During his diabetes clinic appointment at the VA Pittsburgh Healthcare System, Robert Raubach faced a team of professionals who did anything but hurry him along.

Mr. Raubach, an Army veteran from Glencoe, Somerset County, moved from one examination room to the next as he met with a diabetes educator, a nutritionist and two nurse practitioners. They kept him at the High Intensity Diabetes Management Clinic for more than an hour, grilling him about the factors that might contribute to his high blood sugar levels, hypertension and trouble losing weight. Then Dr. R. Harsha Rao, the system's chief of endocrinology, reviewed their findings with Mr. Raubach and discussed a treatment plan.

For Dr. Rao, the one-stop-shop approach to diabetes care is a dream come true -- but it's an approach, he believes, that is unlikely to work in the "real world" outside the government-run health system.

Patients often lack the comprehensive medical monitoring and continuing help in learning to manage their disease that experts believe are essential to optimum care.

Experts say a major hurdle to widespread change is a health care system that readily pays for the devastating complications of diabetes but places less emphasis on preventing them from occurring.

Innovative programs, like the one at VA Pittsburgh, tend to rely on grants or other assistance unavailable to many other physicians.

"Our entire reimbursement system is predicated on acute care," Dr. Rao lamented. "That's why intervention and treatments get overwhelming precedence over preventive care."

Doctors generally are paid more when a patient with diabetes becomes ill and requires more treatment than they do if they keep patients healthy and stable, said Harold Miller, a strategic initiatives consultant for the Pittsburgh Regional Health Initiative.

Insurers typically won't pay doctors for certain services that could be helpful, such as telephoning patients to ask whether they are checking their glucose levels or taking their medicine, he said.

The same is true for people who don't have diabetes but are at high risk for developing it.

Many people with pre-diabetes, for example, lack coverage for exercise or nutrition counseling programs, even though improved diet, exercise and weight loss can often prevent diabetes, said Terry Riffer, director of lifestyle services and the Joslin Diabetes Center at West Penn Hospital's Forbes Regional Campus.

"There are so many people who slip through the cracks," said Dr. Jann Johnston, chief of endocrinology at Mercy Hospital.

The state's new chronic care commission will deliver a plan by Dec. 31 recommending changes needed to implement a model for improving care statewide, said Ann Torregrossa, policy director for the governor's Office of Health Care Reform. If the governor approves the plan, some payment system or other changes could begin to be implemented next year.

Most people with diabetes need to carefully monitor what, and how much, they eat; test their blood sugar and take insulin or other medications, often several times a day; and regularly undergo other tests to measure blood sugar levels and to detect foot or eye problems and other complications.

Follow-through

Besides learning those skills, they may need encouragement to follow through with all the monitoring, medication and other challenges, such as maintaining a healthy weight.

The task of helping those people generally begins with family doctors. But in a typical office visit, those physicians may not have time, or even remember, to address all the issues involved in helping their patients control their disease.

"We do the best we can," said Dr. Robert Potter Jr., a family physician with Genesis Medical Associates, a 17-member group practice in Cranberry and the North Hills.

He relies on a computer system that keeps track of his diabetes patients' medical tests and refers them to diabetes education programs.

Still, under the current payment system, "there's not a big incentive for us to spend time with people to make sure they're taking their medication," exercising and losing weight, he said.

Dr. Douglas Clough, vice president of the Allegheny County Medical Society, noted that much of the challenge of achieving better management of diabetes rests with patients.

"I as a physician cannot force somebody to lose weight. I can't force them to eat the right foods," said Dr. Clough, an internist who practices on the North Side and in the North Hills. "Patients with diabetes need to take some responsibility for their diet and weight loss and taking their medication and checking their blood sugars."

Dr. Potter noted that the cost of medication and diabetic supplies is a problem for many patients, including some who have health insurance. Some rely on sample medications from his office, he said.

To address problems in the system of care for diabetes and other chronic diseases, Gov. Ed Rendell has called for implementing a widely recognized management model developed by Dr. Edward Wagner, director of the MacColl Institute for Healthcare Innovation at Group Health Cooperative in Seattle.

Patient education is a major focus of the model, Dr. Wagner said in an interview, and the approach to educating patients about diabetes has changed.

"It used to be that patients were sent to hospital-based programs that simply educated them about their condition. Those showed limited benefit," Dr. Wagner said.

The current focus, he said, is to help people set goals, then reinforce the need for meeting them in a variety of settings, including diabetes education programs, doctors' offices or support groups.

Physician practices also need information systems to help them keep track of patients and the tests they need, Dr. Wagner said.

"We know it's doable," he said, noting that his group has worked with 1,400 or more physician practices around the nation.

But computer upgrades and other changes can be costly, and many doctors' offices have yet to move in that direction, he said, noting that payment systems are "one large barrier" to change.

"The current general organization of medical practice is a mismatch with the needs of people with conditions like diabetes," Dr. Wagner said.

In Pennsylvania, only about 15 percent of physician practices have electronic reminder systems to help monitor patients with chronic disease, said Dr. Donald Wilson, medical director for Quality Insights of Pennsylvania, which works with health care providers to improve services for Medicare beneficiaries.

As part of Mr. Rendell's chronic care initiative, lawmakers have allocated $2 million to establish patient registries, beginning with patients with diabetes, to help health care professionals track their patients.

Only about half of Pennsylvanians with diabetes who responded to a 2005 survey said they had received formal diabetes education, according to the state's first diabetes action plan, released this year.

Some patients choose not to attend diabetes education programs and others are not referred, said Jan McWilliams, a diabetes specialist with the University of Pittsburgh Diabetes Institute. Some programs, particularly in rural areas, may not be conveniently located.

Experts believe patients might especially benefit from diabetes education provided at their doctors' offices, but such programs are not available at most offices in the Pittsburgh area.

At the University of Pittsburgh Medical Center, the region's largest health care provider, seven primary care practice sites have diabetes education programs that meet standards set by the American Diabetes Association, which allows them to bill for services.

"This is good news, but only touches the tip of the iceberg when it comes to reaching people for diabetes education," said Dr. Linda Siminerio, executive director of the Pitt Diabetes Institute, which is working to establish education programs at other practices throughout the region.

Doctors have traditionally referred patients to hospital diabetes education programs, which often struggle to make ends meet.

Medicare covers diabetic supplies and diabetes education, and a 1998 state law requires that individual and group policies also offer coverage. Still, obtaining the benefits can be a challenge, some health care providers said.

"There are a lot of caveats to it," Dr. Siminerio said. Some insurers require prior authorization of services.

Most states have similar mandates, which have had some effect on use of selected diabetes care services, according to recent findings by the Centers for Disease Control and Prevention. Daily self-monitoring of blood glucose levels, for example, increased. The mandates don't apply, however, to many people whose employers self-insure.

Finding what works

Some researchers have questioned how much diabetes management and education programs really help.

A study of more than 8,600 diabetes patients published last year in the Annals of Internal Medicine, for example, found that disease management strategies were associated with higher rates of screening and other tests, but not with better outcomes such as improved blood pressure, cholesterol or hemoglobin A1C levels. A1C values indicate blood sugar control over two or three months.

Dr. Siminerio said the issue needs more study.

Experts believe better management of diabetes would result in fewer disease complications and long-term health care cost savings, but evidence is lacking to assess what those savings might be, Dr. Wagner said.

That may be one reason, he said, why insurers haven't moved more quickly to change the payment system.

But he said that attitude is "changing a little bit, in part because big insurers are finding those patients often recycle back. So there is some potential benefit to everybody if you could improve diabetes control across a community."

Medicare -- the major insurer for many people with diabetes -- is conducting demonstration projects aimed at improving care, he noted, and is moving toward encouraging doctors to measure and report their performance.

Dr. Wagner said that fulfilling Mr. Rendell's plan for improving chronic care management will require collaboration among insurers, business groups and health care providers. Western Pennsylvania already has had success in addressing another health problem, he said, noting the progress made by a number of the region's hospitals in reducing hospital-acquired infections.

But if all the vested interests look out for themselves, improving the system is "going to be an uphill battle," he said.

When he developed his ideal diabetes clinic, Dr. Rao sidestepped many thorny issues related to reimbursement because VA Pittsburgh is part of a government-run system. Several clinic staff members already were on the VA's payroll, and the Jewish Healthcare Foundation provided funds to hire another and helped with work flow management.

Patients who are having trouble controlling their diabetes are referred to the clinic, which opened last year and sees about 20 to 25 patients a month. Dr. Rao said it is too early to tell if the approach has resulted in improved outcomes.

One goal, he said, is to address the high no-show rates typical of many diabetes education programs by eliminating the need for patients to make a different appointment for that service. Education topics are covered during the clinic visit, and results of blood tests taken at the start of each appointment are available later in the visit.

Mr. Raubach, 70, a retired mine worker and air freight agent who works part-time as a landfill inspector, said he was referred to the clinic after doctors suspected he had kidney problems related to his diabetes. He began making the 90-mile trip to the VA Pittsburgh clinic last year.

"A bunch of us in the family got this sugar," he said, noting four of his brothers also developed diabetes.

Nearly 20 years ago, a blood test showed that his blood sugar levels were getting high and he began taking medication. Then the problem worsened, and he went to insulin injections more than five years ago.

"I see you're checking your blood sugars several times a day," diabetes educator Jan Beattie told Mr. Raubach at the start of a recent clinic visit.

After some discussion, she noted that his levels were running high in the evenings. She said she would ask the nutritionist to concentrate on what meal habits might be contributing to the elevated levels.

Moments later, he was meeting with registered dietitian Kristen Sandulache, who asked for a detailed rundown of what he ate in a typical day.

Mr. Raubach said that he lived alone, usually skipped lunch and often had hamburgers, hot dogs or "something out of a can" for his evening meal.

"We want you to have balanced meals throughout the day," she said, noting that doing so might help him lose weight and keep his blood pressure at normal levels.

More counseling and questions followed about the amounts he ate and his activity level.

At the next station, Mr. Raubach met with nurse practitioner Carol Franko, who focused on his blood pressure and cholesterol levels. The cholesterol readings were good but his blood pressure was high, and she ordered him a blood pressure monitor and asked that he check his pressures every morning.

"It would really help you to lose weight," she said, adding that choosing low-sodium foods also would be a good idea.

"That means my bacon's going with my eggs," Mr. Raubach said. "What about sausage? I guess that has a lot of salt in it."

He then met with nurse practitioner Mary Stosic, who pointed out that his A1C levels had improved but still needed to be lower. She checked his feet and the injection sites in his abdomen for signs of trouble, discussed details from his medical record, then left to consult with Dr. Rao.

"We're going to have to adjust your insulin, my friend," the endocrinologist told Mr. Raubach a few minutes later, ordering increased levels in his twice-daily doses. He also warned that his patient might need to go to three shots per day if his blood sugar levels did not improve.

"That bothered me a little," Mr. Raubach said a few weeks later.

He said he had been getting more exercise and had become more serious about his diet since the clinic visit.

No more potato chips and no more doughnuts, he said. "I don't eat that garbage like I used to."