Mehr als 425 Mio. Menschen leiden heute an Diabetes, das entspricht fast einer Verdreifachung gegenüber 2014. Somit ist einer von 11 Menschen weltweit an Diabetes erkrankt. Vor allem die rapide Zunahme in Regionen wie Afrika und Südostasien wird dazu führen, dass sich diese Zahl bis 2045 auf rund 630 Mio. Patienten erhöhen wird. Die damit verbundenen Belastungen für die Gesundheitssysteme verdeutlicht eine andere Ziffer: 12% der globalen Gesundheitsausgaben von 2017 in Höhe von USD 730 Mrd. entfielen auf die Behandlung von Diabetes, d.h. hauptsächlich auf die Behandlung der Folgeerkrankungen.
Besseres Monitoring in Echtzeit
Am besten lassen sich gesundheitliche Verbesserungen für Diabetiker anhand der sogenannten «Time in Range» messen. Darunter versteht man den Zeitraum über 24 Stunden, in dem sich der Blutzuckerspiegel eines Patienten in einer Bandbreite von 70 bis 180 Milligramm pro Deziliter Blut bewegt. Gesunde Menschen kommen hier auf einen Wert von 90%. Bei Diabetespatienten lassen sich inzwischen Spitzenwerte von 72% erzielen – dank der neuen Hybrid Closed Loop-Systeme. Ein Sensor direkt unter der Haut misst alle 5 Minuten die Gewebeglukose und sendet diesen Wert elektronisch an die Insulinpumpe. Die Informationen werden von einem Algorithmus verarbeitet. Eine drohende Unterzuckerung kann so frühzeitig erkannt und die Insulinabgabe gedrosselt oder gestoppt werden. Im Fall einer Überzuckerung wird die Insulinabgabe erhöht.
Zum Vergleich: bei der klassischen Kombination von Glukosemessungen mittels Fingerpiks und Teststreifen in Verbindung mit mehreren Insulininjektionen täglich liegt die «Time in Range» bei 45%. Die seit einigen Jahren marktreife Kombination von Insulinpumpe und traditioneller Glukosemessung ermöglicht 55%. Der Basal-IQ, also ein einfacher Algorithmus, wie ihn das Unternehmen Tandem Diabetes entwickelt hat, schafft eine «Time in Range» von 65%.
Neue Produkte senken Behandlungskosten
Zahlreiche neue Produkte stehen hier in den nächsten zwei Jahren vor der Marktzulassung, zum Beispiel die Insulinpumpe Tandem t:slim X2 von Tandem Diabetes oder das Advanced Hybrid Closed Loop-System von Medtronic. Noch einen Schritt weiter geht Medtronic mit dem Personalized Closed Loop-System, dessen Markteintritt im 2.Quartal 2021 vorgesehen ist. Bereits im 2. Halbjahr 2020 fällt die Entscheidung für die US-Zulassung der von Insulet entwickelten schlauchlosen Insulinpumpe Omnipod Horizon, einer Einwegpumpe, die direkt auf der Haut getragen wird. Die Produkte adressieren einen Markt, dessen Marktvolumen nach unserer Einschätzung bis 2023 USD 10 Mrd. überschreiten wird. Die kontinuierlichen Glukosesensoren werden dabei im Zeitraum 2017 bis 2023 mit jährlichen Wachstumsraten von 23% auf USD 7 Mrd. die etwas grössere Dynamik bei deutlich höheren Umsatzvolumina aufweisen. Abbott und Dexcom sollen dabei die grössten Umsätze erzielen, gefolgt von Medtronic. Bei den Insulinpumpen und Hybrid Closed Loop-Systemen gehen wir davon aus, dass Insulet und Tandem Diabetes ab 2021 Marktanteile von Medtronic gewinnen werden.
In der Summe liegen die grössten Hindernisse für das künstlichen Pankreas auf der Medikamentenseite. Bei den verfügbaren Insulinen dauert es 30 bis 50 Minuten, bis die vollständige Wirkung einsetzt. Diese Zeitspanne ist nicht schnell genug, wenn etwa nach einer spontanen Mahlzeit der Blutzuckerspiegel schnell steigt. Auf Sicht der nächsten drei bis fünf Jahre sind hier keine marktreifen Lösungen in Sicht. Was die künftige Kostenerstattung angeht, wird die gesamte Behandlung von den Krankenversicherungen noch nicht für alle Versicherte bezahlt. Für den Sensor von Dexcom, der den Blutzuckerspiegel in Echtzeit überwacht, liegen die täglichen Kosten bei USD 8 bis 10. Dazu kommen noch die Kosten für die Insulinpumpe. Demgegenüber stehen die Behandlungskosten für Folgeerkrankungen von Diabetes wie Schlaganfall, Herz- und Niereninsuffizienz. Allein in Nordamerika werden die damit verbundenen Behandlungskosten auf USD 370 Mrd. jährlich geschätzt. Wir sehen es deshalb nur als eine Frage der Zeit, bis mit dem Markteintritt der neuen Produkte die Bereitschaft zur gänzlichen Kostenerstattung steigt.
Diabetesfirmen in unseren Fondsportfolios
Aus Anlegersicht bietet das Diabetesmanagement ein lukratives Potenzial. Hohe Eintrittsbarrieren im Verbund mit signifikantem Potenzial für Kostensenkungen in der Diabetesbehandlung schaffen attraktive Investmentopportunitäten. Der BB Adamant Medtech & Services umfasst die drei Kernthemen Diabetes, robotergestützte Chirurgie und strukturelle Herzkrankheiten. Bei den Services liegt der Fokus auf US-Krankenversicherern. 80% des Portfolios besteht aus Large Caps, per Ende Oktober 2019 waren fast 30% der Portfoliofirmen teils oder ganz in Diabetes tätig. Dabei handelt es sich um Medtronic, Abbott, Becton Dickinson,Dexcom, Insulet und Tandem Diabetes. Der BB Adamant Digital Health ist mit rund 10% des Portfolios im Bereich Diabetes unterwegs. Unser Anlagefokus liegt hier auf Small und Mid Caps, die über 80% der Portfoliofirmen stellen. Im Einzelnen sind es Dexcom, Tandem, Insulet und der Diabetes-Dienstleister Livongo – Firmen also, die beim Umsatz mit einer hohen Wachstumsdynamik glänzen, aber noch nicht alle profitabel sind.
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