Sigrid M. Mohnen, Ph.D.

1. Sigrid M. Mohnen, Ph.D. 13thInternational Conference on Integrated Care The impact of bundled payments for diabetes care on curative health care costs – A 2-year follow-up study based on Dutch nationwide claim data. This study was a contribution to the work of the Evaluation Commission ‘Bundled payment’ on behalf of Minister Edith Schippers of Health, Welfare and Sport.

2. Disease management programs (DMP) for diabetes Background • Standardize quality of health care for chronically ill  Health Care Standard • Enhance cooperation between health care providers • Former Health Minster: Better quality of care  less complications  cost savings More cooperation  less double checks  cost savings More care by GP instead of specialist  cost savings • Fixing the fragmented payment system Experimenting with bundled payment 2007-2009

3. Background Reseach questions Did the introduction of Disease Management Programms led to a decrease in the curative health care costs for diabetes patients over a period of 2 years? What is the effect of the introduction of Bundled Payment on curative health care costs of diabetes patients? SUBQUESTIONS What are the effects of patient characteristics? Do GP and health insurance matter?

4. Methods Overview study population groups

5. Methods Data • Dutch data on health insurance claims, obtained from • 83% of all insured people living in the Netherlands • Care-as-usual diabetes type 2 relatedmedication • Exclusion criteria: missing/false data in a quarter or switchings • 2007 N = 183,721 2008 N = 210,771 2009 N = 312,499

6. Methods Measurements • € Curative health carecost = sum of GP, hospital, and other costs Other costs: medication, primary care like physiotherapy or occupational therapy, and transportation costs

7. Results DMP  cost increase Cost increases in € from 2008 to 2009 for diabetes patients (N=64,011). Intercept of empty model with baseline costs = €171.4 (SE 23.9) p-value <0.0001

8. no change in conclusions Results Sensitivity analyses level-2 variance • ICC GP-level: 0.09% p-value 0.1552 • ICC Insurance-level 0.06% p-value 0.0865 • No change in conclusions when exclusively patients with oral diabetes type 2 medication were used. • Difference between groups largest in insurance-level model. BP increased with € 314 more than CAU.

9. Conclusions Take home message: Our study suggests that the introduction of DMPs did not slow down the cost growth and that the introduction of BP even increased costs • Curative health care costs increased from 2008 to 2009 • The increase of costs of DMP based on MF did not differ significantly from CAU • Chance of cost increase stronger for patients enrolled in BP

10. Discussion Possible reasons for the stronger cost increase of patients in the BP group: Cost-saving effects need more time to develop? Patients were being referred too late to the secondary care? Well-treaded diabetes patients may cause more costs because they live longer? they are able to receive other health care treatments?

11. Literatur JN Struijs, SM Mohnen, CCM Molema, JT de Jong-van Til, CA Baan Special thanks to sigrid.mohnen@rivm.nl