If you haven’t guessed by now, I’m actually an American. I moved to the Netherlands in 2005 to move in with my dutch sweetie that I met in Everquest of all places.
Becoming diabetic has become an adventure because testing, treatments and whatnot aren’t the same as the Land of the Beetus (as I like to call it). It doesn’t help that the EU is incredibly strict so a lot of things that have been approved by the FDA in the states doesn’t get approved here. Or it just takes years for the approval process to go through.
For example, Metformin is available here (hey, it’s cheap and usually effective) but Metformin ER (extended release) isn’t. Then again, it goes in reverse sometimes too. The Freestyle Libre 2 is available in some European countries but probably won’t be in the USA for another year at the minimum.
Your GP is the First Line of Care
I think this is pretty similar to the US, it’s going to be your primary (in most cases) that figures out you’re diabetic during a routine blood screening. Unless you end up in the ER while DKA (diabetic ketoacidosis).
Your huisart (which is the dutch word for family doctor) can order up all the needed tests and start treatment. There’s no need for a diabetic specialist to do this, especially if your case is a very routine case of T2 diabetes. Get prescribed Metformin and wait to see the diabetic nurse for instructions on diet and lifestyle changes.
Even if you’re T1 you can always transfer your care back to your huisart if there’s nothing special going on, although he or she may not feel entirely comfortable with that.
The Diabetic Nurse at Your Doctor’s Office
Most of the doctors offices, or gezondheidscentrums (health centers), will contract with or have diabetic nurses on staff. How it’s been explained to me is usually these are nurses who’ve taken extra education on diabetes so that they can offer nutrition and lifestyle advice. They can’t prescribe medication, so if they want to change your treatment they’ll have to talk to the doctor first.
Apparently this is the end of the diabetic journey for most type 2 diabetics because they will respond well to oral meds as well as changes to diet and increase in exercise.
If you turn out to be type 1 or a difficult type 2 (or completely out of control t2), you’re referred to your local diabetescentrum at a hospital.
The diabetes centers have diabetic nurses that have more medical training than the ones at your neighborhood clinic plus they can prescribe medication. This is also where you would see the internist that is assigned to your case.
Internists Control the Diabetics Fate
I still really don’t understand the difference between an endocrinologist, who would treat a diabetic in the states (and the UK I believe), and why it’s an internist here. But that’s how they have it set up.
At the end of the day, the internist controls everything about your diagnosis. They will order the tests for types and then make the decision on your type if there’s a grey area (I’ve learned that diabetes isn’t black and white).
They’re also the one that ultimately decides if you get an insulin pump or not. So if you’re a type 2 that is insulin dependent, and if you’re unlucky and get a shitty internist, you may not get that insulin pump you’ve been dreaming about.
And of course, if you become controlled for a certain amount of time (I believe this is only for t2’s) they’ll transfer your care back to your primary.
Disagreement with Diagnosis or Treatments
The one thing that is done right in Europe is if you don’t agree with someone’s diagnosis or treatment, you have the right to a second opinion.
I’m going through this now and the process is you go back to your primary and ask for a second opinion. They’ll ask if you know where you want this done at. If there’s a specific hospital then they’ll write you a referral. If not, they’ll pick someplace for you.
I’ll add more here as soon as I go through it!
Medication, Supplies, CGMs, Pumps
This is also the other thing that europe has done right. Countries do NOT let Big Pharma come in to make a huge profit. So T2 medication, insulin, needles, pumps, and pump supplies are covered by insurance.
Unlike in the US, I don’t have a “prescribed amount” of any insulin I’m taking. Whenever I need more, I just order more. And I can order more when I’m half way through a pack of pens, when I’m on my last pen… it doesn’t matter. Same with the needles (and I believe pump supplies, though I’m not there yet).
The only thing that I have a restriction on amount is test strips and lancets (not that I need more lancets, I have several life times worth in a drawer).
For pumps, I think most of the insurances “loan” you the pump for 3 or 4 years. So if you don’t want to use a pump any longer you have to give it back. I’m only now exploring the option of pumps so I’m not sure if the type of pump you want to use is restricted by your insurance, diabetes center, or you can use whatever is available in the country.
Now, CGMs (continuous glucose monitors) are NOT covered unless you can meet one of the 4 criteria:
- under the age of 18 (as soon as you turn 18 you’re paying out of pocket)
- want to get pregnant (cause fuck child free women! and men)
- are pregnant (as soon as you pop it out, you have to pay out of pocket)
- have hypo unawareness (and as soon as it gets better they take it away)
Sometimes if you have really bad control your internist can convince the insurance to pay, or take it out of the hospital budget. Seriously though, sourcing nuclear material to make a dirty bomb is easier than getting a CGM covered in this country which is sad because diabetics (regardless of type) do so much better with the constant and instant feedback.
At the end of the day, I rather be a diabetic in Europe than the USA. I don’t have to stress about my medical costs, when will I get my next batch of medication and supplies, or if I’m going to have to ration.
Don’t get me wrong, it’s still not perfect here. We still have to go with brands of medication that insurance dictates. For example, I was originally prescribed Lantus for my basal but what I got was Abasaglar (i.e. Basaglar) instead. Since this was the first time I didn’t fight it since Basaglar is supposed to be nearly the same formula. It just sucks for everyone that was doing well on Lantus to be switched without notice.
Sometimes insurance still dicks around on medications you’re prescribed. Early on in my diagnosis I was prescribed Ozempic (a GLP-1 inhibitor that increases insulin release and slows down digestion of carbs) and insurance denied me because I “hadn’t injected insulin for 3 months”. I’ve no idea why I’d have to be injecting insulin for 3 months as a diagnosed T2 diabetic but it only cost 126 euro vs. the $600 it would have cost me out of pocket in the states.
However, at the end of the day I know I’ll have my medication when I need it. I don’t have to guess, wonder and if for some reason I have to pay out of pocket I’m not going to feel like I’ve been bent over and fucked up the ass sideways without lube.