In recent years, there have been concerns about disease management programs in the Netherlands. The bundled payment rate that general practitioners receive from the health care insurance on top of their regular rate is in jeopardy. There is also a substantive discussion going on; is disease management, as we make use of it in the Netherlands, real disease management? And does the model fit into the current practice in which we keep seeing an increase in people with multimorbidity and a complex demand for care?

Not whole disease management but half disease management

In disease management, the various stages of care are aligned in such a way that a coherent offer is created, based on the symptoms and needs of the patient. The concept has been adapted from the US to the Netherlands in the 1980s-1990s, where it has been implemented in primary care for patients with chronic diseases, such as type 2 diabetes, cardiovascular problems and COPD. Secondary hospital care, however, was not included in the bundled payment schemes. As a result, there is in fact no disease management in the Netherlands, but rather half disease management. Is this a problem? Yes, because we are not achieving the desired results in terms of quality improvement and cost savings. Where disease management is applied in the Netherlands, we see increasing costs and only minimal improvements on quality indicators. In contrast, clear positive effects have been demonstrated in countries such as the United States, England and Germany. There is a simple explanation for this: in these countries, health care insurers and/or governments include both primary and secondary care providers within their blended payment. As a result these care providers work together in a single organization network. These organization networks have joint quality frameworks and guidelines. This way, it works out fine.


Multimorbidity is the new norm

So is it simply a matter of better implementing disease management and everything will run smoothly? Not exactly. Disease management is a linear model that is perfectly suitable for patients with one chronic condition without any other notable problems. However, the current reality in the Netherlands is different. 11% of the population suffers from multiple chronic disorders and 13.3% has health problems in combination with other complex problems (high need high costs patients). In addition, 50% of the disease burden in OECD countries is already represented by people with multimorbidity. These people are going to run into problems in disease management programs. As it were, they will be divided into pieces and for each chronic disease they will end up with a different chain with corresponding treatment protocol. When this is not properly coordinated, these patient groups will fall between two stools; a very undesirable situation. The question is just: who will take care of the coordination; primary care providers, the hospital? Who will be responsible? This is the discussion that must be conducted.


Chains of care do not exist, but care networks do

Linear models, such as a disease management approach, have their limitations, but when implemented properly, they are certainly of value. For example, they provide a grip on costs. However, given the complexity coming our way, it is important that we take a next step towards coordinating care in the region. In such a care network, everything is linked with one another and care is provided from cooperation and partnership. The power is divided between the different organizations involved. Not ‘a boss for everyone’ but instead ‘everyone is a boss’ is the adage. Control often takes place on the basis of mutually accepted forms of control. This makes it easier to exchange knowledge, products and services. The differences in interests and perspectives between the organizations strengthen the collective.

Coordinated care requires a regional approach; seeing which populations and what problems we are dealing with on a local level, and realizing an organizational network around it. The care within such an organization network is not only based on medical, but also on social, economic, emotional and cognitive factors and has the important advantage that it adapts easily to changes. No new buildings are needed for this new method; it can simply be done digitally. It is a matter of making agreements about how to coordinate care, where we place responsibilities, how we approach each other on these matters and how we measure results.

This may appear revolutionary – and this is true for the Netherlands – but in several countries, the model has already been implemented with good results. A number of best practices show that it works for complex patient groups if you organize care across the entire network of prevention, care and welfare, and make people jointly responsible for the outcomes. This was also shown in a review that we have recently done based on the Rainbow Model for Value-Based Care. There, too, we found a significant link between professional coordination and integration and a decrease in mortality and unwanted hospital admissions.


Looking at the future with a broad view

So, disease management is no more? No, but in the way we are applying it in the Netherlands right now, it does not have a long life. Let’s broaden our view across the walls of our organization, whereby we really take the needs of the patient as a starting point. The increasing multimorbidity and complexity of care also leaves us no other choice. Fortunately, we see that there are shifts going on. Health care insurers, medical specialists and general practitioners realize that the current situation requires a new approach, so that we can keep problems that are lurking under control.

The question is, however: do we dare to embrace this new way of thinking and put it into practice? After all, it means that changes must take place in all layers of care. Coordinated care requires entrepreneurship from local healthcare providers who, together with partners in the region, are willing to run a financial risk for achieving or not achieving health outcomes and cost savings. In addition, contract innovation is required for health care insurers to realize the necessary efficiency and quality incentives. Policy makers must also give the parties in the field the freedom to organize the optimal form and scale of care that fits the local population and to stop stimulating competition and cooperation in the field at the same time. In short: there is work to be done. However, there is scientific proof that arranging care around care networks gives results and moreover, we do not need to reinvent the wheel! So, what are we waiting for?

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dr. Pim Valentijn

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