetooth isn't reliable on that particular handset, which is not uncommon, then we really don't want customers using them. So that's why they end up not being supported. Yeah. A lot. A lot of people say, Well, we get support, tubular support anything, but it's actually interesting. And within each cell phone, there's some different hard functionality, in particular on the Bluetooth chips. And they're not all as reliable as we would want.

Scott Benner 25:46
Yeah, I guess Speaking of things that integrates with Apple Watch g7 to Apple Watch.

Jake Leach 25:53
So geez, yeah, so at launch, you'll have the same functionality as G six in the US launch with, with a secondary display of your information on on your watch, you can clear your alerts. So you basically you get the alert, you can acknowledge it on the watch. But the director, watch, we did build it into the hardware of G seven. So the wearable has the capability to do that functionality. And we're looking forward to some an upcoming release of a new watch OS that has a bunch of support in it that we need to help us make that feature actually happened.

Scott Benner 26:31
How about Garmin,

Jake Leach 26:32
Garmin will be the same as it is today, which is the functionality where if you have the Garmin Connect app, then you can, you know, basically put G seven data on your garmin watch, you just it's it'll be the exact same process. The beautiful thing about those cloud API's that we've launched with partners like Garmin is that which is G 60, G seven, it's a very simple update on our side. And then you may have to log back in, log out and log back into your account with that g7 credential. But really simple

Scott Benner 27:03
check, you have to go where do I have more time? Now you have a few more time? Yeah, I

Jake Leach 27:07
was late. You have more time.

Scott Benner 27:08
Excellent. Thank you. I was like, I'm not sure if I'm getting if we have to go or not. So I didn't want to I don't want to drag you along. So let's talk about that for half a second. Somebody asked me a question that I wasn't going to ask you. But based on what you were just talking about with Apple Watch, I'd like to understand this piece a little better. The question was, could you get me functionality with the apps where it calls me for a low at like sugar made has was which was the statement? And what made? What made me think I wouldn't ask the question is, in my mind, if you can't say that it's going to do it? Definitely, then you can't get it through the FDA. And so that's where functionality like that becomes less easy to try to put into place. Am I right about that?

Jake Leach 27:51
You are you are Scott, you know, the one of the most critical things our product does is the alerting in the FDA and our Dexcom as well view that is it's a really important aspect of the product. And so when it comes to safety, it is the thing that saves lives, when you get those low alerts. And so it, it is something that validation of those things takes, you really have to go through a lot of different use cases, edge cases, all kinds of stuff to make sure you have absolutely everything covered. And that's really been what you know, as we've worked on the director watch with on the Apple Watch platform, ensuring that every user gets reliable alerts, when that thing becomes your main receiver, your phone's not around, your receivers are on your pumps not around. So you're not getting an alert, unless it comes from that watch. And so being able to do that reliably has been something that Apple and Dexcom have worked together on to ensure that that can happen. And from my perspective, on the technology side, we're really close to being being able to introduce that functionality. But as you mentioned, the call feature, it's very similar in that it just has to happen. We do know our partner, sugar mate has that functionality. And trigger mate quickly connected up to our real time API once it's been available now and so there, they do have that. So it's not on our roadmap to add that. But you're right though about it gets pretty difficult to do some of those things what

Scott Benner 29:21
it scared you if I if you say hey, if this thing reaches a certain number, we're gonna send you a phone call. And I don't know it has to do with a cell network and the cell network was down. Then suddenly the alert you told me I was gonna get didn't come and there's nothing you can do about it. So you can't put yourself in that position to begin with.

Jake Leach 29:38
Yeah, yeah. And you probably will call us and it'll be a complaint that hey, it didn't work and we're gonna have to investigate it. And so yeah, it definitely is one of the things that when we when we're doing you know, we listen to customer feedback. A lot of the features in G seven are based on the great feedback that we've gotten from customers around g six, right. And so we we We're very thoughtful about which features we introduced and how we prioritize them. And you're bringing up one of the things that's can actually can add some complexity for sure. G seven is going to be approved for what ages? It's same as G. 602. And up to that's the intent.

Scott Benner 30:17
And let me just ask you about the apps little bit because I feel like we've been talking about these revamped apps for I'm gonna say forever. Maybe, so little things, you wouldn't you wouldn't tell me last time we talked, but are we gonna see rate of change on the new apps?

Jake Leach 30:33
So not not immediately. But it is definitely in the roadmap, because we've gotten a lot of feedback on that. And actually, after our last call, I dug in to see where in the feature priority list it was. So it's not in the initial release. But one of the things that we're doing different with G seven is we have a cadence, we call it our release trains. But we have a whole cadence of things planned for the next couple of years to bring significant value to customers through new versions of the app we've been in the past, you know, which is six, we didn't bring, you know, we did a number of enhancements to it. But they weren't as frequent as I want, as we want. And so what we're working on is, how do we bring more value faster, and it's really doing a lot of what, you know, the tech industry does, in our software team looks much, much different today than it did even a couple of years ago in terms of size, capability and breadth. So what I'm really excited about what we're going to be doing with our apps, as we continue to go forward,

Scott Benner 31:32
do you anticipate more frequent app updates than have been normal in the past?

Jake Leach 31:37
That's, that's the intent. That's what that's the expectation we've set for ourselves is that we're going to be developing features at a much faster cadence than we had in the past.

Scott Benner 31:47
Okay, so I'll hit you with these little things that seem like messages more than questions since the last one, like it might have helped in the past. One of them was overwhelmingly more Android phones, please, which we already talked about. People feel very passionate about the packaging being lesser every time and the ability to recycle things. A lot of people give feedback about that. And then there's a message for you here, which I'll save to the end. But this is the last question, which I think is hilarious as you're trying to get g7 through the FDA. What is GA going to be like?

Jake Leach 32:23
Well, we wouldn't be we wouldn't be Dexcom if we weren't already working on that. So yeah, absolutely, we are working on GA, it's a another kind of step in the wearable technology, making it you know, less than even, you know, more discrete. Manufacturing scale, right, that's become a very important part of how we design our sensors is we need to be able to manufacture you know, hundreds of millions of them. And so there's a bunch of that kind of technology that's going into g8 g7 is going to be a big focus for us, though, our plan is to roll it out as fast as we can across the globe and reach millions of customers with it. And so, yeah, GA is a program, we are running it, and we're excited about what's going on there. But you're not gonna get any secrets at me today.

Scott Benner 33:11
Well, then I'm still gonna ask my last question. Do you have any idea when this might happen?

Jake Leach 33:17
You say an FDA approval and g7 lunch? Yeah, my expectation is it happens this year. We've got you know, we're in that back and forth period with the FDA. Things are going great. We're really happy with how the good the interaction. And so you know, we're thinking sometime after Ada, likely So Ada is coming up here in June. And so, you know, our last earnings call we talked a little bit about, you know, our expectation is sometime after AD will get approval, and then we'll be launching but in a meaningful way this within this this year. It's not like we're launching on December 31. That's not our intent, right? Of course, regulatory timelines are always I've always Kevin CRC, you know, everybody asks us to predict when the FDA approves the product. And so it's, you know, we basically are saying our best estimate at this point, given what we know today is that it'll be some time after ADA but will allow a full launch at but this year, Jake,

Scott Benner 34:14
Kevin's more fun around these questions. And you are, I just want you

Jake Leach 34:17
to know he can be

Scott Benner 34:20
and there's a number of messages from here from people who just wanted me to say thank you for the technology. So I won't I can't read them all to you. But a lot of heartfelt thanks came through as well.

Jake Leach 34:31
Very, very much appreciate all the folks that that use our technology every day to you know, help them manage diabetes.

Scott Benner 34:38
Yeah, no, thank you for taking the time to do this. I appreciate it. Cool. Thanks, guys. Take care Jake. Jake, you think we'll be doing this

I bet you want to know what I asked Jake when I shut off the recording and what he answered, but I guess I'm telling you thank you so much to Jake leech for coming on the show and talking today about Dexcom g7. And thank you to us med for sponsoring this episode of The Juicebox Podcast head over now to us med.com forward slash juice box or call 888-721-1514 Get your free benefits check and get started today with us med. Getting your diabetes supplies should not be difficult, and with us med it won't be

if you're new to the Juicebox Podcast, hit subscribe in your podcast app or any audio app that you're listening in, for instance, audible Spotify, Apple podcasts, etc. etc, etc. Hit subscribe or follow follow and subscribe. Get the next episode right there on your phone. If you're looking for support online, the Juicebox Podcast has a Facebook page it is a private page with nearly 25,000 people in it. They all use insulin or love someone who uses insulin. And they're having vibrant and valuable conversations all day long that you may enjoy. You could get involved in them or just kind of look around and see how people handle things. It's actually very helpful. And a great way to learn about type one diabetes management and the use of insulin in general. So I'm saying type two as well. You hear me? Thank you so much for listening. I'll be back very soon with another episode of The Juicebox Podcast.

#675 How Affordable Insulin Happened

Martin Van Trieste is the President and Chief Executive Officer, Civica Rx. Civica is making affordable insulin.

+ Click for EPISODE TRANSCRIPT

Scott Benner 0:00
Hello friends, and welcome to episode 675 of the Juicebox Podcast.

On today's show, we're gonna have a conversation that I didn't think I'd ever have on this podcast. It's with the CEO of a pharmaceutical company whose goal is to make insulin and make it affordably. I know that's weird, right? Please remember while you're listening that nothing you hear on the Juicebox Podcast should be considered advice, medical or otherwise, always consult a physician before making any changes to your healthcare plan. We're becoming bold with insulin. If you have type one diabetes, and are a US resident, or are the caregiver of someone with type one and a US resident, you are eligible to take this survey AT T one D exchange.org. Forward slash juice box. It's a quick survey. It's not hard. Your answers help people with type one diabetes. It also supports the podcast. It's completely HIPAA compliant. Absolutely anonymous, simple to do, you really can't go wrong. T one D exchange.org. Forward slash juicebox.

This episode of The Juicebox Podcast is sponsored by the Contour Next One blood glucose meter. Learn more about my daughter's blood glucose meter and buy it even if you want at this link. Ready, I'm going to say the link contour next one.com forward slash Juicebox. Podcast is also sponsored by us med. US med offers white glove treatment to its customers, you can get your free benefits check at us med.com forward slash juicebox. Or by calling 88087211514. Start getting your diabetes supplies from us Med and get rid of the headaches that you have now, wherever you currently get your diabetes supplies.

Martin Van Trieste 2:19
My name is Martin Van Trieste, President and CEO of civica. civica is a nonprofit Generic Pharmaceutical company whose mission is to bring quality medicines that are always available and affordable for everyone.

Scott Benner 2:33
Okay, I want to find out how you got to this. So I'm gonna go back pretty far. What did you do in college?

Martin Van Trieste 2:40
So I'm a pharmacist by training. So I got a degree in pharmacy from Temple University School of Pharmacy. And as I was graduating pharmacy school, I had a chance to do an internship at Abbott Laboratories in Chicago, and I decided to take that. And ever since then I've worked in the pharmaceutical industry.

Scott Benner 3:01
Did you go to college with the intention of dispensing pills? Or did you think you were always going to go into Pharma?

Martin Van Trieste 3:06
No, I went to college that game on Sunday with all my own little pharmacy.

Scott Benner 3:10
Really? That's great. That's really interesting. Is there something about it that moved you was just the opportunity and you enjoyed it and just kind of stuck with it?

Martin Van Trieste 3:20
Yeah, I think the first I had the opportunity to go into industry and experience what industry were like when I was an intern. I thoroughly enjoyed that. At that time, I began to become aware of the little mom and pop pharmacies were closing faster than others were opening. And I said, you know, probably don't want to work for a chain pharmacy, or hospital. And so I went into industry, I don't want to date you, but about what year was that? So I graduated pharmacy school in 1983. Okay,

Scott Benner 3:51
so yeah, it's interesting, right? You you grew up with this idea in your head, and then the landscape shifts right out from under your feet, I guess.

Martin Van Trieste 3:58
That's it within a really quick time period. So when I went into pharmacy, there was definitely an opportunity to have a viable pharmacy and when I came out that opportunity had been gone. So just five years

Scott Benner 4:10
well spent that change. It's really fantastic. How quickly could happen. Okay, so you above what did you do the for that first job? Were you in compliance where you

Martin Van Trieste 4:21
say I was in I was a research pharmacist, so I did formulation development. So I was the one who took the active ingredient and made it into something that was pharmaceutically elegant that you could actually administer to a patient. So they could consult to be effective.

Scott Benner 4:39
Yeah. Did you work on anything that you're particularly proud of?

Martin Van Trieste 4:45
Not when I was an intern.

Scott Benner 4:50
You weren't allowed back close to the I

Martin Van Trieste 4:51
guess. I guess I have to be careful about that comment. So I met my wife who was also a an intern at Abbott at that same time, so I worked on Making a family I

Scott Benner 5:01
guess. There you go. Yeah. So you're you're definitely proud of that. But I know my wife will tell me all the time. My wife's in drug safety. And very interestingly, she went to college to be a doctor. And when she got out, she had a little, a little kind of falling out with her family and she just couldn't afford to apply to med schools. So she got a Kelly Services job, they Kelly does scientific stuff, too. And she just was really good at the safety stuff and stayed with it. And she tells me all the time about her second job out of college was with a very small pharma company called forest labs. So she worked on Celexa and, and she's, she's really proud of of what she did with that when she was younger. So that's what what made me ask. Okay, so do you jump on? I mean, Pharma is one of those jump around jobs. Did you bounce around a little bit?

Martin Van Trieste 5:52
Yeah, I mean, I think you know, what I would have to say is, I worked at Abbott for 21 years. Wow. And why was it Abbott, I did numerous kinds of roles. I was a formulation pharmacist, I worked in manufacturing, and then I was in quality. And I left Abbott as the head of quality for the hospital products division. And what happened is, when I was at that point, my career, Abbott had spun off the hospital division to become Hospira. And I said, you know, what, I spent too much time building the organization that I didn't want to be part of the one that was probably going to tear it down, you know, as a standalone company. So I left there, I went to bear healthcare is their global head of quality for their biologics group, based in Berkeley, California. So from Chicago to Berkeley, and then I moved after two years at in Berkeley, I went to Amgen and 1000 Oaks, California, where I was their chief quality officer.

Scott Benner 6:56
You have a little the Chicago in your voice. I don't go Yeah. So when you were moving around inside the company like that, was it a case of you getting bored? Was it a case of you wanting to learn more, or were people poaching you because they saw your work?

Martin Van Trieste 7:14
I think it was a combination of my leadership wanted me to be a well rounded, professional. So Abbott was good at making sure people got exposure to different parts of the company. So when they became an executive, they were well rounded and understood how the company were. So it was partly that it was a little bit partly because, you know, I didn't get bored, but I always wanted to do something different.

Scott Benner 7:44
I understand at some point, you start feeling like you're doing a repetitive job. And that feels like it's time to move, right? Yeah, yeah. I when I was in eighth grade, my guidance counselor said you should be an attorney. And I said, but then I'd be an attorney every day for the rest of my life. And I just, I couldn't imagine even as a little kid, like, doing the same thing over and over again. Anyway. So what I guess the question is, is that what did you pick up along the way or see that made you want to make this leap from Amgen to what you're doing now? Well, it's

Martin Van Trieste 8:15
very interesting. So I retired from Amgen Oh, I retired from Amgen and went into retirement. And one day my phone rang. And I typically don't answer my telephone unless I know who it is. And it rang. I had no idea who it was it says a Utah area code. And for some reason, something said answer this phone call, which is like I never do that. And I answered the phone call. And it was a gentleman by the name of Dan Lilly quest. He was a chief strategy officer at Intermountain Healthcare. And he was talking to me about starting a nonprofit, pharmaceutical company, and he was telling me about his ideas. And he asked if I would come to a meeting that they were having in Utah, where he's bringing in various advisors to, you know, beat up on his idea to see how it'd be how they make it successful. And they were politicians, health system executives, pharma people, academics, so wide group of people came to this meeting in Utah. And I had known no interest in going, right. But I looked at my wife, I said, we haven't been to Utah. All right, let's go to Utah and make your day better vacation. And then one thing, you know, led to another, I kept providing advice over some time to them. And they got to the point where they're gonna announce the official name of the company and started the company. And he had called me about it and I go, Dan, do you have any employees the company yet? He goes, No, thanks. So you can announce some company, whether snow would work. So They said, Well, can you hire some people for me? So I hired the original team at the company. And then I said, Okay, Dan, what are you going to do? Now you need a CEO, someone needs to leave these people I just hired. And I gave him some names to some people. And they came back and they said, no, none of those that they want to do a bigger national search. I said, guys, you're gonna delay you know, the start of this company by a year from do a big national search. I said, You got to, you really got to look at these people are. And one thing led to another dad called me one day and says, we got the answer. I go, good, who to hire, because I got to tell the other ones why they didn't get hired. He goes, No, we want you to be the CEO. I said, you know, what, don't you understand about retirement? I'm happy. I'm retired. I'm just dabbling on the edges helping you? No, no, we want you to be the CEO. And I think I said no, on eight consecutive days, multiple times during the day, when Dan is a very persistent individual,

Scott Benner 11:06
I gather.

Martin Van Trieste 11:09
Finally, my wife tapped me on the show or said, Look, you should probably do this job. It's, you know, it's exactly what you've been preparing for your whole life. You know, your your experience in developing all the drugs that are on the list of drugs we're gonna make are on drug shortage. And I may either formulated them as a pharmacist, I manufactured Deb, where I oversaw the quality of them when I was at Abbott. So So I said, Okay, I'll do it. I told Dan, I said, I'm going to do this job, so you can find her my replacement. So I'm only giving you six months to find my replacement. Four years later, I'm still doing that.

Scott Benner 11:51
Are you Are you pleased about it?

Martin Van Trieste 11:53
Oh, yeah. No, I thoroughly, thoroughly love the work. And you know, it's more of a volunteer assignment for me, because I get no compensation from the company. Oh, no. All Pro Bono. So it's really, it's really been interesting and fun. And I have loved the team we've put together I mean, how many times in someone's career do you get the higher your entire team from scratch? Right. So it's a great team. It's been a lot of fun. And we've had great success. We've done a lot of great things. And so, so yeah, it's been it's been a real pleasure.

Scott Benner 12:29
I interviewed the gentleman that put together the production floor for Omni pod. And his story is so similar to yours. It's fascinating. He was retired from a soda company. And, you know, somebody said, Hey, come take a look at what we're doing. You have any thoughts? And then the next thing you know, he's not retired anymore. But you're not taking a salary. So you were retired and comfortable. And, and you're doing this? I mean, okay, I see why you helped in the beginning and I even see why you took the CEO position. How come you didn't bail on in six months? What kept you there?

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Martin Van Trieste 17:09
Oh, why imbalance expense? Because there was always another challenge? You know, we did we achieved our first big objective, right? And then what's the next object? Right? So there's always a big challenge ahead of us. And at some point, you know, you got to look at it and say, though, always will be a challenge. If you do your job correctly, if you're trying to change the industry and transform and disrupt the way things have been done, but front of you, there's always going to be challenges ahead to keep it interesting.

Scott Benner 17:38
Excellent. So what did you I mean, what were your first steps? Obviously, you set up the company had needed employees. But you're I mean, can you talk a little bit about the difficulties and some of the things that came up in that room when people were trying to shoot holes in this idea of like, what what are the I guess my question is, what are the big obstacles into getting into such a? I mean, into a space that makes a lot of money for the companies that are in there. When you're saying we don't? That's not our goal? How do you get into that? How do you not end up in an alley beat up by?

Martin Van Trieste 18:14
A lot of people ask, Are you afraid that someone's going to kill you? I said, you know, the pharmaceutical industry is so used to competition, right? And for people to try to do things differently, that it doesn't pose a big threat to them, right? Because they know there's always going to be someone doing that and they prepare for it. And they have something new that they're introducing in the marketplace. The other thing is remember we're working on old generic, very old generic drugs that are on shortage. And by just that definition that they're on shortages. People don't want to make them anymore. Okay. Right. So there's, there's limited competition, the drugs are on shortage. So So that's part of it. The other part is, you know, people took us for granted, they didn't think we could do it. I remember one quote from the CEO of a very large generic company, who said to one of our members, the CEO of a large health system, go you know, you guys don't know how to make drugs, you're not going to be successful. You don't bother me. And I think that was a prevailing thought process. When we introduced the company that they thought, you know, a bunch of hospital executives aren't gonna know how to make drugs. They didn't realize that the hospital executives are really smart and they hired a pharmaceutical executive. Pharmaceutical team knew how to do

Scott Benner 19:42
that. Did you go look at his back catalogue of drugs and decide which ones you could make? Just to show him

Martin Van Trieste 19:50
actually, how we select our drugs is really, really interesting. So civica is a member driven organization, right? So large health says firms are members of the company. And they decide what drugs we should make. So they look at their portfolio of where they're having trouble finding a drug. And then they look at what is the patient impact for not having that drug, okay. And they prioritize it together to say, here's what we want you to make. Now, it's a great idea on paper. But when we went to execute it, I thought this was going to be total chaos. Right? We had 60 people in a room, hospital pharmacists supply chain professionals, nursing nurses, in a room to say, we can only do 10 drugs to start in the first year, what 10 Do you want us to make, and her over two, at that time, there were like 280 drugs on the FDA drug shortage list. And over half of them were sterile injectable products were, which is what our focus was on. And I thought this was going to be total chaos. Right? It was a four hour meeting. And after the first hour, we had consensus on the first 25 drugs that we should work on. And they actually prioritize them one through 25. So I was pretty impressed, because that really showed what was important for the patient was into getting a bunch of people in a room who could agree on something that quickly says they're really focused on what that patient needs. Yeah.

Scott Benner 21:28
And it means they all they're all seeing the same thing over all right, yeah, was insulin on that initial list of 25.

Martin Van Trieste 21:35
Insulin was not on that list of 25. But it was something that people were asking us about, because insulin is not was not on shortage, it was high price. But it wasn't on shortage, right. So we want to focus on the drugs that were on shortage. And I was in I was, I really did believe that the marketplace would fix the insulin problem. As generic insulin would come to the market, the marketplace would correct itself. And we watch that market very carefully, hoping that the marketplace would correct itself, and it hasn't. And so we had a bunch of philanthropic individuals come to us and said, Can you make insulin. And we said, we can that we did look at it, we know how much it costs to bring it to the market. And they said Walmart will raise the money to make it happen. So Dan, Lilly quest led that initiative for us. And we set a goal of $125 million in capital to be raised to bring the three different insolence to the market. And those three insolence would be the generics of Lantis, human live, and overlock, which is about 80% of the insulin used in the United States. And that's why we picked those three, and they were off patent, which is important. And we're on well on the way we've raised over two thirds of that 120 $5 million to bring those three molecules to the market. And I'm pretty sure by the end of the summer, we'll have all of that money.

Scott Benner 23:09
Wow. up when you said you thought that the market would correct on insulin, it never did. Do you have an idea about why or a guess? Yeah, I'm

Martin Van Trieste 23:19
pretty confident. I know why. And it's these perverse incentives that creeped into the market. So the higher the someone raises the price on insulin, and gives giant rebates to a pharmacy benefit managers, these are middlemen between the pharmaceutical company and the patient. And they're negotiating contracts for insurance companies in large employers, and they develop these formularies. So if you go into the pharmacy, there's a formulary. And depending on who the insurance company is, that drug that's higher on the formulary has a higher probability of being dispensed. So you have three insulins out there, they're very similar in the way they work. And so the what they want to do is to be very high on that formulary, they want to be the first choice. So what they do as they raise their price, and provide big rebates, the Pharmacy Benefits managers, who then put them higher in the formulary than anybody else. Now you have three players in the marketplace that are competing by seeing who can give the biggest rebate. And so it's estimated that probably 80% of the list price of insulin is a rebate is rebated to the PBM. So if you look at that means $100. If the if Lilly raises they've crossed $100 For VIOME Lilly insulin, that means $80 has been given to pharmacy benefit

Scott Benner 24:50
managers so they put you higher on the list. So that

Martin Van Trieste 24:53
puts you higher on the list. Now what happens is for those who have no insurance Right, they pay that list price. And insurance company negotiated a lower price through that pharmacy benefit manager. So an insurance company's paying the $20 per $100 spent, right? So the person with no insurance, or have big deductibles in their insurance plan, pay that list price until they can get something, you know, till they meet their deductible or they pay it the entire year. Okay, so what that says is, the sickest people in society pay the highest price for their medications. And that seems the that's the perverse way what insurance is supposed to do, right? Insurance is supposed to say, the healthy of us take care of the sickness. Right. But because these perverse incentives have creeped into the system is broken the insulin market and it's an it's not going to get fixed easily.

Scott Benner 25:58
How did if you know how to pharmacy benefits managers wiggle their way into this system? Was it through large employers?

Martin Van Trieste 26:06
I honestly don't know the history of how that all started. Okay.

Scott Benner 26:11
Yeah. So this, it's kind of crazy, because it's almost like it's a little like three card monte when you're talking about it. So. So the insurance company is are they paying more like who's paying for this? Because if the people who were insured, I mean, there, I pay, I don't know what I pay it, to be honest with you. 20 $40, when my daughter gets insulin, I don't think it's much I think my health care probably cost. I hate to think about it, but I have recently, I've a family of four, we might be around eight $9,000 a year, like when you know, what comes out of the check what's out of pocket, etcetera, etcetera. But I mean, after that, who's, who's paying for this.

Martin Van Trieste 26:57
So, the way the system is set up, the benefit never reaches the patient, right? So you would assume that if there's rebates being paid the pharmacy benefit managers that some of that rebate makes its way to the patient, and that doesn't happen. So pharmacy benefit managers are providing money to the insurance companies to large employers. And it's being dispersed through the system. But the vast majority of that of that rebate stays with the pharmacy benefit manager.

Scott Benner 27:29
So these people are just passing money around to each other. That's right. Okay. What percentage of patients do you think aren't covered by insurance? So who is really being hit by this numbers wise?

Martin Van Trieste 27:44
Yeah, that's a good question. It's and there's not a good statistic on that, that I've been able to find. But I hear enough horror stories about people and the cost of their insulin that says that we'll be able to have a pretty significant market impact. Great. And remember, it's not just those without insurance. It's also those who have those high deductible plans. Yeah, no, sure. Right, that unique need to meet your deductible. And we're and at the end of the day, if we can transform and disrupt this system, really helpfully premiums can be lowered for people who have insurance.

Scott Benner 28:21
Why? Why are they not fighting more about this? Where are they are they just see you described earlier, a scenario that made me think the the way the NFL works, which is offense is developed something then defensives figured out how to get through it, and then the offense changes? Are they just changing their offense right now? Are they letting you do this?

Martin Van Trieste 28:42
Yeah. So I think they're, they're not taking us for granted because we have a proven track record that we can disrupt and transform. But it's part of our society is what have you done for me this quarter? Right, I have to meet my quarterly objectives to my shareholders are rewarded. So they're not focused on something that's coming out in 2024. They're focused on what's coming out in May, August, right. So it's that short term view of the world that I think, but I do see, as we get closer to the launch of civic insulin, we will see a bunch of gnashing of teeth of those pharmacy benefit managers. But they also will shift the rebate game away from insolence some other product.

Scott Benner 29:31
Okay. Just some other vectors gonna get hit by this.

Martin Van Trieste 29:35
That's right. Yeah. So if you think about it, the first big rebate drug that comes off patent will be humera in 2023, used for arthritis and psoriasis, and so forth. That's the first big drug that pays a lot of rebates. It's going to come and get generic competition. And we'll watch what happens in 2023? Will the generic companies play the rebate game to try to get better preference on the list? Or will the generic company one generic company say I'm going to try to break the system? So we're going to watch that closely. Okay, I the actress or Milan slash NaVi actress Aviatrix, now they have generic insulin called sem sembly. Right. And when they introduced it, they tried to break the marketplace with a low price. But they then had two versions of the same product, one that played the rebate game, and one that just has a low price. Okay, we're trying to serve two different marketplaces with that,

Scott Benner 30:43
well, that work because that's always what I've wondered, I've always wondered why the big companies don't just, I mean, from my, I have a bit of a hippie attitude, you know, and I always just thought, like, well make the money the way you're making the money off the insured people and everybody else just give it to them. Like, who cares? Right? Is that not viable?

Martin Van Trieste 31:02
Well, they're not doing it. Yeah, no.

Scott Benner 31:06
Well, why don't have the viable and palatable are the same thing. But you know, I was, you don't mean, like, at some point, do you just? Well,

Martin Van Trieste 31:15
they're all these companies have patient assistant programs. Right? The really, really poor people have access to the medicine. But it's more affecting your the middle class, I would say, Okay, who don't have the insurance or in between jobs, you know, things of that nature?

Scott Benner 31:35
Yeah, yeah. How are you? So in this idea, where you just kind of keep paying attention to drugs? Like how many drugs do you manufacturing right now.

Martin Van Trieste 31:43
So we offer 60 products to our members. We don't manufacture anything right now. We acquire them through other suppliers. So remember what I was saying drugs around shortage, that means people used to have a license to make something and they stop, or they're having difficulty making it. So we try to find alternate suppliers, bringing them back into the marketplace, by providing them a better economic model than what's currently in the system?

Scott Benner 32:14
And are you able to accomplish that because of the collection of hospitals that you're feeding, so you have enough need for them to go back into manufacturing?

Martin Van Trieste 32:22
Right, so we guarantee them a certain market size, and a certain market price for a five year period. Okay, so they we've taken uncertainty out of the system for them, right, know how much you're gonna charge how much they need to make over a five year period. And the other thing we do that's different than the current system, is we go to them and we say, You know what, we want to buy this product from you. And we'll pay you the day you deliver the batch to us. Current system doesn't do that current system, you take it and put it into the wholesale network. And the whole seller pays you after they sell it. Yeah. So it could take you six 810 months a year to be paid for a batch when we pay you instantly. So we're changing the model. And we also then tell the supplier, you don't need to keep inventory, we keep all the inventory, and we'll keep six months of the inventory. So there's always resiliency in our supply chain, so we won't have a shortage. When I

Scott Benner 33:27
was growing up, my buddy worked in a bookstore is a long time ago now. Over 1300, Geez, how old am I it's over 30 years ago. And you know, paperbacks would come out. And they sell as many as they could. And when they were done and the interest was gone. If they had 10 books left, they'd return eight of them. But the way they got returned was they rip the covers off of them sent the covers back to prove that they hadn't sold them. And then the books were just destroyed. And I don't know what about what you just said made me think about that. But I think that most people who don't understand how this stuff works, would be shocked to know that you don't I mean that that, um, so that you're paying up front? Is that got to be a huge comfort to them. And are you actually using the drugs? You're not? Are you? Are you getting stuck with stuff that you are doing books with covers ripped off from laying around?

Martin Van Trieste 34:17
No, no, we've not had any product. We have 60 products we offer our members. Remember, we have guaranteed business from our hospital systems. Right? We can forecast off of that. So we don't have product that expires because we know what the health systems needs are, what their buying patterns are. And so we build our inventories to support that

Scott Benner 34:39
it's amazing. It really is.

Martin Van Trieste 34:42
Now insulin is going to be different, right? Insulin is not going to be just given to our members. Insulin is going to be provided to anybody and everybody.

Scott Benner 34:50
Mark You're good at this. Hold on. Let me just scratch off my next question from my little tip sheet in front of you that I was writing. My next question was how do you get it out? side of the system to the people go ahead, how are we doing that?

Martin Van Trieste 35:03
So, so we're gonna give it to anybody and everybody. And of course, we're gonna have the help of diabetes advocates. So you know, JD Rh, right? Beyond type one. So these organizations that have raised money to support us to bring insulin to the market, are going to be advocates for us and let their pay their membership, know where our insulin is available, how much it's going to cost, etc, etc. So they'll be advocates for us, we will provide that insulin to anybody who agrees to our pricing policy, right. And so our pricing policy is for a vial of insulin, it will not be more than $30. And we're going to communicate that through those advocacy organizations, we're actually have a little QR code on our product labeling, so that you can read that QR code, you get the package insert, but more importantly, you know, there'll be a note that says you shouldn't pay more than $30 for this. So we're trying to give that information to the people with diabetes or their families. Let them know that if you pay more than that, you know, find another pharmacy. Somebody

Scott Benner 36:17
is up charging you. Hey, just for clarity you misspoke a second ago, you meant JDRF?

Martin Van Trieste 36:24
JDRF. Yeah.

Scott Benner 36:25
You said, Ah, that was oh, I'm sorry. No, don't be sorry. I just I was like this. There's someone I don't know about. I wanted to double check to see, okay, this has to go to pharmacies, then. I mean, there's no other way to distribute it right?

Martin Van Trieste 36:39
Well, it's what your call your definition of a pharmacy, right? So clearly has to be dispensed by our pharmacy. But a pharmacy can be at Walmart, or Costco, or Amazon, or a bunch of these new pharmacies that are being developed called Digital pharmacies. Okay? Right. So has to be dispensed by a pharmacy, but there are different kinds of pharmacies today than the brick and mortar ones on the corner.

Scott Benner 37:06
So this can be on this may be online as well, then. That's right, it could be online. And so you're, you're gonna direct ship from your, from your stock.

Martin Van Trieste 37:16
We it depends on how we're doing and who we're working with. But we could direct ship from our stock, I don't think we'll be using wholesalers.

Scott Benner 37:24
Okay, this was I sat in a room once, I don't want to say with what company and I kept saying, Can't you guys just ship it directly? Like, why don't you get out of this model. And it seemed like something no one was interested in at the time. But it made sense to me in the moment, like listening to the wash of what they thought their problems were and their things to overcome. I was like, just sell directly to people like start your own. Like, I remember saying in that room, like start your own. Just do it. I was like you could pay yourself I was I was kind of genius, Nolan. Everybody's like. So is the real thing here is that the way this is getting accomplished is through desire. And that and that somebody had to step outside of the system and and want to do this because inside the game, no one person could make this change, right? Like you couldn't, if you would have stood up and had this idea at a big pharma company, everyone would have just turned their back on you and walked out of the room because like, I need this job. I don't want to talk about this. Like, that is the thing, right? It had to start over.

Martin Van Trieste 38:26
Ya know, clearly, it needed a disruptive, transformative and innovative approach to be successful. And, and, you know, it takes startup companies to do that. You know, Big Pharma is traditionally very conservative. And conservative organizations try not to be disruptive.

Scott Benner 38:53
Okay. Yeah, yeah, that's what I see, too. I just, I mean, there was, because people are always saying, like, why don't you just why don't you just and I think to myself, like, if you were there, you'd know, that's not possible. Like it's theoretically possible. But once you get into the system, you're not breaking free of that idea. I mean, you know, you know, in your regular job, good luck getting rid of the birthday cake they bring out on Friday for people like you couldn't, you couldn't get consensus on stopping that, you know, so how are you going to get involved in this? Well, this is really kind of amazing. How, how long ago? Was that meeting in Utah? Tell me again.

Martin Van Trieste 39:32
So that meeting was, I want to say January 2017.

Scott Benner 39:39
Wow. So over five years ago, yeah, yeah. And just for people to understand, like the length of time that things like this take to happen. And because that person you've met with he had that idea prior to that even so you're you're over five years of just thinking Planning and trying. And then the next step is I'm trying to imagine how you get startup money from people when you're not trying to profit. That seems like that might have been a daunting task as well or no.

Martin Van Trieste 40:14
So it wasn't that hard. Okay, but it was, but it wasn't easy. Don't get me wrong, it wasn't easy. But it wasn't that hard. There was a there, there was a giant problem impacting patients lives in hospitals. But also, it was driving any efficiencies and higher costs in hospitals. So traditionally, what most hospitals have a drug shortage team consisting of pharmacists, supply chain, nurses, and even physicians, and they meet on a regular basis. And sometimes they move even daily, to say, what can we get today to treat the patients? And how are we going to have to do something different a different procedure, or buy a different drug. So now you have these people meeting every day, they're coming up with alternative ways of treating a patient, which means you got to train people in the hospital. And then you maybe have to buy more expensive drugs than the ones that were on shortage. It is estimated by like, you know, the Government Accounting Office vizient, which is a large group purchasing organization, that that's somewhere between 600 million and a billion dollars annually, that's added costs in the health system. So you have that pain and suffering that's going through the health system, patient care, and financially. And you want to solve this problem. So you have a big problem that wants to be solved. And we asked you for some startup capital to go do it. And it's not a hard sell. Okay? Right. So we very quickly brought in about 1/3 of the hospitals in the country into our membership group. Now, when we just go and talk about insulin, that's another type of different kinds of thing. The pain and suffering that diabetics deal with every day, with die price insulin and rationing their insulin, not taking their insulin right leading time really bad consequences for them for doing that. Over the long term. There are a lot of people who are wealthy, that want to change that that paradigm, and they gave us money. You talked about the length of time. You know, we're building our own manufacturing plant in Virginia. And that plant was originally designed to make these drugs that are on drug shortage, that that process from the time you say, let's go and do it to the time you're completed is about five years. Yeah. Right.

Scott Benner 43:07
It's a it's a long haul. It really is. Do you think other? Well, I have a question before that question. When you're talking about the flange, the flange? Where did that word just come out of people who want to help you? I'm not gonna sit here and try to say, say that word that won't come out of my mouth for some reason that I clearly know. When you when you're trying to get money from those people. And it's coming in? Do you think it does it need to keep coming or once you're up and running, you'll be okay.

Martin Van Trieste 43:38
So our entire business model, both on the drug shortage side, and on the incident side, is once we're up and running with any particular product, that product has to be self sustaining. Okay, so we have to charge enough for an individual product, that it's self sustaining. So we operate on a cost plus basis, what does it cost us to make a particular product? Let's add a little bit of margin to that. So the product is self sustaining.

Scott Benner 44:10
Okay, that's amazing. So the end, these donors are not expecting any return on their money at all, or they are. They're not. Okay. Wow, I didn't know if that was part of your business model where eventually the money comes even just their initial money comes back to them or not. Do you think? Do you think that this is something that you can scale to keep impacting things? Or do you imagine other companies might start up like you and do similar things in other spaces?

Martin Van Trieste 44:38
So clearly, there's there's enough things that need to be corrected in the in the marketplace that there's room for lots of competition? Yeah. And we don't view it as competition. Right, because our whole goal is not how much market share we get. That's not our goal. It's how much market impact we make. Right? We fix To America, but there are other nonprofits starting up that are trying to do similar things and other pieces of the of the area. You have other organizations that are for profit that want to break the system and do things differently, all those digital pharmacies, they're trying to break the system. You have Amazon, they're trying to break the system. Right? So you have lots of lots of people trying to do things different in this marketplace to try to change it.

Scott Benner 45:26
Do you think if the system was successfully broken down, would that drive the major players out of the insulin game or other drug companies from making drugs?

Martin Van Trieste 45:36
I don't think people would leave the market. Especially the insulin market, you know, Lilly and Nova and Sanofi right are heavily invested in insulin. And they're always working on how to make improvements. So I just read yesterday that one of Lily's drugs, that lowers blood sugar causes weight loss, and just like novice drug does, and so they're looking at taking that a product that lowers your sugar levels to drive weight loss, right? So they're always working on something in the space are always figuring out how to make improvements. And like I say they're used to generic competition. They've right since 1984, the hatch Waxman Act has encouraged generic competition. And so they're used to it and they're always trying to innovate. So if their product goes off patent have something to replace it.

Scott Benner 46:29
You didn't get any pushback politically for this.

Martin Van Trieste 46:32
Oh, no, everybody, the entire political spectrum, basically loves us. Okay. It's a bipartisan issue. Right? Patients are Republicans, Independents, and Democrats, they all hear the pain that patients have gone through. Every time I go to Washington, it's amazing. Every time I sit with a congressman or a senator or their staffers, how positive they are about us, they're encouraging us to be successful. And so no, it's it's very positive from Washington. Now, I know others are lobbying against us Sure. Every, every time I go sit with the senator or congressman, they, they basically say, when you're going to do insulin, when you're going to do insulin, that was from day one, when you're going to do insulin,

Scott Benner 47:23
do you find that what they're saying in the room is reflected in their actions in public?

Martin Van Trieste 47:29
You know, in public, they can't agree on anything. Right? Right. I mean, they wouldn't even be able to agree that Washington's Birthday should remain a holiday. Right? So to me, you know, what they do publicly is, you know, is is very, is very partisan. And this this issue, you know, at least insulin, they're talking about a $35 cap on insulin. And that actually is very complementary to what we're doing, okay? Because if you do a $35 cap, the pharma companies are still going to charge the price they charge, you're still gonna give rebates to pharmacy benefits managers, so someone has to backstop what the current price is to the $35 cap. Yeah, right. So whoever is paying that backstop, if it's the government, and we're charging $30, they benefit from what we're doing. Right? If it's an insurance company, they're benefiting from that backstop. And by the way that that $35 cap only affects someone's copay. Okay. All right. So if you're uninsured, that doesn't help you that $35 backstop.

Scott Benner 48:44
Right. Well, you know, it's it's just it's almost, it's angering it is for me, it's angering to think that this entire problem is built off of people just like basically lining pockets to stay higher on a list so they can sell their thing. And at the same time, I actually understand how they fell into it. Like once it was there, I understand why they played the game, you know, where they wouldn't be selling.

Martin Van Trieste 49:08
And I think the game started with EPI pens. Really. That's where someone was smart enough to figure out. Okay, generic competitions coming from my epi pen. I charge right now $300 For two epi pens. What I'm going to do is I'm going to and when I was charging $300 for two epi pens, I was keeping $260 and the pharmacy benefit manager was getting 40 Okay, I'm gonna raise my price, I'm gonna double my price. I'm going to double it to $600 and I'm going to give $300 to the pharmacy benefit manager to keep me at the top of the list and not put the generic guys anywhere on the list at all. And I now know I don't keep to under $60 I keep $300. And the pharmacy benefit managers, they don't get $40 they get 300. So now I want to bring a low cost epi pen to the market, I have to go to those pharmacy benefit managers. Right, I have to go through them for the get the insurance companies to pay for me. And I got generic epi pen I want to bring to epi pens for $50 to the market. And they go, but you gotta give me 300 to get on the list. Why can't give me 300 I'm only charging 50. It's

Scott Benner 50:36
like trying to get into a club in the 80s. Right, you just you grease some palms at the door to get in. I have two questions here. So my first one is, and I just want to kind of come from this from the other angle for a second. Is there how to I mean, this making a drug is not easy. You're obviously a bright person. Right? And and you have a lifetime worth of experience. And I think that as a as a layperson, I want bright people with lifetime's worth of experiences making drugs. Is there. Is there a world where you break the system so much that a kid coming out of college won't choose Pharma? And do we weaken the system that way? I know that's a real big picture idea. But I was wondering if you ever thought about

Martin Van Trieste 51:24
it? I mean, well, we think about it from a different perspective. Okay. So we say we do not want 100% of the volume for any drug. Because if we do that, eventually will become the problem that we're trying to solve. Right? Right, if we provide one or percent of any drug, and if something goes wrong in our supply chain, will no longer be able to provide that drug. And that's not good. So we try to limit the amount of a drug that we produce to no more than 50% of the market. And we work with our members to kind of worked through that those calculations and those forecasts and those commitments we talked about. So we're trying not to do that, from that perspective. Could we break the market in such a way that no one would want to go into the, into the pharmaceutical industry in the future? I think that's hard to do. I mean, one company can could hurt another company, right? I could take all the sales of insulin, for example. And, and Sanofi and Lilly and Nova would be really financially hurt by that. But that's just three companies in an industry that has 1000s of companies making pharmaceuticals. So I think it's hard for us to do to break the model so bad that people won't want to go into pharmacy

Scott Benner 52:57
and civic as an example. Are you compensating employees similarly to how they're they be compensated in a foreign?

Martin Van Trieste 53:05
Absolutely, I'm the only one that makes nothing.

Scott Benner 53:10
somebody's walking,

Martin Van Trieste 53:12
otherwise, we pay very competitive salaries, or I would not have been able to hire the team of people that I have. Yeah,

Scott Benner 53:19
I get that. It's just It's, uh, you know, in my mind, those people, they go to Expensive Colleges, and they come out and they have, you don't I mean, there's still people and they still have dreams, and they want to put kids through college, etc. But I think what we're really hearing is that some people civic are walking around with Martin's money in their pockets. It's a really, it's a really kind thing you're doing, I have a couple more questions, I'm gonna let you go. Have you ever considered open sourcing what you're doing going to other companies and sharing what's working and what's not working so it can grow?

Martin Van Trieste 53:52
We were very transparent organization, and we actively teach our model to anybody who wants to learn it. And so not only companies, but I've had foreign governments call me and say, How did you do this? What are you doing? What can we learn from it? So we're very transparent, and we do teach the model to people.

Scott Benner 54:14
It's wonderful. It really is. Okay, well, we have painted a really rosy picture of of insulin pricing in the future for people who I mean, you imagine mostly this is going to be people who don't have insurance, right? This is going to help?

Martin Van Trieste 54:28
Well, so it'll definitely help those people people with high deductibles. Right. But also, right. It'll help insurance companies, right, because insurance companies are paying a higher price and then we'll be selling it for so to help insurance companies and hopefully the insurance companies then lower their premiums based on those savings.

Scott Benner 54:53
I guess if I just want to stick it to the man I could buy your insulin if I wanted to. Right. But

Martin Van Trieste 54:57
clearly, I mean think about it, right? I go to buy some generic drugs for myself, right? I, I'm an old white guy, I have hypertension and high cholesterol and things, bad knees. And so you take take all your medicine. And so I know the cost of generic drugs and what it is, and I'll go to a pharmacy, and my insurance deductible might be $10 $15, right. And I go and pay cash and I pay $7. Or sometimes some of the generic drugs that I had take, there was one example, where I went to the pharmacy, and they wanted to charge $250 for the drugs, right, and my insurance company, that was my deductible with the insurance company to their $50. And I went on good RX. And I found out if I go next door to the pharmacy next door, it'd be $25. Right. So clearly, there's games going on, in, in the insurance space, too, that people should be aware of tools like good RX, and things like that, to get that information to have the power.

Scott Benner 56:08
So you might not I don't know if you'll be comfortable commenting on this. But I'm just asked me a question. So there are for profit, people who are still delivering drugs at more affordable and really affordable prices, their people are still being well compensated. We're talking about like obscene wealth at the top of organizations, right? Like, I don't have a Maserati, I have seven miles or Audis. And so does my wife and my girlfriend like that kind of thing. But right, it's just, it's a piling of money at some point. Am I right about that?

Martin Van Trieste 56:38
Well, CEOs in all industries are highly compensated. Yeah. But that doesn't, that has very little to do with the price. Right? Because you can deduct, you can say that person gets no money, it's not going to significantly lower the price of any of the medications, right? Because one, people are trying to maximize the, for a for profit company is designed to create shareholder value. Yeah. Right. So the way you create shareholder value is either you increase your sales, increase your price, or cut your cost, right, there's no other way to create that shareholder value. And that's, that's what people are supposed to do in a for profit space, right?

Scott Benner 57:20
I had a person come to me once and with this idea, and they said, Well, why don't they just stop marketing, if they put so much money into marketing, and I said, you're gonna fire the marketing guy, I was like, He's 50. He's got two kids, one of them just went off to school, he's got diabetes, now he can't afford his insurance like, and by the way, when they fire him, they're not going to take his $100,000 Or two, whatever the hell he makes a year and split up between all of us. And even if he did, the, you need a quarter of a penny that badly, you know, like, it's, it's a big, you really have to understand the space to impact it's so great that you were able to pull that group of people together, or those other people as invested in like, a civic, I guess, is the feeling I get from you. Is it pervasive? Or you don't I mean, like, sometimes people are just selling widgets, you know what I mean?

Martin Van Trieste 58:09
So I would say clearly, the clearly the leadership team is, is looking fast, right? I mean, it's hard to get people to change jobs, right, who are highly successful in their industry? Sure. And they change jobs, because they believed in the mission and what we were doing. And it's interesting that the rest of the organization, the number of people who come to us, say, I want to work for you, I want to make that difference. Yeah. Right. And I can't make that difference where I'm working today. I'm like the cog in the gears, right?

Scott Benner 58:49
That's very interesting. My wife talks about that all the time that she, she felt she felt more fulfilled as a as the parent of somebody with diabetes when she worked at a company who just made diabetes stuff, you know, and not that she doesn't enjoy her job now, but that she there was extra for. It's amazing.

Martin Van Trieste 59:09
And it is true, we found out after we made the announcement that we were going to do insulin, the number of people who want to come to work for us that had that diabetes connection, like you said with your wife was was overwhelming and not just coming to work for us. A bunch of people who are at the end of their careers said I'm going to retire I've come to work for you for free. Wow. Do what I did. Right? Because of that diabetes connection.

Scott Benner 59:38
That's terrific. All right. Well, all right. I'm sold Martin. When When does this happen?

Martin Van Trieste 59:43
So we'll deliver our first insulin and we'll be the biosimilar of Lantus Claridge clergy in early 24.

Scott Benner 59:52
No kidding. You think first quarter or do you not say out loud but you think I always say out loud Guess you're not publicly held, you can say whatever the heck you want. But

Martin Van Trieste 1:00:04
we're really pushing for the first quarter of 24. Okay? It's got to be a tight schedule and a green light schedule to get there. But it will happen in 2024

Scott Benner 1:00:15
is the similar human lager Novolog. Next,

Martin Van Trieste 1:00:19
so everyone will have a little bit of a lag behind it. So right, we've developed the first insulin, the our partner who's making the active ingredient does, he then makes the first one that has a turnover and makes the second one a turnover and makes the third and repeats the process. So Glargine will be first. And then the other two will follow

Scott Benner 1:00:42
shortly thereafter, in sequence, give a timeline for those are the All of those will

Martin Van Trieste 1:00:47
be in 24. It's about a quarter between each one to get the first ones to the market.

Scott Benner 1:00:53
Do you have to do you have a an amount of time you'll need to ramp and scale? Or will it happen pretty immediately?

Martin Van Trieste 1:01:01
Well, when I say we're coming out in 24, we've built that ramp and scale into Oh, that's beautiful. Now we anticipate that in our fourth year of operation, we'll have about 1/3 of the market for those products. That's based on a forecast. Yeah, you know, forecast are wildly incorrect, right? They're not they're not an accurate thing. So. So we'll say that it will all depend on how the Marketplace responds, right?

Scott Benner 1:01:31
Well, if you ever want to come back on here and let people know about it, I'd be thrilled to talk to you more. I think it's a really wonderful thing that you guys are doing. Am I not asking you anything that I should be?

Martin Van Trieste 1:01:44
No, you asked all the right questions, did I because I'm

Scott Benner 1:01:47
surprised by that. Martin, when we sat down what I knew was your name was Martin. So I just went with the conversation. Good, good.

Martin Van Trieste 1:01:56
I mean, you go through this, you, you you have association with diabetes, you know, what it's like, I have a question for you. Okay. So we hear from diabetics, that they keep large quantities of insulin, stored in the refrigerator for fear that there's going to be a shortage of insulin, or they can't afford to pay for it, change companies, whatever it is. I find that amazing that people feel the need to do that, in our very, you know, well to do society, right. Do you, does your family do that? Do you keep large stocks of insulin?

Scott Benner 1:02:41
So I have, I think because I'm gonna have to, I think because of a job change that my wife experienced, at some point, we got into a position where we had to send scripts to a new insurance through a new insurance company, and we got insulin that we kind of didn't need. And so we had some left, and then more came in. And then since then, I've been able to maintain that backlog, I guess, as a lack of a better way to put it. Prior to that, I would have felt uncomfortable. It's funny, I would have felt uncomfortable under four vials. And my daughter probably uses what she uses 200 units every three days. So it's not a I don't have that fear that you're talking about. But I have spoken to many, many people who have it. And I do generally subscribe to what you said there are literally four pharmacies within a mile of my house and I have insurance and if I needed insulin, I could go get it. I'm not pressured by it, but I understand when people are you know, I guess that's my answer.

Martin Van Trieste 1:03:51
Oh, good. It's really nice to meet you, Scott.

Scott Benner 1:03:53
You as well, Martin, this was this was absolutely terrific. Thank you, I wish you all the best with this thank you again for what you're doing. Right? You want to take a printer out of that place or a pack of paper or something you know what I mean? One time just be like this is Martin's and just leave with it. I like to see you compensated

Martin Van Trieste 1:04:15
I've been very fortunate in my life. We you know from a family we're having a great family and three great kids and you know working in great companies and you know I'm well to do and you know, this didn't it just didn't seem nice start take

Scott Benner 1:04:28
us out really lovely. And there's no diabetes in your family. Is that

Martin Van Trieste 1:04:31
right? No diabetes in my family. Okay, well, from all of us.

Scott Benner 1:04:35
Thank you very much. I really appreciate it. All right. Yep. Take care you too.

Well, let me start off by thanking Martin for coming on the program. This was an excellent conversation. I'd also like to thank the Contour Next One blood glucose meter and remind you to go to come contour next one.com forward slash fuse box to get started today. And let's not forget us med I wasn't going to forget them. I just you know, it's a way to start talking and let's not forget us med white glove service, always 90 days worth of supplies and fast free shipping. Get your free benefits check at us med.com forward slash juice box or by calling 888-721-1514

I have to go get knee surgery tomorrow. So I'm going to keep this brief. If you're enjoying the podcast, please tell a friend subscribe in a podcast app. That's pretty much it. Thank you so much for listening. I'll be back very soon with another episode of The Juicebox Podcast. It's a simple knee surgery please don't worry about me. I'll be fine.