Netherlands diabetes clinics show how integrated care reduces costs and improves outcomes

In 2006, Henk Veeze and Henk-Jan Aanstoot felt frustrated. The two doctors were trying to set up a specialist diabetes clinic in the university hospital where they worked but found it almost impossible to overcome the many bureaucratic and technical hurdles.

“There were too many silos in the hospital and we didn’t control staffing, which was managed centrally,” recalls Veeze. “We wanted to choose nurses and dieticians with specialist expertise in diabetes but it was out of our hands.”

They also sought to build a bespoke IT system to track patient outcomes but were restricted by the hospital’s generic data policies which were ill-suited to their vision of specialist diabetes care.

“A general hospital is like a big warehouse where everything is made as general as possible, whereas we wanted to drive for specialisation and excellence,” Veeze said. “Together we realised that we could either suffer on until pension age – or get real.”

Leap of faith

Veeze and Aanstoot resigned from the hospital, put their homes up as collateral against a bank loan, rented a building and secured a license to operate a clinic. It was a leap of faith. “We knew it was a big risk but we believed it was the right thing to do, and we had a lot of support from our families and our patients.”

In the early days, money was so tight that their families helped them clean the premises at the weekends, while patients showed their support by cutting ties with the hospital to use the new service.

The first Diabeter clinic was run by a multidisciplinary team of diabetes-focused professionals. It had a strong focus on measuring patient outcomes and an ehealth system that allowed the team to use patient data to individualise care. It became the template for later expansion.

Around this time, Aanstoot met Elizabeth Teisberg, co-author with Harvard economist Michael Porter of ‘Redefining Healthcare’ a landmark book on value-based healthcare. The book sets out a vision for patient-centred, data-driven care delivered by specialist clinics known as Integrated Practice Units.

Reading it, Veeze and Aanstoot realised Porter and Teisberg were describing the model that they had rolled out in Rotterdam. “Sometimes an idea’s time has come,” said Veeze. “Just as printing was discovered in many places around the world at around the same time, several people saw the potential of organising healthcare in this way.”

They bought a copy of Redefining Healthcare for every health insurer in the Netherlands. A decade later, in April this year, they were awarded the Value-Based Healthcare Prize by Porter for revolutionising diabetes care at the Diabeter network of five clinics.

Controlling glucose – and costs

Good diabetes care means controlling patients’ blood glucose levels. This is key to reducing hospitalisation and long-term complications. The target in children is to keep HbA1c, the standard proxy measure for blood glucose, below 7.5% (58 mmol/mol). 

At Diabeter, 55% of children under the age of 18 reach the target, making it the best performing clinic in the Netherlands.

Diabeter’s IT system has dashboards that track results for each patient and makes it possible to compare outcomes between clinics, doctors and therapies, driving improvements across the network of clinics.

“When we started, the [overall] hospital admission rate was between 20 – 30 per cent. Now most clinics can get to around 10 per cent while we have rates of between 1 – 3 per cent” said Veeze. “That’s a real benefit for patients and a big cost-saver.”

One of the Netherlands’ largest insurers evaluated all the costs of caring for diabetes patients and found that 75 per cent of providers have higher costs than the Diabeter clinics.

Veeze attributes this to Diabeter’s IT system, which dramatically reduces the administrative burden on staff, freeing them up to concentrate on patient care. “Nurses can take on twice the patient load,” he said. “This also means our staff get twice as much experience, helping them to become highly specialised, which further improves outcomes.”

Fans in high places

These results have earned them plaudits from big thinkers in healthcare policy, notably Porter himself, who on presenting the VBHC Prize 2017, hailed Diabeter as an exemplar of value-based healthcare.

“What we saw here is all aspects of value-based healthcare rolled together,” Porter said. “It’s not just trying to be great in the Netherlands; it’s trying to be great globally….Hopefully [they] can take over the world.”

Accepting the award, Aanstoot said it was recognition of Diabeter’s focus on “linking excellent clinical outcomes to acceptable costs, innovative patient-friendly processes and high-quality integrated care.”

In 2015 Diabeter was acquired by Medtronic, a major producer of diabetes products, which sees the clinics as an example to be rolled out around the world.

Having fine-tuned the model under the radar for many years, Veese is now busy fielding queries from specialists, governments and insurers that are keen to apply the model. “We are investigating a number of possibilities in other countries and regularly have visitors to our Rotterdam clinic,” he said. “It was a big risk and a lot of hard work but, in the end, it has been worth it.”