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类型J.P. 摩根-美股-医疗保健行业-糖尿病设备调查:外胰岛素泵与CGM市场展望-2018.6.8-32页.pdf

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    J.P. 摩根-美股-医疗保健行业-糖尿病设备调查:外胰岛素泵与CGM市场展望-2018.6.8-32页.pdf
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    1、North America Equity Research08 June 2018Diabetes DevicesJPM Survey: Outlook for the External Insulin Pump Upgrading DXCM to OWMedical Supplies (2) integrated CGM and pumps, with the goal of achieving an artificial pancreas; (3) expanding access to care for patients; and (4) technology leadership. W

    2、e see Medtronic as the clear winner as the innovative 670G gains pump market share and expands CGM usage, as well as Abbott with its low-cost, easy to use Freestyle Libre glucose sensor. In addition, we are upgrading Dexcom to OW in conjunction with todays survey (here) as we see significant upside

    3、to both 2018 and 2019 Street sales forecasts on (a) better G6 patient adoption and (b) less downside from competitive launches than the Street is assuming in models. Open the note to review the extensive 27 question survey details. We are upgrading Dexcom to OW from N and raising our 2018 YE PT to $

    4、115, see separate Dexcom upgrade note (here). We see significant upside to both 2018 revenues (JPM $876M vs. Streets $860M) and 2019 ($1,037M vs. $993M) as we think the Street is (a) being too conservative on the near-term sustainability of Dexcoms Hardware business (transmitters and receivers), and

    5、 (b) assuming an overly significant headwind to both new patient adds and base business patient attrition due to uptake of Medtronics 670G and Guardian Connect and Abbotts Libre. We view managements $850-860M (+18-20%) 2018 sales guidance range and the Streets $860M as highly conservative vs. Street

    6、 high JPM $876M. We believe guidance and Street estimates assume that (1) hardware pricing is quickly deteriorating (its not), (2) G6 sensor pricing will get worse (in fact, management admitted there is upside to pricing), (3) the attrition in the existing user base would accelerate above elevated S

    7、treet assumptions (not supported by our survey), or (4) new patient adds would significantly decline in the face of new competition (we already assume a decline in 2Q18-4Q18). We would be long the Diabetes space into the June 22-26 American Diabetes Association (ADA) conference. We expect the confer

    8、ence to be a positive event for the broad space as (a) Dexcom shows off the just-launched G6, which by all accounts has been very well received, (b) Insulet showcases the just-approved Dash controller, which will be launched in early 2019, (c) Medtronic continues to highlight the excellent glucose c

    9、ontrol with 670G and demo the Guardian Connect, and (d) Tandem (not covered) comes out this summer with the t:slim X2 pump with predictive low glucose suspend using Dexcoms G5. Notably, Abbott wont be hosting any specific investor events at the conference, which we see as a messaging benefit for Dex

    10、com, Medtronic, and Tandem. Turning back to the survey, Medtronic is the clear winner as 670G is expected to drive both pump and CGM share gains. Similar to past surveys, Medtronic was ranked as having both the best pump sales force and customer service, as would be expected with its leading market

    11、share position, followed by Tandem and then Insulet. In addition, 670G was voted #1 in overall pump appeal for adults, #2 for pediatrics behind OmniPod, #1 in ease of ongoing use, and #1 in pump reliability. Completed 08 Jun 2018 02:49 AM EDTDisseminated 08 Jun 2018 02:53 AM EDT2North America Equity

    12、 Research08 June 2018Robbie Marcus, CFA(1-212) 622- Starting with insulin pumps, respondents expect 670G to drive 600bps of share gain from 2017 to 2019 for Medtronic, which compares to a 700bps loss for J and (2) Abbotts FreeStyle Libre is firmly viewed as a market expanding technology rather than

    13、a share-taker from Dexcom and Medtronic. This years survey again reads bullish for ongoing CGM adoption, with sensor utilization expected to increase for Type 1 and Type 2 patient demographics across the board. This is driven by a number of recent and upcoming product launches, including Medtronics

    14、670G, Abbotts FreeStyle Libre, Medtronics standalone Guardian CGM, Dexcoms G6 CGM, and Senseonics Eversense CGM. Respondents expect Type 1 CGM penetration in pediatric pump patients to increase from 45% to 58% in 2017-2019, 43% to 60% in Type 1 adult patients, and 24% to 39% in Type 1 Medicare-aged

    15、patients. In MDI patients, CGM penetration is expected to grow from 37% to 44% in Type 1 pediatrics, 35% to 44% in adults, and 21% to 35% in Medicare patients. These penetrations rates are higher than the national average, which we estimate at 20% for Type 1 patients, split 17% in adults and 34% in

    16、pediatrics, with 30% and 51% penetration in pumpers, 11% and 17% penetration in MDI patients, respectively, and 9% in Medicare patients. The survey was clear that Libre has a much-needed place in the market as a low-cost option, but it isnt viewed as a replacement for patients already on Dexcom or M

    17、edtronic CGMs. When asked which Type 1 and Type 2 patients Libre is most appropriate for, 60% said non-compliant patients using BGM, 46% said adult patients, 46% said those with restrictive CGM insurance policies, 43% said all Type 2 patients, and 37% said all Type 1 patients. This was followed by y

    18、oung adults and active patients (34%) and Medicare patients (23%), while only 17% said pediatric patients, where it doesnt currently have a labeled indication. What gives us more confidence that patient attrition at Dexcom wont materially increase due to Libre is that only 5% of respondents viewed L

    19、ibre as most appropriate for their patients already on Dexcom or Medtronic CGMs. This confirms our view that while Libre is a great product and can expand more continuous glucose monitoring to patients in an easy and cost effective manner, it isnt a substitute for patients on CGM. Instead, it likely

    20、 acts as a bridge between BGM and CGM for many. As we and the Street already model, Abbott and Medtronic are forecast to gain CGM share in the US share loss for Dexcom was roughly in-line with our model.The survey was over-represented by Dexcom users, with a 74-78% 2017 US CGM share in Type 1 adults

    21、 and pediatrics vs. 69% in our model, and under-represented Medtronic share. In the survey, respondents expect Abbott Libre share to grow from 2% in 2017 to 8% in 2018 and 12% in 2019 in adults (vs. 0% to 31% in our model for all patients) and 4% to 30% in pediatrics, although this is skewed by one

    22、high volume user. 4North America Equity Research08 June 2018Robbie Marcus, CFA(1-212) 622-Medtronic, inclusive of both the 670G and Guardian Connect standalone, is expected to grow from 20-21% to 27-34% (vs. a decline of 33% to 22% in our model). For Dexcom, share is expected to fall from 74-78% to

    23、62-65% in 2018 and to 43-53% in 2019 vs. 67% in our model falling to 61% and 48% in 2018 and 2019. Given the difficulty for physicians to forecast market share when so many new patients are starting CGM, we think the trends are more representative, and view the shifts for Dexcom as in-line with what

    24、 we have forecast in our model. Cost and patient self-consciousness continue to be the two biggest headwinds for CGM adoption. Three responses were cited by more than half of our respondents for their Type 1 populations: cost (83%); patients not wanting to “wear their disease” (60%); and availabilit

    25、y and ease of reimbursement (51%). When asked to compare Libre vs. G6 vs. Guardian Connect (which hasnt launched yet), Abbotts FreeStyle Libre was the clear winner on cost, but also led on ease of use and reimbursement access followed closely by Dexcoms G6. Libre ranked last in accuracy, behind both

    26、 G6 and Medtronics Guardian Connect. Medtronics Guardian Connect scored poorly on all metrics, though this may be due to the fact it isnt broadly launched in the market yet. Looking ahead to new technologies, Medtronics 690G is the most anticipated new platform on the horizon. With the diabetes tech

    27、nology space constantly evolving, we also explored the perception of a few technologies that are not yet FDA approved. To this end, Medtronics upcoming 690G commanded the most interest (34%), followed by the Insulet-Dexcom hybrid closed-loop device (31%), the Tandem-Dexcom low glucose suspend system

    28、 (23%), Bigfoot Biomedicals integrated device with FreeStyle Libre (9%), and Senseonics 90-day Eversense CGM (3%). Medtronic continues to have a lead on the competition in the integrated space, despite the messy 670G launch; however, the Tandem Control-IQ hybrid closed-loop with the TypeZero algorit

    29、hm and Dexcom G6 could close the gap and potentially leapfrog Medtronic. Well need to wait to see the full dataset.5North America Equity Research08 June2018Robbie Marcus, CFA(1-212) 622-Survey DetailsSurvey RespondentsWe surveyed 35 high-volume US endocrinologists who treat an average of 1,009 diabe

    30、tics. This includes an average of 261 Type 1 patients, 328 Type 2 insulin-intensive patients (i.e. use both basal and bolus insulin), and 420 non-insulin-intensive Type 2 patients. All told, our survey respondents treat 9,127 Type 1 patients, 11,475 Type 2 insulin-intensive patients, and 14,704 non-

    31、insulin-intensive patients. This is divided between 4,107 pediatric patients, 20,669 non-Medicare adult patients, and 10,530 Medicare patients.Figure 1: Survey Patient CharacteristicsSource: JPM Diabetes Survey - June 2018Figure 2: Survey Patient CharacteristicsSource: JPM Diabetes Survey - June 201

    32、8Question 1: What percentage of your Type 1 patientsin each of the below patient groups were on the following therapies in 2017?Question 2: What percentage of your Type 1 patients in each of the below patient groups were on the following therapies in 2018?Question 3: What percentage of your Type 1 p

    33、atients in each of the below patient groups were on the following therapies in 2019?For Type 1 patients in 2017, insulin pumps were used in 57% of pediatric patients, 52% of adults, and 31% of Medicare patients. We note that this is likely a high pump utilization population, with our overall Type 1

    34、pump penetration estimate at 34.5% for 2017. Despite the higher penetration, respondents still expect increases in pump penetration across all demographics in 2018 and 2019: pediatrics pump utilization is expected to go to 62% in 2018 and 74% in 2019; adult pump utilization is expected to go to 54%

    35、in 2018 and 57% in 2019; and the senior/Medicare population is expected to go to 37% in 2018 and 40% for 2019.12%59%30%PediatricAdultSenior02,0004,0006,0008,00010,00012,00014,00016,000Pediatric Adult SeniorType 1Type 2 IIType 2 NII6North America Equity Research08 June 2018Robbie Marcus, CFA(1-212) 6

    36、22-Figure 3: Type 1 Pediatric Insulin Pump and MDI Penetration Rates: 2017-2019Source: JPM Diabetes Survey - June 2018Figure 4: Type 1 Adult Insulin Pump and MDI Penetration Rates: 2017-2019Source: JPM Diabetes Survey - June 201843% 38%26%57% 62%74%0%10%20%30%40%50%60%70%80%90%100%2017 2018 2019Insu

    37、lin PumpMDI48% 46% 43%52% 54% 57%0%10%20%30%40%50%60%70%80%90%100%2017 2018 2019Insulin PumpMDI7North America Equity Research08 June2018Robbie Marcus, CFA(1-212) 622-Figure 5: Type 1 Senior Insulin Pump and MDI Penetration Rates: 2017-2019Source: JPM Diabetes Survey - June 2018Question 4: What perce

    38、ntage of your Type 2 insulin-intensive patientsin each of the below patient groups were on the following therapies in 2017?Question 5: What percentage of your Type 2 insulin-intensive patientsin each of the below patient groups were on the following therapies in 2018?Question 6: What percentage of y

    39、our Type 2 insulin-intensive patientsin each of the below patient groups were on the following therapies in 2019?For Type 2 insulin-intensive patients in 2017, insulin pumps were used in 43% of pediatric patients, 18% of adults, and 11% of Medicare patients. In addition to having much lower penetrat

    40、ion for pumps in this population, we also note that respondents indicated usage of other therapies to control insulin in addition to pumps and MDI, which included oral agents and Valeritas V-Go. Figure 6: Type 2 Insulin-Intensive Pediatric Pump, MDI, and Other Penetration Rates: 2017-2019Source: JPM

    41、 Diabetes Survey - June 201869% 63% 60%31% 37% 40%0%10%20%30%40%50%60%70%80%90%100%2017 2018 2019Insulin PumpMDI57% 59% 50%43% 41% 50%0% 0% 0%0%10%20%30%40%50%60%70%80%90%100%2017 2018 2019OtherInsulin PumpMDI8North America Equity Research08 June 2018Robbie Marcus, CFA(1-212) 622-Figure 7: Type 2 In

    42、sulin-Intensive Adult Pump, MDI, and Other Penetration Rates: 2017-2019Source: JPM Diabetes Survey - June 2018Figure 8: Type 2 Insulin-Intensive Senior Pump, MDI, and Other Penetration Rates: 2017-2019Source: JPM Diabetes Survey - June 2018Question 7: In your opinion, what are the biggest impediment

    43、s to greater insulin pump adoption in Type 1 patients? Please select all that apply.The most significant barriers to greater pump adoption remained similar to what weve seen in past surveys with the top 3 responses being that patients dont want to “wear” their disease (69% of respondents), cost (66%

    44、), and reimbursement limitations (46%). Interestingly, awareness was the least common factor selected, at just 3% of respondents, down from 16% in last years survey.69% 60%55%18% 26%32%13% 14% 14%0%10%20%30%40%50%60%70%80%90%100%2017 2018 2019OtherInsulin PumpMDI82% 82% 78%11% 12% 15%7% 7% 7%0%10%20

    45、%30%40%50%60%70%80%90%100%2017 2018 2019OtherInsulin PumpMDI9North America Equity Research08 June2018Robbie Marcus, CFA(1-212) 622-Figure 9: Barriers to Type 1 Pump AdoptionSource: JPM Diabetes Survey - June 2018Question 8: For each of the below criteria, please rank the top 5insulin pumps in your v

    46、iew. For each pump, please rank from 1-5, where 1 = best insulin pump for this criterion, 2 = 2nd best insulin pump for this criterion, etc.To understand the endocrinologists perceptions of different pumps in a landscape with no Animas, we asked them to rank the 5 insulin pumps in the market today o

    47、n 7 different characteristics: appeal for pediatrics, appeal for adults, size and space required on-body, ease of learning, ease of ongoing use, interconnectivity with smartphone apps, and pump reliability.Results here were mixed, with the 670G viewed as the best for appeal to adults, ease of use, a

    48、nd pump reliability. Tandems t:slim X2 pump was seen as the easiest pump to learn and for offering the best interconnectivity with smartphones. Finally, Insulets OmniPod was ranked the best for pediatric patients (although 670G was very close behind) and for its form factor. This made sense given it

    49、s unique patch pump design and key target demographics of both children and active patients.Figure 10: Best Overall Pump for Pediatrics (Age 18)Source: JPM Diabetes Survey - June 201869% 66%46%26% 23%20% 17%3%0%10%20%30%40%50%60%70%80%Dont Want to“Wear“ DiseaseCost ReimbursementLimitationsToo Complicated Can Only AffordP

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