A: Ninety-five percent of diabetic patients get care from primary care physicians in the context of acute reactive care. The average diabetic patient shows up at a random time in the middle of a chaotic day and is seen by a physician who is disorganized and behind schedule. That is modern life with medicine.

Here is a patient who has a chronic illness. We know from the evidence what things are needed to improve that certain case — how often to have eye exams, blood pressure checks, and blood glucose control checks. Even though we know that, most patients just show up 4, 5, 6, 8, 10 times a year seeing somebody in the primary care physician's office — it may be with a sore throat, it may be with a sprained ankle — and if the physician remembers, he will try to plow through the charts and figure out the last time the patient had an eye exam.

In other words, typical care is unplanned acute reactive care in the setting of a fairly chaotic system that is set up for reactive care and not planned care. The correct way to care is to have planned proactive care. That is not to say you don't need to provide acute responsive reactive care when an acute problem comes up.

Q: What have you found are the biggest barriers to change?

A: Most physicians already feel like they are working as hard as they can and this seems like more work. You need to convince them this is not going to be more work; it is going to be a more efficient way of using your time. Same work but better outcomes.

They underestimate how many diabetic patients they really have and overestimate how well they are doing with them. The most effective intervention there is to quietly do an audit of the practice in a non-threatening way and ensure the fact that they don't have 62 diabetic patients, with 80% that are getting the right things done. They have actually got 155 diabetic patients, and barely 20% have the right things done. When you assure them it is not wrong, they start to get defensive. If you point out that they are not incompetent or inept or uncaring but it is a system that is set up that makes it not easy, then you have a way in. You give them tools that will irrevocably change the way they practice for the better.

Q: What difference can it make in a person's life when they start getting good chronic care?

A: In the short term, most patients start getting friendly phone calls from a nurse to remind them that they haven't been in for over a year for an eye exam or that a new study came out about a new drug and by the way your foot exam is due next week. They are getting planned, integrated, coordinated care, and their anxiety level and personal satisfaction with life in general goes up.

The short-term benefit is that most patients can tell that they are getting coordinated care and end up coming in less often. A big fear when we proposed doing this 6 or 8 years ago was that they would have to call in people for additional visits and look at their eyes and their feet and have to give treatments; providers were concerned that people would end up coming in more often, and it would cost them. It is not true. You will find that if you have an organized system, people come in and get everything dealt with much more efficiently. They are much more satisfied and they come in less often rather than sporadic visits because they were just anxious and wanted to touch base.

In the long term, it is clear that if you can dramatically increase the percentage of patients who are getting appropriate care, blood pressure checks, blood glucose checks, and their eyes examined outcomes are going to improve. What we have shown already is that short-term costs are down because of much more efficiency in the health care organization. What is undoubtedly going to be seen in the next five to ten years is the overall societal health care costs are going to be down because health outcomes are going to be better.