When the non-profit group Minnesota Community Measurement released its first physicians report four years ago, only about 4 percent of diabetic patients statewide had tight control of their blood sugars. Today more than 12 percent of patients meet the group's strict control standards.
At the highest performing clinics the success rate is even better.
"If you had asked me a number of years ago could we get there in that amount of time I would have said no," says Barry Bershow, a family physician at Fairview Health System, which has raised its score from 4 percent to 20 percent.
"I was optimistic we could improve. But I wasn't sure we could really improve that much."
That's because the rating system's guidelines for optimal diabetes care are tough to achieve. Patients have to keep their hemoglobin, blood pressure and bad cholesterol levels within a certain range. Older diabetics are supposed to take a daily aspirin. And all diabetics must be tobacco-free.
It's a lot to track and it can easily take up the better part of an ordinary office visit. During a recent patient exam, Dr. Bershow devoted more than 15 minutes of his time to Mike Romanov's diabetes, even though Romanov came to the clinic for a different health reason.
First Bershow checks his patient's feet to make sure that he feels a strong pulse.
"Your feet are nice and warm. The color is pretty good. You have nice pulses," says Bershow.
“What we've done has gotten us where we are and where we are isn't quite good enough.”Charles Fazio, Medica Chief Medical Officer
Diabetics often develop circulatory problems in their extremities that can lead to ulcers or sores. Severe ulcers can require amputation.
Bershow also checks Romanov's heart and quizzes him about his many diabetic medications. He asks him if he's having any trouble sticking to his regimen or paying for his drugs. The questioning goes on and on. Romanov says he's used to his doctor's preoccupation with his diabetes.
"When I visit him he checks a lot more things regardless of the original reason for my visit," says Romanov.
Bershow believes the extra attention pays off because Fairview gives him the encouragement he needs to make sure his diabetic patients are on the right track. In fact, there's even a little peer pressure built into the system. At the end of each month Fairview uses its electronic medical records to review the charts of all of their diabetic patients. The results are then fed back to doctors, who can compare their performance with their colleagues. The highest performing doctors get bonus payments from Fairview.
Fairview is a big enough health system to absorb some of the costs, since health insurers typically don't pay for the additional care it takes to manage diabetic patients, Bershow says. But he thinks his clinic could do even better if insurers would pay for some of those extras - like nutritionists or nurses who could keep tabs on diabetic patients between their regular office visits.
Bershow says the current insurance reimbursement system actually gets in the way of good care. A fan of sports analogies, he explains it this way.
"If a physician throws 60 passes, if they see 60 patients over a 3 day period and none of them get the right treatment or none of them do well, we pay that physician more under our current reimbursement plan than a physician who sees only 20 people but connects a pass on all 20," says Bershow.
The non-profit group that has been tracking doctors' performance agrees.
"The payers, the health plans and employers need to help the groups, to not just pay them for office visits, but to give them more payment for getting the outcomes that we're looking for," says Jim Chase, executive director of Minnesota Community Measurement.
Chase says he wondered for the first time this year whether there might be a limit to how much doctors can improve care, if the reimbursement system doesn't change. He says after a couple years of solid performance gains, the Minnesota Community Measurement clinic ratings stalled this year.
"It was across the board for all of our conditions that we're seeing not much change in the results," says Chase.
A number of reasons could account for that stagnation. But even some health plans agree they might be partly to blame.
"I think we were all surprised and somewhat disappointed that the Community Measurement numbers didn't move more this year," says Charles Fazio, chief medical officer at Medica.
Fazio says it is true that the current reimbursement system doesn't always work that well in dealing with chronic conditions. That's why Medica is going to launch a pilot program next year that will pay clinics a lump sum of money to beef up their diabetes care.
Fazio says clinics can use the funds to hire more diabetes staff or bring in new technology to improve their diabetes tracking.
"What we've done has gotten us where we are and where we are isn't quite good enough," says Fazio. "So we're open to look at other ideas and in combination with the practitioners we have a reasonable expectation that this will work."
Medica isn't doing this for purely altruistic reasons. The health plan is hoping the project will prevent huge costs down the road. The more patients control their blood sugars, the less chance for diabetes complications like heart disease and limb amputations.
Medica's pilot program starts in January. Fairview has two clinics that have been selected to participate in the project. The program will give Fairview doctors even more freedom in how they care for their patients, Dr. Barry Bershow says.
"Maybe we've been doing it wrong for 500 years in requiring them to come in and see the doctor," says Bershow.
"Maybe there are better ways of taking care of these patients."
Fairview is already experimenting with group visits for diabetics, where patients learn from each other. The clinic system is also trying out electronic visits for some patients who want to find out their lab results online and ask questions by e-mail.
Bershow predicts these innovations will engage patients more in their care and ultimately make them healthier. Medica says if its pilot program is successful, it will expand the program to include other chronic conditions such as heart disease and asthma.