Diabetes Care in The Netherlands:
Improving Health and Wealth

1

Diabetes Care in The Netherlands:
Improving Health and Wealth

This book was issued at the occasion of World Diabetes Day 14 November 2011.

Preface
Diabetes mellitus, a silent killer of pandemic proportions. Not only
is it a medical challenge but at least as much a burden for the
Dutch economy and society. Costs related to loss of productivity
as well as costs related to the treatment of the disease amount
to billions of euros in The Netherlands on a yearly basis. With
currently about 1 million people with diabetes in The Netherlands,
do we really know how diabetes will change our future? Do we
really have the information and tools necessary to defeat the
disease? Do we really know what initiatives are effective and cost
efficient when initiating diabetes care innovation?
These questions and uncertainties have inspired Novo Nordisk B.V.
to ask Booz&Co to investigate diabetes care in The Netherlands
and define recommendations for effective policies. It is the
mission of Novo Nordisk to defeat diabetes, its human disaster
and the societal burden on the basis of reliable information and
by means of relevant innovations.

The team at Booz&Co, led by professor Ab Klink, has done a
tremendous job. They have written a very inspiring report full of
innovative ideas and practical solutions. The contributions from
experts in the field of diabetes care, from insurance companies,
hospitals, patient organisations and professional organisations
have been instrumental.
We sincerely hope that the results of this report will bring
patients, health care professionals, health insurance companies,
government, Novo Nordisk and society more closely together in a
common fight for a healthier future with less diabetes.

Piet van der Wal, MD, PhD
Director Public Affairs
Novo Nordisk B.V.

www.changingdiabetes.nl

3

Summary
Diabetes is a serious and demanding disease. Complications can
be severe (e.g. stroke, heart disease, visual impairment, kidney
disease). Effective treatment allows most patients to live a life
close to normal, but diabetes treatment requires disciplined selfmanagement. Patients need to manage diets and exercise carefully
to control or lose weight, and most take daily medication. Insulin
dependent diabetes patients need to closely match insulin intake
with their diets and with their exercise intensity. Too little insulin
will lead to long-term complications and too much insulin may
lead to hypoglycaemic episodes (hypos) – risking unconsciousness,
coma and/or brain damage. A frustrating side-effect of insulin
therapy is weight gain.
For society, diabetes is a source of medical costs and lost
productivity. Our analysis suggests that the problem may be
underestimated. While recognizing that further studies are
needed (especially where data sources are conflicting), we
estimate that there are already more than one million diabetes
patients in the Netherlands. We estimate the costs of treatment
and complications of diabetes at EUR 2-3 billion, twice as high as
typically reported. Adding other medical costs, the total medical
costs of diabetes patients are EUR 4-5 billion. In addition, we
estimate that the costs associated with lost productivity for
diabetes patients are EUR 5-6 billion. More importantly, all

4

estimates and sources have one thing in common; they stress the
impact of diabetes on patients and society.
Professionals and patients can be proud of diabetes care in the
Netherlands. Quality of care is high compared to other countries
and the majority of patients enjoy a close to normal life. Evidence
from a selection of primary care groups suggests that large
quality gains have been realized since the nineties. For these care
groups, roughly two thirds of patients have blood glucose levels
(HbA1c) below the target of 7% (53 mmol/mol).
However, substantial non-compliance and apparent practice
variations in quality of care suggest that there is still potential to
further improve the health of Dutch diabetes patients. Further
improving health of diabetes patients may lead to EUR 1.5-2 billion
of medical cost and productivity benefits in 2020. The national
primary care benchmark for diabetes under development by the
patient federation and professionals will be important to develop
detailed insight in practice variation.
Projected cost savings from better care for people with chronic
diseases are sometimes received with scepticism, grounded in
the idea that complications can be delayed but not avoided.
But delaying complications reduces the time that people live
with costly complications, and increases participation in both

the workforce and in social life. In addition to societal benefits,
social participation is in itself also an effective stimulator for the
wellbeing of patients.
We conclude that there are still important barriers to innovation,
to quality improvement and to improving self-management
capabilities for patients. The result is an environment that can
be frustrating for passionate professionals, patients and insurers.
Our recommendations address these barriers. They are intended
to contribute to a more rewarding climate for quality, innovation
and engagement of employers, participative care and the patient’s
social network.
Recommendation 1: Refine economic incentives to
encourage integrated primary and specialist care and
quality improvement
Current economic incentives do not encourage quality
improvement and innovation. Professionals are still primarily
rewarded for volume, not for quality of care. For insurers, savings
that can be expected from investing in quality are difficult to
trace on the macro level and easily fail to materialize. Individual
patients may have fewer hospital admissions, doctor visits and
other health care costs. However, there is a risk that second
‘cash change’ does not occur involving the closure of beds and

surgery infrastructure, redeployment of staff or reduction in
procurement activity. Hence, the risk is that insurers pay double:
for the innovation initiative and for the unchanged volume of
regular care.
Economic incentives should create more room for doctors, nurses
and patients who are passionate about improving care. Our
proposed refinements include:
• Integrate contracting of primary care and specialist care
in networks. Introducing a model where primary care and
specialists jointly evaluate diabetes patients. This further
empowers primary care to treat diabetes patients. It also
reduces the inclination for specialists to maintain patients in
a specialist care environment. Volume agreements between
insurers and health care providers are needed to ensure
that win-wins are traced and materialized. Gain-sharing
creates the right incentives to encourage continuous
quality improvement (quality production instead of volume
production) and will remove some of the frustrating
disincentives that so often block quality initiatives.
•	
Extra insurer compensation for diabetes patients in the risk
equalization scheme. Incorporating a small profit margin
on diabetes patients in the risk equalization schemes will
encourage competition between insurers on quality of

5

diabetes care. Extra compensation will mitigate the risk
that insurers investing in high quality care attract more
financially unattractive patients.
•	
Build infrastructure for integrated primary care and specialist
care. The integrated funding model of network care should
be expanded to include hospital care for diabetes (e.g. by
incorporating specialist care in the keten-DBC). Insurers
should support professionals in creating a supporting IT
infrastructure.
Recommendation 2: Engage employers, UWV and
participative care in diabetes care
Employers, the UWV and participative care are still little engaged
in diabetes care. There is more economic benefit of better care
in improving labour (and social) participation than in lowering
medical cost. Productivity benefits will gain even more importance
given the expected tight labour market and the associated risks
of wage inflation and waiting lists for cure and care due to
personnel shortage.
There is a role for employers and government to contribute to
increased participation of diabetes patients.
•	
Insurers can offer collective diabetes insurance modules
focused on increased participation of diabetes patients;

6

•	Companies and UWV can invest in such collective insurance
for employees and welfare recipients (potentially negotiated
in central labour agreements);
•	
Insurers can integrate contracting of participative and
curative care;
•	
Participative care’s primary role should be to ensure a
working environment that encourages patients to comply
with therapy and that keeps patients motivated to keep
working as long as possible. Coping with a disease in a
stimulating environment can be highly complementary to
the more classical function of curative health care.
Recommendation 3: Encourage the patient’s social
network to support self-management
The patient’s social network is not systematically engaged in the
patient’s care, leaving many patients alone in self-management.
For the majority of patients, regular doctor visits are sufficient,
but for many this is not enough.
Physicians should have tools to encourage support for patients
who need it. Patients and the patient federation should have a
key role in developing these tools. We recommend:
To include behavioral dimensions in medical guidelines for
diabetes (e.g. family present at key doctor visits);

To scale up the use of social media. Health communities with
patients, the patient federation and professionals encourage
frequent interaction and informal support in self-management;
To educate amateur coaches for non-adherent patients.
Physicians should be able to refer an eligible group of patients
to coaching. The coach is preferably someone from the social
circle of the patient (partner, parents, children). These coaches
should receive a basic education in diabetes care (via insurers or
pharmaceutical companies). Physicians may refer to professional,
intensive coaching by diabetic nurses for a small group of difficult
to reach patients.

Conditional access models are a solution for treatments
and medication with a likely but unproven upside of better
compliance. In conditional access models, professionals, patients
and insurers evaluate real-life impact on compliance. CVZ can
base the final scope of insurance coverage on this evaluation, and
professional and insures can include any behavioral benefits in
guidelines. Pharmaceutical companies and insurers should share
the financial risks of a negative decision on final access. DVN and
NDF are currently proposing pilot projects for conditional access
with ZonMW.

Recommendation 4: Introduce conditional market access
models for new therapies and medication to assess
behavioral impact
The current generation of diabetes medication is therapeutically
highly effective. Curing diabetes inspires fundamental research
and innovation. In the coming decade most innovation can
be expected in increasing therapy convenience for patients
- e.g. reducing the risk of hypos, simplifying monitoring and
eliminating weight gain effects. Higher convenience will lead
to better compliance and ultimately to health benefits. Clinical
trials required for regulatory approval, however, typically do not
provide evidence for such behavioral impact.

7

• Diabetes is a challenging disease for patients
– Treatment requires large behavioural change and poses a real risks of side effects
– Complications from diabetes are potentially severe (e.g. stroke, kidney disease heart disease)
– 	Fortunately high quality treatment and strict compliance has proven to keep diabetes patients healthy for a long time
•	Novo Nordisk has asked Booz & Co to perform a study with the objective to identify how our health care system could be
improved to empower professionals in providing high quality of care for diabetes
• Better diabetes care has value for patients and society
– Improves health of the patient: improving life expectancy and quality of life
– Reduces health care cost: prevention, reduction, and delaying of complications
– 	Reduces the demand for increasingly scarce labour health care (ZorgInnovatiePlatfrom projects 450.000 vacant employment
positions in health care in 2025)
– Improves productivity by increasing workforce participation of diabetes patients
•	This document presents the findings of the study. It is intended to serve as a basis for further discussion with patients, medical
professionals, policymakers and insurers

8

Contents
Summarized findings and recommendations
The opportunity
•	Diabetes is a major and underestimated source of medical costs and lost productivity
•	Diabetes care in The Netherlands has reached a high level of quality, but there is still opportunity for further improvement
• Further improving health of patients may lead to EUR 1.5-2 B of economic benefits in 2020
The road
• Refine economic incentives to encourage integrated care and quality improvement
• Engage employers, UWV and participative care in diabetes care
• Engage the patient’s social network to support self management
•	Introduce conditional market access models for new therapies and medication to assess behavioural impact
Appendix: list of sources

9

Main conclusions
conclusions
Main
Objective
Further improve
health for
patients and
society

1 Diabetes
1	
is a is
challenging
diseasedisease
for patients,
and a major
and
underestimated
source of
Diabetes
a challenging
for patients,
and
a major
and
medical
costs and lostsource
productivity
for society
underestimated
of medical
costs and lost productivity for society
• 1.0-1.1M
diabetesdiabetes
patientspatients
(~100,000
more diagnosed
patientspatients
than reported)
1.0-1.1M
(~100,000
more diagnosed
than reported)
• E UR 4-5EUR
B total
forcosts
diabetes
patients,patients,
of whichofEUR
2.5 EUR
B costs
diabetes
4 -5medical
B total costs
medical
for diabetes
which
2.5for
B costs
for
diabetes
treatment
and
complications
(more
than
double
of
reported).
top
treatment and complications (more than double of reported). On top that EUR 6 On
B lost
of that EUR 6 B lost productivity
productivity
Total
costsrise
could
rise16-19
to EURB 16
-19 B in 2020
• Total costs
could
to EUR
in 2020

•2 Diabetes
Diabetes
inNetherlands
The Netherlands
has reached
a high
levelbut
of there
quality,
but
2	
carecare
in The
has reached
a high level
of quality,
is still
there is still
opportunity
for further improvement
opportunity
for further
improvement
3	
improving
healthhealth
of diabetes
patients may
lead to
EUR 1.5-2
B ofEUR
economic
3 Further
Further
improving
of diabetes
patients
may
lead to
1.5 -2benefits
B of in
2020
(less medical
costs in
and2020
higher(less
productivity)
economic
benefits
medical costs and higher productivity)
1 Insurers and governments should adjust certain economic incentives to
stimulate
high
qualitytocare
1	Refine
economic
incentives
encourage integrated care and quality improvement

The road
Fewer barriers
for quality in our
health care
system

Booz & Company 14 November 2011

10

2	
employers,
UWVparticipation,
and participative
care in diabetes
carecompanies can invest in
To increase
labour
government
and
2 Engage

diabetes care via collective insurance

models

3	Engage the patient’s social network to support self management
3 Insurers , patient federations and Pharma companies could facilitate
4	Introduce conditional market access models for new therapies and medication to assess
network solutions around the patient to support better diabetes care
behavioural impact
4

Government and insurers could introduce temporary medication market
access models to assess impact on therapy compliance
Prepared for Novo Nordisk

2

1
1

Diabetes is a major and underestimated source of medical costs
Diabetes is a major and underestimated source of
and
lost costs
productivity
medical
and lost productivity
Higher
prevalence

More than 1M diabetes patients in the Netherlands

Diabetes Type 1 may be more prevalent than assumed

2010; ‘000

2010; ‘000

~920-975

~95-190

~1,0 M-1.1 M

~100--125
75-90

~710-850

Diagnosed
other sources 1)

Diagnosed
Booz estimate

Undiagnosed

2)

Total

Traditional estimate

Booz estimate

Costs of complications and treatment diabetes double of reported. Lost productivity more than medical costs
EUR B , 2010

5-6

>X2

More costs

X2

1.2

1.3

Reported
medical costs (RIVM)

Unreported
cost of complications

2-3

1.8

Costs diabetes
treatment and
complications

Other medical costs
for diabetes patients

~1.4 M Diabetes Patients in 2020

4-5
Total medical costs
for diabetes patients

Lost productivity
disabled

2010
1)
Source:

Type 2

42%

Type 1

Medical and
productivity costs
diabetes patients

EUR B

+3%
1.0-1.1

58%

Total costs could rise to EUR 16-19 B

M

Faster growth

10-11

1.3-1.5

2020

Cost grow faster due to
increasing share of
diabetes patients in
workforce age

+5%

16-19

10-11

2010

2020

Other sources include CBS (710), DVN (750) and RIVM (850) (2) Range between 10% and 20%
CBS, DVN, RIVM, SFK, Janssen et al. Screening Study, DFN, IDF, CMR-Nijmegen, ADA, Diabetes Richtlijnen, DBC pricelist 2011, DiabetesZorgBeter, UWV, Booz & Company Analysis

Booz & Company 14 November 2011

4

Prepared for Novo Nordisk

11

22

Diabetes
Diabetes care
care in
inThe
TheNetherlands
Netherlandshas
hasreached
reachedaahigh
highlevel
levelofof
quality,
quality,but
butthere
thereisisstill
stillopportunity
opportunityfor
forfurther
furtherimprovement
improvement
Diabetes care clearly improved in The Netherlands
Selected
Care Groups–
1996-2010
Diabetes care
clearly
improved
in The Netherlands

Opportunity for further improvement
in high
quality carefor
andfurther
better compliance
Opportunity
improvement

inleads
hightoquality
care and
compliance
High quality care
better outcomes
tobetter
fewer complications

Selected Care Groups – 1996-2010

•	The population in DiabetesZorgBeter shows a lower relative risk of major
High quality care leads to better outcomes to fewer complications
complications (kidney insufficiency -80%; chronic heart failure -50%;
– The
population in DiabetesZorgBeter shows a lower relative risk of major
stroke
-40%)
complications
(kidneyrealized
insufficiency
-80%;
heart failure
•	PoZoB diabetes program
HbA1c<7
% chronic
(53mmol/mol)
with -50%;
~70%stroke 40%)
of the patients and improvements in both blood pressure and cholesterol
– PoZoB diabetes program realized HbA1c<7 % (53mmol/ mol) with ~70% of
levels
patients andachieved
improvements
in both blood
pressureinand
cholesterol
levels
•	Kaiserthe
Permanente
1.2% reduction
of HbA1c
a program
focusing– on
poorly
controlledachieved
patients1.2%
(withreduction
values much
aboveinthe
averagefocusing
NL
Kaiser
Permanente
of HbA1c
a program
level)on poorly controlled patients (with values much above the average NL level)

Average HbA1c values now below target value
7.5%

Target value <7 % (53 mmol/mol)

7.1%

1996

2000-2007

6.7%

6.8%

2008

2010

Average cholesterol level has decreased with ~ 20%
mmol/l

6.0
5.1

4.5

1996

20081)

2000-2007

4.7

Better compliance
can be
and
fewerhospitalizations
Better compliance
canstimulated
be stimulated
andleads
leads to
to fewer
hospitalizations
– Kaiser Permanente has achieved a 45% reduction in hospitalizations with
•	Kaiserbetter
Permanente
has achieved a 45% reduction in hospitalizations with
compliance
better compliance
– US study shows that total medical costs (including medication costs) of fully
•	US study
shows that total medical costs (including medication costs) of fully
compliant can be up to twice as low as the cost of non -compliance
compliant patients can be up to twice as low as the cost of non-compliance

20102)

Average systolic blood pressure lowered substantially
mm Hg

155
145

1996

2000-2007

na

na

Clear potential in high quality treatment implementation and compliance

138

138

2008

2010

14,156

52,630

Clear potential in high quality treatment implementation and
improvement seems likely
compliance improvement seems likely

– Incentives
in heath
the heath
system
encourage
highestquality
qualitycare
care
•	Incentives
in the
carecare
system
do do
notnot
encourage
highest
•	Regional
variances
in care
patterns
still seem
high.high.
The national
primary
– Regional
variances
in care
patterns
still seem
The national
primary
care benchmark
for diabetes
under
development
care benchmark
for diabetes
under
development
byby
the the
DVNDVN
andand
profesprofessionals
provide
more
precise
insight invariation.
practice variation.
sionals
will providewill
more
precise
insight
in practice
•	Various
studies
suggest
thatthat
non-compliance
is a common
problem
– Various
studies
suggest
non -compliance
is a common
problem

Databased
based
DiabetesZorgBeter
1)1)
Data
onon
DiabetesZorgBeter
studystudy
GPCare
Care
groups
included
2)2)
4 4GP
groups
included
Source: Diabeteszorggroepen
Diabeteszorggroepen
en keten-DBC
de keten-DBC
DiabetesZorgBeter
, Zorg
voor patienten
metmellitus
diabetes
mellitus
type
2 in2008,
de 1eDiabeteszorg
lijn 2008, Diabeteszorg
Zorggroepen
2010, Booz
& Company analysis
Source:
en de
2010,2010,
DiabetesZorgBeter,
Zorg voor
patienten
met diabetes
type
2 in de
1e lijn
Zorggroepen 2010,
Booz & Company
analysis
Booz & Company 14 November 2011

12

Prepared for Novo Nordisk

5

3 3

Furtherimproving
improvinghealth
healthof
ofdiabetes
diabetespatients
patientsmay
maylead
leadto
to EUR 1.5
Further
2 B of
economic
benefitsbenefits
in2020 in 2020
EUR
1.5-2
B of economic
Estimated Economic Benefits
EUR M , 2020
1.000-1.500

1.500 – 2.000

Less medical costs from
reduction in
complications

Reduction of lost productivity

Medical costs and
productivity benefits

• Reduction in cost due to
less complications

• Reduction in inflow of new
working disabilities
• Reduction of ab- and
presenteeism in line with
reduction in complications

Fully disabled

400-600

Comments:

Source:

Partially disabled
Presenteeism
Absenteeism

Booz & Company Analysis

Booz & Company 14 November 2011

6

Prepared for Novo Nordisk

13

1
1

Recommendation 1: Refine economic incentives to encourage
Recommendation
Refine improvement
economic incentives to encourage
integrated
care and1:quality

integrated care and quality improvement
Barrier

Diagnosis
• Insurers are supporting quality improvement, but they
are confronted with (perceived) financial disincentives

Current
economic
incentives do
not encourage
quality
improvement
and innovation

Booz & Company 14 November 2011

14

-

High quality care is perceived to only delay complications and
cost (however, an indicative analysis suggest ~25% life time
cost reduction if complications are delayed with 3 years)

-

Differences in risk exposure for specialist and primary care

-

Higher quality diabetes care may attract more loss-making
patients for the insurer

-

(Hospital) capacity that is freed up by quality improvements
tends to fill up with other patients (leading to double cost)

• Limited collaboration incentive for primary care and

specialist care
• Quality improvement initiatives are frustrated by
fragmented budgeting (and ad hoc budget cuts)
• Individual quality incentives are lacking for Primary Care,
Specialists and Patient
• Significant evidence gaps in basic statistics and in
treatment evidence suggest insufficient supporting
incentives for critical research

Prepared for Novo Nordisk

Recommendation
Insurer
• Integrate contracting of primary
care and specialist care in networks
• Provide patient incentive for
compliance (bonus miles, gainsharing)
• Enable research funding from
regular budget
Government
• Adjust risk equalization scheme to
ensure small profit margin on
diabetes patients for insurers
• Create an integrated funding model
for primary and specialist care
networks

7

2
2

Recommendation 2: Engage employers, UWV and participative
Recommendation
2: Engage employers, UWV and participative
care
in diabetes care

care in diabetes care
Barrier

Diagnosis

Recommendation

Insurer

• Offer collective insurance modules for
• Ageing will create an extremely tight labour market over
Employers,
UWV and
participative
care are still
little engaged in
diabetes care

the coming decade
• Labour shortage from late nineties illustrates the risk for
our economy
• Diabetes has a high prevention potential for lost
productivity
-

92,000 of working disabled have diabetes,

• However, curative and participative care (arbo- and

diabetes to increase the participation
of diabetes patients

• Integrate contracting of participative
and curative care
Companies and UWV

• Invest in collective insurance for
employees and welfare recipients

bedrijfsarts) are still two different worlds

Participative care
• Ensure a working environment that
encourages compliance and
motivates to work as long as possible

Booz & Company 14 November 2011

Prepared for Novo Nordisk

8
15

33

Recommendation
thethe
patient’s
social
network
tosupport
Recommendation3:3:Engage
Engage
patient’s
social
network
to
self
management
support
self management
Barrier

Diagnosis

• Medical treatments for Diabetes Type 1 and Type 2
can be effective, however compliance is a huge
challenge

The social
network is not
systematically
engaged in
patient’s care

-

Effects of non-compliance are severe

-

Non compliance is a challenge of distant benefits and large
required behavioural change

• Facilitated patient networks are successful in other

distant benefits – high behavioural change conditions

• Examples of patient networks for other conditions (e.g.
obesitas) can be instructive for diabetes

• Integrated behavioural interventions have been
successful in improving compliance (e.g. Kaiser
Permanente Evidence)

Booz & Company 14 November 2011

16

Prepared for Novo Nordisk

Recommendation
Medical professionals: Include
behavioural dimension in medical
guidelines
• Include family in standard treatment
(e.g. family at key doctor visits)
• Add checklist for aligning treatment with
personal life (mass customization)
Novo Nordisk: Scale-up social media
• Scale-up diabetes health communities
with patients and their professionals
(mijn zorgpagina DVN, mijnzorgnet)
Novo Nordisk: Educate amateur coaches
for non-adherent patients
• Develop screening instrument for
coaching eligibility for physicians
• Educate amateur coaches
• Select professional coaches in a
selected group of complicated cases

9

4
4

Recommendation 4: Introduce conditional market access models
Recommendation
Introduce
conditional
access impact
models
for
new therapies 4:
and
medication
to assessmarket
behavioural

for new therapies and medication to assess behavioural impact
Barrier

Diagnosis

• Optimal treatment with current generation of diabetes
Decisions on
insurance
coverage tend
to undervalue
behavioural
impact

Booz & Company 14 November 2011

medication is therapeutically highly effective if patients
are compliant

• But new medication could add a lot of value in boosting
compliance

• CFH medication access criteria allow evaluation of impact
on compliance, however the required evidence is usually
not generated by trials

Prepared for Novo Nordisk

Recommendation

Government and insurer
• Define models that allow for
conditional access to proof
indirect effects on compliance
• Include compliance in the
guidelines as a factor driving the
choice of medications

10
17

Contents
Summarized findings and recommendations
The opportunity
•	Diabetes is a major and underestimated source of medical costs and lost productivity
•	Diabetes care in The Netherlands has reached a high level of quality, but there is still opportunity for further improvement
• Further improving health of patients may lead to EUR 1.5-2 B of economic benefits in 2020
The road
• Refine economic incentives to encourage integrated care and quality improvement
• Engage employers, UWV and participative care in diabetes care
• Engage the patient’s social network to support self management
•	Introduce conditional market access models for new therapies and medication to assess behavioural impact
Appendix: list of sources

18

Already more
more than
than 1M
1M diabetes
diabetes patients
- Already
patients in
in the
theNetherlands
Netherlands
~100.000more
more diagnosed
diagnosed than
than usually
~100.000
usually reported
reported
Number of Diabetes Patients
Number of Diabetes Patients
2010, ‘000
2010, ‘000

~1.0-1.1M

95-190
920-975
850
710
Type 2
557

Type 1

153
CBS : based on
patient survey

752

795-875

98

100-125

RIVM based on sample of
GP registrations (2007
figure extrapolated to 2010)

Booz estimate
(based on SFK data
on diabetes
medication users)

Total number of diabetes patients
that use medication plus estimated
10% to 15% patients that use no
medication

Undiagnosed (based
on ’02-’04 study in
southwest NL) 1

Total number of diabetes
patients (estimated)

(1) 	Based on study of 50-70 years old patients. Undiagnosed rate of 10-20% has been extrapolated. SFK reports 830.000 patients on diabetes medication. SFK data covers 92% of the market. We have not
scaled up SFK numbers because there is also a fraction of over-registrationPrepared
SFK data
(~5-10%) as some people taking medications from multiple pharmacies are counted twice
Booz & Company 14 November 2011
for Novo Nordisk
12
Source: CBS, RIVM, SFK, Janssen et al. Screening study, Booz & Company Analysis

19

Diabetes Type
Type11may
maybe
bemore
moreprevalent
prevalentthan
thanassumed
assumed
––but data
Diabetes
but
dataare
sources
areconflicting
highly conflicting
sources
highly
Comments
Comments

Number of Diabetes Type I Patients based on
different sources
2010, ‘000
DVN / DFN

150

CBS

153

1)

•
•

DVN and NDF quote 150,000 Type 1 patients (methodology not further explained)
This translates into 20% of diagnosed diabetes patients

•

Survey sample in which patients responding yes to 3 questions were identified as Type
1: (1) Do you have diabetes? (2) Do you use insulin for this? (3) Did you start using
insulin within 6 months after being diagnosed?
Drawback of methodology is that the answers to the questions may not be a reliable
proxy for share of Type 1 patients
PoZoB (GP support Brabant) includes 15,500 Diabetes Type 2 patients in their
programs, of which 14% uses insulin
Extrapolating this to the national level, and with a total of 285,000 insulin users
(source SFK), this would imply 162.500 Type 1 patients
RIVM estimates 10% Type 1 of diagnosed patients, based on GP registration
Drawback of methodology is that maybe not all Type 1 patients are registered by GP,
such that GP registrations are not fully accurate

•

Based on sample
in Brabant

163

•
•

RIVM

98

•
•

International
Diabetes Federation

98

•

IDF estimates 10% Type 1 of diagnosed patients, however not NL specific

CMR -Nijmegen

96

•
•

CMR -Nijmegen estimates 9.8% Type 1 (‘05-’08 period) of diagnosed patients, based on
GP registration in Nijmegen
Drawback of methodology is that representatively may be questionable

•
•

Booz estimates 100,000 to 150,000 Type 1 patients, based on different sources
For calculation purposes the average of 125,000 will be used

Range
Estimate

1)
Source:

125

2011 estimate
DVN/DFN, CBS, RIVM, IDF, CMR-Nijmegen, Booz & Company analysis

Booz & Company 14 November 2011

20

100

Prepared for Novo Nordisk

13

Costs of
of complications
complications and
and treatment
treatmentofofdiabetes
double
of of
Costs
diabetes
double
reported, lost
lostproductivity
medical
costs
reported,
productivitymore
morethan
than
medical
costs
Cost of diabetes

>X2

EUR B , 2010
3.5
In 2007 the average cost of
diabetes patients was EUR 4,443 /
year in comparison to the national
average of EUR 1,646 / year

X2
1.3

1.8

Type 2
58%

2.6

4-5

0.2

2-3
42%
Type 1

1.2

Reported
medical
costs ( RIVM)
Comments

1)
Source:

Estimated by
RIVM

Unreported Costs diabetes
Other
cost of
treatment and medical costs
complications complications for diabetes
patients 1)
Bottom up Booz
estimate

Difference between
medical costs for
patients with diabetes
and medical costs for
treatment and
complications of
diabetes

Total medical Absenteeism &
costs for
presenteeism
diabetes
patients
Based on total
medical costs
for diabetes
patients
(NPCF )

Effect of hypos
on absence from
and inefficiency
at work, based
on ADF study
(but numbers
vary in different
publications)

Other unreported medical costs include costs caused by additional use of medical care by diabetes patients; 2007 estimate
Prepared for Novo Nordisk
NPCF, ADF, CBS, RIVM, SFK, DiabetesZorgBeter, Diabetes Richtlijnen, DBC
pricelist 2011, Booz & Company Analysis

Booz & Company 14 November 2011

10-11

Welfare
payments
disabled

Lost
productivity
disabled

Based on 75% of
modal income *
and 98,000
disabled with
diabetes

Based on modal
income and
98,000 disabled

• Complications and
lost productivity /
welfare assumed
100% distributed
as insulin patients
• Other cost
assumed 70%
distributed as
insulin patients
and 30% total
patients
• Insulin patients:
Type 1 ~45%
Type 2 ~65%

Medical and
productivity
costs diabetes
patients

14
21

Costs
of
diabetes
complications
and
treatments are
are
Costs
of
diabetes
complications
and
treatments
underestimated
BACK -UP

Medical costs for diabetes patients
EUR M , 2010
~4,000-5,000

~1,800
Nerves (neuropathy)
Eyes (retinopathy)

~1,300

2,000-3,000

Kidney dialyse
Heart failure
& disease

X2
~1,200

Other

167

Second line

52
158 104

Cost of treatment of
diabetes and
cost of complications
unique to diabetes 1)

Unreported costs
of complications 2)

Costs diabetes treatment
and complications

Other medical costs
for diabetes patients 3)

Booz estimate total medical
costs for diabetes patients

Other includes other health care providers and maintenance; costs of diabetic foot and hypos are included in the second line
Cost of direct treatment of complication for heart disease, eyes and nerves; lifetime costs of stroke, heart failure and kidney dialyse
Other
medical care
care by
by diabetes
diabetes patients
patients
Other unreported
unreported medical
medical costs
costs include
include costs
costs caused
caused by
by additional
additional use
use of
of medical
NPCF, RIVM kostenvanziekten.nl, DiabetesZorgBeter , Diabetes Richtlijnen , DBC pricelist 2011, Booz & Company analysis
NPCF, RIVM kostenvanziekten.nl, DiabetesZorgBeter, Diabetes Richtlijnen, DBC pricelist 2011, Booz & Company analysis

Booz & Company 14 November 2011

22

853

684

Medications

1)
2)
3)
3)
Source:
Source:

Stroke

5
18
95

305

Prepared for Novo Nordisk

15

Numberof
of patients
patients reaches
reaches ~1.4M
~1.4M in
in 2020
2020
Number
Diagnosed Type 1
3.7%

Total number of Diabetic patients
‘000
2.6%

Undiagnosed
Diagnosed

~1350-1475

‘000

2.5%

60

83

125

160

1990

2000

2010

2020

• Past figures
extrapolated
from CBS data
• Future growth
maintained at
average growth
• Estimate type 1
based on higher
end of range 2010

3.4%
~1000-1100

Diagnosed Type 2
‘000

~900

2.6%

6.8%
~550
220
1990

1990

Diagnosed
rate

Source:
Source:

2000

2010

2020

445
2000

60%

80-90%

80-90%

1,070

2010

2020

Undiagnosed
-3.4%

50%

825

• Past figures
extrapolated
from RIVM
• Future growth
based on actual
Type 2 growth
2000 to 2010

280

360

1990

2000

‘000

2.8%
140

185

2010

2020

• Past rate based
on quotes
• Current rate
expected to be
stable in future

RIVM, SFK CBS, Booz & Company analysis
RIVM, SFK CBS, Booz & Company analysis

Booz & Company 14 November 2011

Prepared for Novo Nordisk

16
23

Medical
costs
and
lost
productivity
of diabetes
patients
could
rise
Medical
costs
and
lost
productivity
of diabetes
patients
could
to ~
EURB16-19 B
torise
~ EUR
16-19
Total cost of Diabetes to Society
EUR B , 2010-2020

16-19

6.5

Lost productivity disabled

3.5

4.8

Welfare payments

2.6

0.5

Absenteeism & presenteeism

0.2
1.8

2.3

Other medical cost

1.7

Cost of complications

1.6

Direct medical cost

10-11

1.3
1.2
2010

2020

Source:Source:
RIVM, Booz
Company
AnalysisAnalysis
RIVM,&Booz
& Company
Booz & Company 14 November 2011

24

Prepared for Novo Nordisk

17

Increaseininlost
lostproductivity
productivityis is
driven
increasing
number
Increase
driven
byby
anan
increasing
number
of of
diabetes patients in workforce (~380k in 2020)

BACK -UP

Increase and breakdown of diabetes patients in workforce
2010 - 2020, ‘000
• Disability estimates based on welfare
registration of the UWV
• Reflects the number of disabled with diabetes
Younger diabetic population
Retirement age 67

117
20
22

Net increase patients ’10 – ‘20

75

261

~380

189

Working with
disability assumed
30% disabled

24

2010
Total workforce
diabetes patients

Increase ’10
to ’20

2020
Number of
diabetics
in workforce

Working with
with no
disability

Working with
disability
without
adjustments

24

141

Working with
disability
with adjustments

Not able
to work

One out of three new diabetes patients in the workforce will be
Type 1 patients
Source:

CBS, UWV, Booz & Company Analysis

Booz & Company 14 November 2011

Prepared for Novo Nordisk

18
25

Contents
Summarized findings and recommendations
The opportunity
•	Diabetes is a major and underestimated source of medical costs and lost productivity
•	Diabetes care in The Netherlands has reached a high level of quality, but there is still opportunity for further improvement
• Further improving health of patients may lead to EUR 1.5-2 B of economic benefits in 2020
The road
• Refine economic incentives to encourage integrated care and quality improvement
• Engage employers, UWV and participative care in diabetes care
• Engage the patient’s social network to support self management
•	Introduce conditional market access models for new therapies and medication to assess behavioural impact
Appendix: list of sources

26

Diabetes care clearly improved in the Netherlands – Values from
Diabetes
care
clearly
improved
in theNetherlands – Values from a
a selected
group
of care
providers
ILLUSTRATIVE
HbA1c values (target value 7% - 53 mmol/mol)

HbA1c < 7% / 53 mmol/mol
% of patients

7.5%
69.0%
7.1%

66.5%
6.7%

63.0%

6.8%

60.6%
NA

1996

2000-2007

2008

2010

1996

2004

2008

Systolic blood pressure

Cholesterol level

mmHg

mmol/l

2010

6.0

155

5.1

145

1996

2003

2000-2007

138

138

2008

2010

4.5

1996

2000-2007

2008

4.7

2010

Note: 	1996 data based on 5 networks of GP’s; 2000-2007 data based on all publications from GP’s; 2003 and 2004 hbA1c values < 7% based on study with 7,893 patients spread of NL; 2008 data based on study
with 14,156 patients from 8 networks and cholesterol
level from
networks;
data
based on
52,630
patients
in 6, Julius
networks
voor
met DiabetesZorgBeter
diabetes mellitus type
2 in de 2010
1e lijn,
Interview
Prof.
G.E.H.M
Rutten
Center, Booz & Company analysis
Source: Diabeteszorggroepen en de keten-DBC, Zorg voor patienten met diabetes mellitus type 2 in de 1e lijn, Interview Prof. G.E.H.M Rutten, Julius Center, Booz & Company analysis
Booz & Company 14 November 2011

Prepared for Novo Nordisk

20
27

High quality care leads to excellent outcome values and to fewer
complications
CASE EXAMPLES
DiabetesZorgBeter 1 st line protocol
reduces risk of major complications
Frequency of diabetic complications
(2008)
Chronic
heartfailure

2.1%
1.0%

Acute
heartfailure
Stroke
Kidney
insufficiency

2.1%
1.2%

5.3%

-1.2%

53.0%
36.1%

7.0%

54.3%

Cholesterol
LDL < 2.5

DZB

Control
Group

-0.2%

44.3%
2010

2007

Main interventions
• Standard protocol supported by IT
system
• Training of GP’s & assistants

Main interventions
• Focus on poorly managed diabetes
patients (starting level much higher
than average NL situation)
• Personalized coaching
• Patient networks on- and off-line

DiabetesZorgBeter, PoZoB, Kaiser permanente, Booz & Company analysis

Booz & Company 14 November 2011

28

Kaiser
Permanente

3.3%

Main interventions
• Strict protocol for diabetes
management supported by IT-system
• Benchmarking of GP’s
• Training of GP’s & assistants

Source:

67.5%

Bloodpressure
BBD < 140

Eye
illness
Average NL

Through personalized coaching Kaiser
permanente reduces HbA1c by 1.2%
Change HbA1c values (1999)

68.4%

HbA1c < 7% (<53
mmol/mol)

0.7%
0.3%

0.6%

PoZoB achieves HbA1c objectives with
~70% of the patients – also improvements
in blood pressure and cholesterol levels
Indicators DM (2007 -2010)

Prepared for Novo Nordisk

21

Better compliance
compliancecan
canbe
bestimulated
stimulatedand
andleads
leadstotofewer
fewer
Better
hospitalizations

CASE EXAMPLES
44% reduction in hospitalizations at
Kaiser permanente program
Hospitalization/1000 persons -months (1999)

Medical cost of fully compliant patients up to half of
non-compliant patients
Average Expenditure per year (USD, 2005)
-49%
$8,878
$7,124

$6,522

-44%

$6,291
27

$4,571
15

1-19%

20-39%

40-59%

60-79%

Control
group

80-100%

Compliance Levels (% Days Supply / 1 Year)
Main interventions
• Compliance to treatment plan:
- Medication
- Doctor’s visits
- Lifestyle advice (quit smoking, etc.)
Source:

Kaiser
permanente

Main interventions
• Focus on poorly managed diabetes
patients
• Personalized coaching
• Patient networks on- and off-line

Sokol M et al. Impact of Medication Adherence on Hospitalization Risk and Healthcare cost, Kaiser permanente, Booz & Company analysis

Booz & Company 14 November 2011

Prepared for Novo Nordisk

22
29

Clear potential
potentialin
inhigh
highquality
qualitytreatment
treatmentimplementation
implementationand
and
Clear
compliance improvement

ILLUSTRATIVE

Article:
Life expectancy in a large
cohort of type 2 diabetes
patients treated in primary
care
Lutgers LH, Gerrits EG,
Sluiter WJ, Ubink-Veltmaat
LJ, Landman GWD, Links
TP, Gans ROB, Smit AJ,
Bilo HJG; (ZODIAC-10).
PlosOne 2009;

Regional variances in care patterns are
still high
% of Type 2 insulin patient in first line (2008 )
% of insulin patients

Primary care protocol can
bring life expectancy of Type
2 patients to normal levels

Non-compliance significant as
different studies indicate

19 %

Studies of therapy adherence on the
Dutch diabetes Type 2 patients

Zwolle Region Region Region Region Region Region
% of patients with HbA1c < 7% per health care group in
2009 & 2010
68%

68%

Paes e.a.; 1998:
Therapy adherence related to:
• Frequency of dosage
66-99%
• Prescribed doses
38-79%
Cramer; 2004:
General Therapy adherence
• Type 2 diabetes
36-93%

67%
63%
61%
59%
56%

Selected care groups in The Netherlands

Professionals and DVN are developing national primary care
benchmark for diabetes for more insight in practice variations
Source: DiabetesZorgBeter - Prof H. Bilo, PoZoB, Kaiser permanente , Diabeteszorg Zorggroepen Nederlandse Huisartspraktijken - van Rutten , Booz & Company analysis
Source: DiabetesZorgBeter - Prof H. Bilo, PoZoB, Kaiser permanente, Diabeteszorg Zorggroepen Nederlandse Huisartspraktijken - van Rutten, Booz & Company analysis
Booz & Company 14 November 2011

30

Prepared for Novo Nordisk

23

Contents
Summarized findings and recommendations
The opportunity
•	Diabetes is a major and underestimated source of medical costs and lost productivity
•	Diabetes care in The Netherlands has reached a high level of quality, but there is still opportunity for further improvement
• Further improving health of patients may lead to EUR 1.5-2 B of economic benefits in 2020
The road
• Refine economic incentives to encourage integrated care and quality improvement
• Engage employers, UWV and participative care in diabetes care
• Engage the patient’s social network to support self management
•	Introduce conditional market access models for new therapies and medication to assess behavioural impact
Appendix: list of sources

31

Further
of patients
patients may
may lead
lead to
toEUR
EUR1.5
1.5-2
B of
Further improving
improving health
health of
-2 B of
economic benefits in 2020
economic benefits in 2020

Reduction in cost of
complications:
~ EUR 0.5 B

• Estimated based on a combination of improved compliance and an increased reach
of high quality care. Two high-level approaches result in a similar estimate
– A Kaiser Permanente study shows that total medical cost of 80-100% compliant
patients are ~25 -30% lower than of patients who are 60-80% compliant
– If the national average would show the same relative risk of complications as in
the DiabetesZorgBeter study, this would reduce cost of complications by more
than 30%
• The combination of improved care and improved compliance may have higher
potential

~ EUR 1.5 – 2 B
Reduction of lost
productivity:
~ EUR 1.2 B

• Absenteeism and presenteeism and the related cost decline in line with the
expected decline in the number of complications
• Assumption is that 50% of the inflow of disabled in the workforce with diabetes,
would have been able to remain active in the workforce if there would not have
been diabetes complications
• Estimate is that 50% inflow can be reduced in line with the assumed reduction in
the number of complications (~30%)

Source: CBS,
CBS,DiabetesZorg
DiabetesZorgBeter
Beterstudy,
study,
UWV,
Booz
& Company
Analysis
Source:
UWV,
Booz
& Company
Analysis
Booz & Company 14 November 2011

32

Prepared for Novo Nordisk

25

Contents
Summarized findings and recommendations
The opportunity
•	Diabetes is a major and underestimated source of medical costs and lost productivity
•	Diabetes care in The Netherlands has reached a high level of quality, but there is still opportunity for further improvement
• Further improving health of patients may lead to EUR 1.5-2 B of economic benefits in 2020
The road
• Refine economic incentives to encourage integrated care and quality improvement
• Engage employers, UWV and participative care in diabetes care
• Engage the patient’s social network to support self management
•	Introduce conditional market access models for new therapies and medication to assess behavioural impact
Appendix: list of sources

33

Insurers
are
supporting
quality improvement,
improvement, but
butthey
theyare
are
Insurers
are
supporting
quality
confronted with (perceived) financial disincentives
confronted with (perceived) financial disincentives
Perception that investing in diabetes care is only delaying and not
eliminating complications and therefore not generating revenues
• This perception is invalide but will need to be addressed specifically

Low

Differences in risk exposure to primary care and specialist
• The risk and budget allocation mechanism lead to a lower risk burden for the
insurer for hospital care versus primary care

Impact

High quality diabetes care may attract more than fair-share diabetes
patients
• Diabetes patients seem to be on average loss-making even after budget
allocation corrections
(Hospital) capacity that is freed up by quality improvements, tends to fill
up with other patients (leading to double cost)
• Cost benefits on the patient-level often lost due to extra volume from other
patients

High

Insurers do invest in initiatives – but they tend to see it as a quality
differentiator with no or modest economic benefits
Source:
Source:

Booz && Company
Company analysis
analysis
Booz

Booz & Company 14 November 2011

34

Prepared for Novo Nordisk

27

Delaying complications
complications saves
saves medical
medical costs
costs–– despite
occasional
Delaying
despite occasional
skepticism

ILLUSTRATIVE

Cost per year (based on average costs of
Details
treatment and complications, excl. other medical costs
EUR ‘000
• Given that patient is alive
and remains within
10
insurance plan
5
• Complications assumed
to occur after 5 years
0
• Assumed that
60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75
intervention can delay
complications for 3 years
Age

Illustration: calculation, the value of 3
year delay of complications
NPV, annual costs EUR ‘000
16.3

-24%

Illustration is for a 60 year
old male patient already
diagnosed

12.4

Attrition
10%

%

4
5%

2

0%

0
NPV

• Attrition level assumed
constant at 5%

60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75

60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75
Patient of 60 years old diagnosed with Type 2 diabetes.
assuming complications will occur after 5 years

Age

Age

Cost if we would be able to delay complications with
3 years with an intervention, less complications occurring
after 8 years

Mortality
%
10%
5%
0%
60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75

• Mortality % of diabetes
patients estimated 2.2
times as high as person
without diabetes (source
interview medical
specialist)

Age
Source:
Booz14&November
Company2011
analysis
Booz
& Company

Prepared for Novo Nordisk

28
35

Higher quality diabetes care may attract more loss-making
patients for the insurer
•	
Diabetes patients typically have high per patient health care cost (cost that are assumed to be caused by diabetes plus other
health care expenditures). Total costs EUR 4,500 per diabetes patient versus EUR 1,650 average
–	‘Diabetes patients typically have a wide range of health problems, not necessarily related to diabetes’
–	‘Diabetes Type 2 is a lifestyle disease, but an unhealthy lifestyle can lead to a lot more problems than just diabetes’
–	‘Diabetes is a disease of the system. It deteriorates your overall health to a wider extent than the regular diabetes complications’
•	
Still a suspicion that the risk equalization scheme does not sufficiently compensate
–	
Diabetes patients have historically been loss making (2006 EUR 74 per person loss after equalization; 2007 EUR 140 per person
loss after ex-ante compensation – but differences not statistically different from zero)
–	
The 2011 risk equalization proposal indicates a EUR 3,409 loss per self reported diabetic, which is equalized to a loss of EUR 235
(which is statistically not significantly different from zero). (source: Prof. Van der Ven)
–	
The classification criteria for diabetes within the risk equalization scheme are strict. As a result, the insurer does not receive ex-ante
risk compensation for all its diabetes patients
•	
Hence, there is a downside in offering higher quality, since insurers offering high quality would be likely to attract more
patients

Source:

36

Booz & Company analysis. Expert interviews. Expert interview with Prof. van der Ven – Erasmus University

Limited
Limited collaboration
collaboration incentive
incentive for
for primary
primary care
care and
and specialist
specialist care
care
Objectives

• Provide complete
and comprehensive
care
• Realize income

Primary Care

Resource

• Applying the GP
diabetes protocol
• Referring to
specialist

GP
POH

Constraints

Practice that would result
from objectives, resources
and constraints

• Lack of time for
dedicated diabetes
service
• Lack of specialist
diabetes
knowledge
• No control on what
is happening in the
hospital

• Most patients are
effectively treated
• But some patients
may be unnecessarily
referred to medical
specialists
• Some patients may
receive late referrals
to specialists

Relatively little interaction
and collaboration
• Provide the best
diabetes care
• Realize revenues
for the hospital and
himself/herself

Hospital care

• Applying hospital
services
• Applying Specialist
knowledge

Medical
specialist

• No information on
patients in primary
care
• No influence on
patients in primary
care

• Tends to keep
patients in the
hospital
‘Once they have been here,
surrounded by diabetic
specialist, it is hard to send
them back to the first line’
Medical Specialist

Diabetic nurse

Despite limited collaboration incentives, care groups have
achieved much progress in quality of diabetes care
Booz & Company 14 November 2011

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30
37

initiatives are
are frustrated
frustratedby
byfragmented
fragmented
Quality improvement initiatives
budgeting
budgeting (and
(and ad
ad hoc
hoc budget
budget cuts)
cuts)
Problem
No full cycle
business case
underpinned

Providers
• Ambitions are often only qualitative
(whereas investments are quantified)

Insurer
• Initiatives with cost saving potential,
may be interpreted more as quality
differentiators than cost savers
–

Insurer support for lean initiatives hospitals, antismoking programs etc .

Fragmentation

• Initiatives often optimized for a single
provider in the chain
• High quality may lead to budget
overruns and consequently budget cuts

• Initiatives may be evaluated from a
single funding compartment (e.g.
AWBZ/ZFW), instead of full value chain

No scalability

• Initiatives are often fully dependent on
the passion and intrinsic motivation of
the initiators

• Limited tools to stimulate initiatives
outside the group of passionate
initiators

• Resulting behaviour from other players
in the value chain is not anticipated nor
mitigated

• Cost benefits on the patient-level often
lost due to extra volume with other
patients

• Frustration that great ideas for care are
not always embraced by the insurer

• Wary of investments in care, since
benefits are not guaranteed to
materialize

Fill -up effects

Booz & Company 14 November 2011

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31

Individual
Individual quality
quality incentives
incentives are
are lacking
lacking for
for primary
primary care,
care,
specialists
specialists and
and patients
patients
Keten-DBC is related to number of contacts, no quality commitment
• No incentives for monitoring of therapy adherence
Primary care

Specialist is paid for volume rather than quality input or outcome
• No financial incentive to critically review necessity of treatment
• No payment for quality outcomes and monitoring of therapy adherence
• No incentive to refer back to primary care
Specialist

No short-term financial incentive to comply
• E.g. reduction of deductible, bonus points
Patient

Booz & Company 14 November 2011

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39

Significant
Significantevidence
evidencegaps
gapsin
inbasic
basicstatistics
statisticsand
andin
intreatment
treatment
evidence suggest insufficient supporting incentives
EXAMPLES

Descriptive
statistics

• How many patients are there?
• How many Type 1 patients are there?
• In what stages of the disease are they?
• In which regions and which groups is therapy adherence high?
• How often do complications really occur?
• What is the impact of labour productivity of the different complications?
• What is the average cost of treatment Type 1 and 2 per stage of diabetes?
• What is the relationship between cost of complications and the progression of the disease?
• What are cost of treatment differences per region?

Effect of
treatment

• How often do which diabetic complications lead to working disability?
• What is the impact of therapy adherence?
• What is the life expectancy of Type 1 and Type 2 patients?
• What is the impact of prescribing insulin when currently SU-pills are prescribed?
• How would GLP -1 contribute to therapy adherence?

Booz & Company 14 November 2011

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33

Recommendation
Insurershould
shouldintegrate
integratecontracting
contractingofof
Recommendation 1:
1: Insurer
primary
carein
innetworks
networks
primary care
care and
and specialist
specialistcare

Integration contracting of
primary care and specialist
care
• Gain sharing for primary care
• Expected impact of substitution
in volume agreements with
hospital
• Specialist can charge standard
hour tariff for support to
primary care
• Support IT infrastructure

Objectives

Resource

Constraints

Resulting
behaviour

• Provide
complete and
comprehensive
care
• Realize income

• Protocol
• Income related
to quality gains
• Access to
specialist advice

• Lack of time for
dedicated
diabetes service

• High quality
primary care in
collaborations
with the
specialist

Resource from
integrated care

GP
POH

Impact
Integrated care

Primary care
Interaction and collaboration

• Provide the best
care
• Realize
revenues for the
hospital and
himself/herself

Insurer

• Periodic reviews
with GP on
patients in the
GP practice
• Enabling IT
support

• (Largely) fixed
income for
diabetes
patients

• Supports GPs
in providing
better care
• Serves patients
who really need
specialist care

Resource from
integrated care

Constraint from
integrated care

Impact
Integrated care

Diabetic nurse

Specialist care

Booz & Company 14 November 2011

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34
41

Recommendation
: Other
Recommendation11:
Otherrefinements
refinementsinineconomic
economicincentives
incentives

Insurer

Government

Booz & Company 14 November 2011

42

Patient

• Provide incentives to patient for compliance by reducing own risk

Research funding

• Enable research funding from normal budget
– Fund trials to increase the evidence base of regular medical treatments

Risk equalization
scheme

• Incorporate small profit margin for insurers in the risk equalization scheme
so that insurers will compete for diabetes patients
– E.g. 5 -10% margin

Integrated funding

• Create an integrated funding model for primary care and specialist care
– E.g. incorporating specialist care in keten-DBCs
• Avoid fragmented budgeting and ad hoc budget cost (these frustrate
innovations that are effective over the full cycle of care)

Prepared for Novo Nordisk

35

Contents
Summarized findings and recommendations
The opportunity
•	Diabetes is a major and underestimated source of medical costs and lost productivity
•	Diabetes care in The Netherlands has reached a high level of quality, but there is still opportunity for further improvement
• Further improving health of patients may lead to EUR 1.5-2 B of economic benefits in 2020
The road
• Refine economic incentives to encourage integrated care and quality improvement
• Engage employers, UWV and participative care in diabetes care
• Engage the patient’s social network to support self management
•	Introduce conditional market access models for new therapies and medication to assess behavioural impact
Appendix: list of sources

43

Ageingwill
willcreate
createan
anextremely
extremelytight
tightlabour
labourmarket
marketover
overthe
the
Ageing
coming
comingdecade
decade
Leading to enormous shortages

Labour market is ageing rapidly

E.g. 450.000 projected vacant employment positions in health care

Employees x 1.000
280330 940 210 1090 155

1530

60 125 1410

530 580

470.000

100%

20.000

450.000

90%
80%

>45y

70%
60%
50%
40%
30%

27y-45y

20%
10%

<27y

0%
Trans/Tel
Industry
Trade FS
Horeca Building

Government
Services
Health
Other
Education
Agriculture

Increase in
Increase in supply
Labor (2010-2025)
(2010-2025)

Source: Vergrijzing en krapte op de arbeidsmarkt UWV Werkbedrijf, SEO, CBS, Randstad , Raad voor de Volksgezondheid , Skipr ; Booz & Company analysis
Source: Vergrijzing en krapte op de arbeidsmarkt UWV Werkbedrijf, SEO, CBS, Randstad, Raad voor de Volksgezondheid, Skipr; Booz & Company analysis
Booz & Company 14 November 2011

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Gap 2025

37

Labour shortage from late nineties illustrates the risk of tight
labour markets for our economy
Competitive Power Based on Labor Cost 1)
(Index, 1995 = 100); 1995–2004
5%

115

4%

110

3%

105

2%

100

1%

95

0%
-1%1995 1996 1997 1998 1999 2000 2001 2002 2003 2004

90
1995 1996 1997 1998 1999 2000 2001 2002 2003 2004

EU

Netherlands

US

Euro competitors

All competitors

Development of Productivity: 1995–2004
5%
4%
3%
2%
1%
0%
-1%1995 1996 1997 1998 1999 2000 2001 2002 2003 2004

Productivity (left axis)

Booz & Company 14 November 2011

AIQ (right axis)

6%
5%
4%
3%
2%
1%
0%
-1%

1995 1996 1997 1998 1999 2000 2001 2002 2003 2004
Netherlands

Prepared for Novo Nordisk

EU

Inflation difference

38
45

Diabetes has
hasaahigh
highprevention
preventionpotential
potentialfor
forlost
lostproductivity
productivity
Diabetes

Diabetes is a common condition in workforce

Good treatment increases participation substantially

15 – 65 years of age, 2009, ‘000, %

261

12.7%

92

Workgroup
age
diabetics

• The life expectancy in our treatment program of
Type 2 patients is the same as the general
population due to earlier diagnostics and high
quality care’
Prof. dr. Henk Bilo; VUMC

3.3%

Disabled
with diabetics

• Quality of primary care is really good. The vast
majority of patients have excellent values and can
live active lives’
Prof. dr. Guy Rutten; Julius Center

% diabetics % diabetics
of workforce
of
disabled

• ‘Type 1 patients, when adhering to the medication,
are able to have a relative normal life and perform
well in most types of jobs’
Prof. dr. Cees Tack, UMC St Radboud

Limited insight in the reasons why diabetes patients obtain
working disabilities
Source: CBS
Booz
&&
Company
Analysis
Source:
CBSStatline,
Statline,UWV,
UWV,
Booz
Company
Analysis
Booz & Company 14 November 2011

46

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39

However, curative
curative and
and participative
However,
participative care
care are
are still
still two
two different
different
worlds
Curative Care

Participative Care

Company
GP

Diabetic nurse
Patient
Arbo-medic

Specialist

Dietician

Insurance
medic
Embedded in professional life

Embedded in private life
Role
• How to prevent complications
• No advice on participation
Source:

Booz & Company Analysis

Source:

Booz & Company Analysis

Booz & Company 14 November 2011

Company
medic

Role
• How to improve participation in society
• How to change working environment
• No advice on treatment

Prepared for Novo Nordisk

40
47

Recommendation 2:
2:Increasing
Recommendation
Increasingparticipation
participationof
ofdiabetes
diabetespatients
patients
should be
be aa priority
priority for
for employers
employers and
and government
should
government

Insurer

UWV /
Companies

Offer supplementary
collective diabetes care
modules for employers

• Offer collective insurance modules for diabetes for
increasing the participation of diabetes patients
– Specific intensive coaching, services by non-curative care
medics (‘ bedrijfsarts ’ or ‘arbo arts’ ) if needed

Integrate contracting of
participative and curative
care

• Integrate collaboration models
• Align funding incentives for curative and participative care
– Bonus fee on top of keten DBC for GP to align with non curative care medics
– Negotiated tariff for non-curative care medics

Companies and UWV to
invest

Participative Ensure a positive working
care
environment

Booz & Company 14 November 2011

48

Curative Participative
care
care

• Companies and UWV to invest in collective insurance for
employees and welfare recipients (directly or via collective
supplementary modules)
– Such arranges could be part of central labour agreements

• Encourage compliance
– Supporting treatment recommended by curative care
• Encourage working environment that motivates to work as
long as possible
Prepared for Novo Nordisk

41

Contents
Summarized findings and recommendations
The opportunity
•	Diabetes is a major and underestimated source of medical costs and lost productivity
•	Diabetes care in The Netherlands has reached a high level of quality, but there is still opportunity for further improvement
• Further improving health of patients may lead to EUR 1.5-2 B of economic benefits in 2020
The road
• Refine economic incentives to encourage integrated care and quality improvement
• Engage employers, UWV and participative care in diabetes care
• Engage the patient’s social network to support self management
•	Introduce conditional market access models for new therapies and medication to assess behavioural impact
Appendix: list of sources

49

Medical treatments for Diabetes Type 1 and Type 2 can be
effective, however compliance is a huge challenge

Type 1 treatment:
‘Living a pleasant life with diabetes is possible! But you
need to put an effort in it. Watch your blood levels,
carbohydrate intake, treatment schedule; actually
everything you do. Every day again. That takes up energy,
but is worthwhile. Because a healthy lifestyle makes you
feel good.’

…But this requires compliance to a demanding
treatment scheme…

Activities

Type 2 treatment
‘People with diabetes can eat everything that healthy
people enjoy, but the key to a safe diet is to limit intake of
unhealthy food’

SUD

Insulin

Lifestyle

Metformin

• Changing
lifestyle;
• Diet
• Exercise

• Intake of • Intake of • Injection of insulin 1
pills 1 to 4
pills 1 to 4
to 4 times a day (with
times a
use of pump Type 1)
times a
day of met day of met • Self measurement 3
and SUD
to 4 times a day
• Adjusting insulin
intake to lifestyle

Stages of
progression

It is possible to live a very good life
with diabetes…

Applicable • Type 1 & 2 • Type 2
to

• Type 2

• Type 1 & 2

Studies indicate non-compliance can be up to 65%
Source: Beterlevenmetdiabetes.nl,
Beterlevenmetdiabetes.nl,
diabetesfonds.nl,
Booz
CompanyAnalysis
Analysis
Source:
diabetesfonds.nl,
Booz
&&
Company
Booz & Company 14 November 2011

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43

NonNon-compliance leads to severe complications- - Diabetes affects

the whole organism

Stroke
(cerebrovascular disease)

Visual impairment:
diabetic retinopathy,
cataract and
glaucoma

Heart disease
(cardiovascular disease)
Bacterial and fungal
infections of the skin

Kidney disease
(diabetic nephropathy)

Severe hardening of
the arteries (atherosclerosis)

Autonomic neuropathy
(including slow emptying
of the stomach and diarrhea)

Sexual
dysfunction
Poor blood supply to lower limbs
(peripheral vascular disease)
Necrobiosis lipidoica

Sensory impairment
(peripheral neuropathy)
Gangrene

Source:

Ulceration

World Health Organization, American Diabetes Association, NIDDK, National Diabetes Statistics fact sheet. HHS, NIH

Booz & Company 14 November 2011

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51

Non-compliance is a challenge of distant benefits and large
Non-compliance
is a challenge
required
behavioural
change ofdistant benefits andlarge

Weak motivation to
comply

• Motivation to change is typically limited: no sense of urgency
– No feeling of illness (especially in early stages)
– Acceptance of illness
– Benefits of compliance are distant
• Compliance creates a short–term risk of side effects
– e.g. especially hypos

Extensive
behavioural change
required

• Far reaching change in daily routines
– Sleep times,
– Diet
– Exercising
• Requires an adjustment in social life
– Social pressure to engage in social activities not congruent with treatment
– Environment may perceive the distance as an ‘excuse’ to avoid participation
• Requires an advanced understanding of the disease
– Complex intake schemes that are dependent on the context of daily activities
– Need to develop a optimized personal routine

Source:
Source:

Apotheke
-Compiance,Booz
Booz& &Company
CompanyAnalysis
Analysis
Apotheke und
und krankenhaus
krankenhaus Ursachhen
Ursachhen der
der Non
Non-Compiance,

Booz & Company 14 November 2011

52

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45

Facilitated
Facilitatedpatient
patientnetworks
networks are
are successful
successful in
in other
other
distant
distant
benefits
– high behavioural
change conditions
benefits
– high behavioural
change conditions
Chronic quadrangle
Diseases with deferred consequences

Technology dependent diseases

Motivation to comply with
best known therapy

Weak

Patients will
probably adhere

Alzheimer’s

Asthma

Parkinson’s
HIV

Obesity

Type 2
diabetes

Chronic hepatitis B
Type 1
diabetes

Epilepsy

Patients will adhere
Allergies

Depression

Facilitated Patient
Networks

Patients will probably not
adhere but participate at their
own volition in networks
Chronic back pain

Patients are likely to
have relatively low
adherence rates and
need to be
motivated
to participate in
networks

Diseases with immediate consequences

Strong
Minimal
Source:

Disease Management
Networks

Addiction:Smoking,
alcohol etc.

Behaviour dependent / influenced diseases

Consequences versus behavior/technology dependency

Degree to which behaviour change is required

Extensive

The Innovator’s prescription, Christensen, Booz & Company Analysis

Booz & Company 14 November 2011

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46
53

Examples
of
patient
networks
for
other
conditions
may
provide
Examples
for
patient
networks
for
other
conditions
may
provide
learnings for diabetes
EXAMPLES

Alcoholics Anonymous

Weight Watchers

Quitting smoking – ‘De Opluchting’

• The network organises events in which
patients share their experiences

• Online community of people that share the
same aim of loosing weight

• Online community of people that want to
quit smoking

• Online patient network in which the
participants teach each other how to
overcome the disease of alcoholism

• Points plan for weight watchers; a clear
guide in which all nutrition is translated in
points - a participants is only allowed to use
a certain amount of point per day

• Online video classes in which the addiction
is explained, participants are prepared for
the first period of quitting and help with their
decision is provided

• Weekly meetings in which participants are
weighted and in which a coach provides
support in reaching their target weight

• E -mail courses that aim to make
participants more aware of their smoking
habits

• Help line that is 24 hours available

• Training in which participants learn how to
better understand their addiction and how
to quit

• Help line that is 24 hours available

Source:
Source:

www.aa-nederland.nl,
www.stoppenmetroken.com, Booz
Booz && Company
Company Analysis
Analysis
www.aa-nederland.nl, www.weightwatchers.nl,
www.weightwatchers.nl, www.stoppenmetroken.com,

Booz & Company 14 November 2011

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47

Integrated
Integratedbehavioural
behaviouralinterventions
interventionshave
havebeen
beensuccessful
successfulinin
improving
improvingcompliance
compliance
Example: Diabetes Population Management Program of Kaiser Permanente 2003)
(
Level 3

Intensive Care

Level 2

Care Management

• ED visits
• Hospitalization
• HgA1c > 8.5%
• Microalbumin > 30
Any of the above WITH
• HTN . Dyslipidemia

Case Manager
• Coaches members in crisis
• Manages access to specialty
and ED care
• Coordinates care across continuum

Endocrinologist / Diabetologist
• Confirms diagnosis
• Identifies comorbidities
• Optimizes medication regimen
• Mentors case and care managers

• Complex medical issues
• Psycho -social barriers to
self-management

Outreach and Triage
• Prioritize CV risk factors:
• HTN Dyslipidemia (LDL > 100)
• Treatment according to protocols
• Behavior change / motivation
• Reinforce self-management
• Patient returns to Level 1

Week 1

Intake Visit
• One -to-one
• Office visit
• Risk reduction
• Goal setting

Week 2

Monthly

2-6 Months

Group Appointment Group Appointment
Telephone
• Assessment
• Clinical / behavioral
Follow-up Visits
• Care Manager
interventions
• (1:1 office visit as
• Behaviorist
• Care Manager
needed)
• Dietitian
• Behaviorist
• Dietitian

As Needed

Level 1

Self-Care

• Diabetes is well controlled
• Member practices effective
self-care

Source:

Living Well with Diabetes Class
• ,,, and others

Educational Resources
• Healthwise Handbook
• KP online

Primary Care Team
• Reviews, adjust
medications
• Regular screening
• Reinforces
self -management

Kaiser permanente, Booz & Company Analysis

Booz
& Company
14 November
2011Booz & Company Analysis
Source:
Kaiser
permanente,

Prepared for Novo Nordisk

48
55

Recommendation3:
3:Facilitate
patient
Recommendation
Facilitate network
networksolution
solutionaround
aroundthe
the
patient
to support
better diabetes
care
to support
better diabetes
care
Suggested
initiators

Recommendation

Impact

Scale-up use of social
media

• Scale-up diabetes health
communities with patients, their
families and their professionals
(mijnzorgnet)
• Participation of professionals is
key

• Lower barrier to ask questions
• Shared experiences, tips and tricks
between GPs and patients
• Family members / friends can engage
for patients without access
• Unities patients and health care
providers so that they can share
experiences

Amateur and
professional coaching
for non-adherent
patients

• Develop coach select screening
instrument (who should receive a
coach for what)
• Educate amateur coaches
• Select an amateur coach; and
select a professional coach for
difficult patients

• Encourages disease knowledge with
patients
• Encourages adhere to therapy

Prepared for Novo Nordisk

‘You shouldn’t
be alone in self
management’

io n

• Actively engage family members to
support treatment
• No need for patient to remember
everything alone (extra ear from family
member)
• Stimulate early discussion on how to
combine treatment with personal life

l

• If appropriate, include family and
friends in standard treatment
(e.g. family present at key
doctors visits)
• Add checklist for aligning
treatment with personal life
(mass customization; checklist
on lifestyle before therapy starts)

E

Include behavioral
dimension in medical
guidelines

Booz & Company 14 November 2011

56

Description

49

Social
Socialmedia
media examples
examples
BACK -UP

Mijn zorgpagina

Source:
Source:

Mijn zorgnet

mijnzorgnet.nl, Booz & Company Analysis
mijnzorgnet.nl, Booz & Company Analysis

Booz & Company 14 November 2011

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50
57

Contents
Summarized findings and recommendations
The opportunity
•	Diabetes is a major and underestimated source of medical costs and lost productivity
•	Diabetes care in The Netherlands has reached a high level of quality, but there is still opportunity for further improvement
• Further improving health of patients may lead to EUR 1.5-2 B of economic benefits in 2020
The road
• Refine economic incentives to encourage integrated care and quality improvement
• Engage employers, UWV and participative care in diabetes care
• Engage the patient’s social network to support self management
•	Introduce conditional market access models for new therapies and medication to assess behavioural impact
Appendix: list of sources

58

Optimal
medication
Optimaltreatment
treatmentwith
withcurrent
currentgeneration
generationofofdiabetes
diabetes
medication
is therapeutically highly effective if the patient is compliant
is therapeutically highly effectiveif the patient is compliant

10

HbA1c (%)1

9

Diet and
exercise
OAD
Monotherapy

OAD
combination

OAD
uptitration

OAD +
basal insulin

OAD + multiple
daily insulin
injections

Complications
standard
treatment2

Average HbA1c
standard treatment

8

7

Average HbA1c
optimal treatment

6

Duration of diabetes
Del Prato S Del
et al.
Int SJ et
Clin
2005;
Prato
al. Pract
Int J Clin
Pract 59:1345–1355.
2005; 59:1345–1355.
2
2Stratton IM
Stratton
et al.
BMJ 321:405–412.
2000; 321:405–412.
et al. IM
BMJ
2000;

OAD =
oral anti-diabetic
OAD = oral anti -diabetic
Booz & Company 14 November 2011

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52
59

But
lot of
of value
value in
in boosting
boosting
But new
new medication
medication could add aa lot
compliance
compliance
Reasons of non -compliance

Motivation

• Motivation to change is typically limited: no sense of urgency
– No feeling of illness (especially in early stages)
– Acceptance of illness
– Benefits of compliance are distant
• Compliance creates a short–term risk of side effects
– e.g. especially hypos

Behavioural
change

• Far reaching change in daily routines
– Sleep times,
– Diet
– Exercising
• Requires an adjustment in social life
– Social pressure to engage in social activities not congruent with
treatment
– Environment may perceive the distance as an ‘excuse’ to avoid
participation
• Requires an advanced understanding of the disease
– Complex intake schemes that are dependent on the context of
daily activities
– Need to develop a optimized personal routine

Potential impact of easier -touse -medication
• Inherent property of the
disease

• Potentially less invasive
treatment schemes

• Potentially less invasive
treatments schemes

• Therapy may be easier and
less time consuming

Source:

Apotheke und krankenhaus Ursachen der Non-Compiance, Booz & Company Analysis

Booz & Company 14 November 2011

60

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53

CFH access
access criteria
criteria evaluate
evaluate impact
impact on
oncompliance,
CFH
compliance,however
however
evidence
evidence is
is usually
usually not
not generated
generated by trials
Category

Argument

Characteristics
Medical

Improvement vs current
medication
Side effects vs current
medication

Patient

Economics

CFH
criteria

Metrics
Composition, type of
administration, dosage,
Operational area
Relevant end points in
term of morbidity and
mortality. Report utilities
and survival

CFH Document

Type of evidence
from trial

Would extra
compliance lead to
higher score?

Farmacotherapeutisch
dossier

No

Farmacotherapeutisch
dossier

No

Farmacotherapeutisch
dossier

Yes

Ease of use / ease of
administration

QALY’s

Farmacotherapeutisch
dossier

?

Yes

Quality of life

QALY’s

Farmaco -economisch
dossier

?

Yes

Life expectancy

Increase in years

Farmacotherapeutisch
dossier

Yes

Direct treatment cost
per year

EUR

Farmacotherapeutisch
dossier

No

Indirect cost per year

EUR

Farmacotherapeutisch
dossier

No

Long term cost effect
(medical)

?

?

No

Loss of productivity

?

?

No

Booz & Company 14 November 2011

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54
61

Contents
Summarized findings and recommendations
The opportunity
•	Diabetes is a major and underestimated source of medical costs and lost productivity
•	Diabetes care in The Netherlands has reached a high level of quality, but there is still opportunity for further improvement
• Further improving health of patients may lead to EUR 1.5-2 B of economic benefits in 2020
The road
• Refine economic incentives to encourage integrated care and quality improvement
• Engage employers, UWV and participative care in diabetes care
• Engage the patient’s social network to support self management
•	Introduce conditional market access models for new therapies and medication to assess behavioural impact
Appendix: list of sources

62

List of sources used
Sources Used
• A
 lcoholics Anonymous, www.aa-nederland.nl
• American Diabetes Association (ADA), Economic Costs of Diabetes
in the U.S. in 2007
• Apotheke und krankenhaus Ursachen der Non-Compliance
• Beter leven met diabetes, www.beterlevenmetdiabetes.nl
• CBS, Statline: http://statline.cbs.nl/StatWeb/publication/?
DM=SLNL&PA=81173NED&D1=2-4&D2=0-13,32-37,6874&D3=0&D4=l&VW=T http://statline.cbs.nl/StatWeb/publication/
?DM=SLNL&PA=70084NED&D1=a&D2=1&D3=a&HDR=T&STB=G
1,G2&VW=T
• CMR Nijmegen, http://www.nationaalkompas.nl/gezondheiden-ziekte/ziekten-en-aandoeningen/endocriene-voedings-enstofwisselingsziekten-en-immuniteitsstoornissen/diabetes-mellitus/
omvang/
• DBC pricelist 2011
• De Opluchting, www.stoppenmetroken.nl
• DVN, http://www.dvn.nl/diabetes/in-cijfers
• DiabetesZorgBeter, Prof H. Bilo
• Diabetesfonds, www.diabetesfonds.nl
• Health and Human Services (HHS)
• Impact of Medication Adherence on Hospitalization Risk and
Healthcare cost, Sokol et al.
• International Diabetes Federation, http://www.idf.org/types-diabetes
• Kaiser permanente
• MijnZorgnet.nl

• N
 ational Diabetes Statistics Fact Sheet
• National Institute of Diabetes and Digestive and Kidney
Diseases (NIDDK)
• National Institutes of Health (NIH)
• NDF Richtlijnen, http://www.diabetesfederatie.nl/downloadendocumenten/richtlijnen.html
• Nederlandse Patiënten Consumenten Federatie (NPCF) Eindrapportage 2007
• PoZoB
• RIVM, Diabetes tot 2025, C.A. Baan & C.G. Schoemaker
• RIVM, Kostenvanziekten.nl, http://www.kostenvanziekten.
nl/kvz2005/cijfers/start-tabellen-grafieken-volgens-zorgrekeningen/Default.aspx?ref=kvz_v2l1b1p4r0c4i0t1j0o3y4a1g0d25s54z0f0w2
• Screening study: Low yield of population-based screening for Type 2
diabetes in the Netherlands: the ADDITION NL study, Janssen et al.
• SFK, http://www.sfk.nl/publicaties/2011denf.pdfm
• The Innovator’s prescription, Christensen
• UWV provided, data available on Statline, http://statline.cbs.nl/
StatWeb/publication/?DM=SLNL&PA=70084NED&D1=0,2-3&D2=7
9&D3=6&HDR=T&STB=G1,G2&VW=T
• UWV provided, data available on Statline http://statline.cbs.
nl/StatWeb/publication/?DM=SLNL&PA=70087NED&D1=03&D2=31&D3=6&VW=T
• Weight Watchers, www.weightwatchers.nl
• World Health Organization
63

Booz & Company is a global management and strategy consulting firm, helping the world’s top businesses, governments and organizations. With more
than 3,300 people in 60 offices around the world, Booz & Company brings
foresight and knowledge, deep functional expertise, and a practical
approach to building capabilities and delivering real impact. Booz & Company is ranked the #1 management consultancy firm by clients in the annual
Dutch Incompany 100 Survey of 2011.

Former minister of Healthcare, Ab Klink, works at Booz & Company in
Amsterdam. Ab Klink combines this job with his position as Professor of
Healthcare, Labour and Political Direction at the Vrije Universiteit in Amsterdam.
His extensive knowledge and insight in the healthcare sector contribute to
high quality strategic advice on urgent issues in Dutch healthcare.

As a world leader in diabetes care Novo Nordisk’s aspiration is to defeat
diabetes by finding better methods of diabetes prevention, detection and
treatment. This includes initiatives contributing to activities to reduce the
growth of diabetes related costs for society. The Changing Diabetes program
has been developed to support these initiatives. The program entails various
national and international initiatives, focussing on communication with and
providing information to people with diabetes, their families, friends,
educators, politicians, health care professionals, healthcare insurance
companies, and other stakeholders. With the Changing Diabetes program
Novo Nordisk wants to change and improve the way diabetes is treated and
managed by society.

Novo Nordisk is a global pharmaceutical company with almost 90 years of
experience in the field of diabetes care. The company offers innovative
medicines, advanced administration systems as well as services to optimise
the treatment of people with diabetes. Furthermore, Novo Nordisk sets the
standard in the areas of haemostasis, growth hormone therapy and
hormone substitution therapy.

www.booz.com

Novo Nordisk has more than 30.000 employees in 76 countries, bringing
products to patients in 179 countries. Novo Nordisk B.V. holds the third
position in the 2011 Great Place to Work listing and is 16th on the European
list of the 25 Best Multinational Workplaces in Europe 2011. This makes
Novo Nordisk one of the best employers in The Netherlands in 2011.
www.novonordisk.nl
www.changingdiabetes.nl

9 789081 787741