Darrell Sapp, Post-Gazette Dr. Swarna Varma stands in the doorway of one of her exam rooms. Dr. Varma has developed a protocol for teaching Type II diabetics to better control their diabetes. Click photo for larger image.

With true-believer zeal, Dr. Swarna Varma has developed a plan to cut the nation's annual price tag for diabetic care by as much as $18 billion.

Her philosophy is simple: Prevention is cheaper than treatment.

But to make it happen, the Bridgeville endocrinologist said, doctors should be paid to train diabetics to achieve better control of their disease.

And there's the rub.

Her plan would require schooling patients in the ABCs of good health to keep blood glucose, blood pressure and cholesterol levels under tight control. But the current approach, she said, pays doctors only to treat problems that beset diabetics who don't remain under strict control.

"We get reimbursed for heart attacks, vision problems, strokes, prosthetics, ulcers and dialysis," she said. "Do we get reimbursed to get their ABCs under control? No."

What doctors can't achieve in prevention must be addressed later with more expensive treatment, she said.

The American Diabetes Association has accepted her study abstract, "Controlling the ABCs of Diabetes: A Community-Based Private Endocrinology Practice Experience," and she's now completing a manuscript.

Her study, based on analysis of medical data from 395 of her patients over five years, advocates a practical approach for doctors to improve control of the disease.

The nation spent $90 billion in 2002 on direct costs of medical care for diabetics, with 80 percent of those expenses -- $72 billion -- used to treat complications resulting from lack of control, she said.

In her practice, her patients are up to three times as likely to be in control than the national average, based on her philosophy of working with them to reach specific health goals. If her patients' numbers were applied nationwide, she speculates, it would cut the bill for diabetic complications by half, to $36 billion.

But her approach would require payments to doctors to train diabetics, rather than just treat them. That estimated $18 billion cost, however, still would leave about $18 billion in total health-care savings, she said.

"We need to be compensated to help achieve that goal," she said.

Her numbers don't take into account $40 billion in indirect costs of uncontrolled diabetes, including lost work days and other expenses employers must bear.

But persuading health insurance companies to pay doctors additional money to train diabetics and track the results remains her challenge.

Denise Grabner, spokeswoman for Highmark Blue Cross Blue Shield, which has 3.1 million members in Western Pennsylvania, said Highmark already pays physicians rewards to encourage prevention among diabetics.

"Everyone has a vested interest in diabetics getting appropriate care in the beginning so they don't have complications," she said.

The state also mandates that Highmark pay for diabetic education through diabetic educators. The National Committee for Quality Assurance evaluates Highmark and other health insurance companies on how well they care for diabetics and boosts their score if they provide preventive health care, Ms. Grabner said.

But Dr. Varma said there should be precise reimbursement for doctors who train diabetics, track results and provide daily assistance in reaching goals.

She said diabetic care also would improve if patients received a rebate check from their insurance company for reaching annual guidelines, much the same way good drivers receive discounts on car insurance. Dr. Varma cites other studies, including one that appeared Jan. 30, 2002, in The New England Journal of Medicine, that revealed fewer complications in Type II diabetics who received intensive therapy to control glucose levels, blood pressure and cholesterol.

She said she sets goals in those areas for her patients, then charts results during each visit to gauge the level of control.

During appointments, Dr. Varma said, she spends as much time as necessary with patients to help them understand and improve their numbers, with follow-up phone contact. She also said success depends on a team concept involving the patient, the patient's family, the doctor and support staff.

In her Bridgeville office, she's the only doctor. But she has two registered nurses and two medical assistants, among other help, to provide support staff for patients.

"Without homework, goals won't be achieved," she said.

Her office receives 50 telephone calls a day from patients with questions. "I pay for this by working 12 to 18 hours a day," she said.

The onset of Type I diabetes usually occurs in childhood when an autoimmune reaction damages the pancreas, hindering or eliminating its ability to produce insulin, the hormone that turns blood sugar into energy.

As a result, blood-sugar levels rise dangerously and must be controlled with injections of insulin and blood-glucose testing to make sure the patient's levels do not go too high or low.

Type II, what used to be known as adult-onset diabetes, results when a person's body no longer produces enough insulin or can no longer use the insulin it produces. Weight and lifestyle problems not only can prompt the disease but also make it more difficult to treat.

Treatment for Type II diabetics can require insulin injections and other medications, lifestyle alterations and a daily blood-testing regimen to keep blood glucose levels as close to normal as possible.

"It's a complicated disease, but we simplify it the best we can for the human mind," Dr. Varma said.

Besides setting goals, she advises patients to follow a diet low in fat and sugar and provides nutritional information and a grocery list as a reference in buying healthier food.

"I don't want them to be hungry," she said. "No one can lead a life being hungry. I make it doable."

To get their attention, she provides new patients the following battery of statistics, emphasizing the wisdom of monitoring blood glucose, altering one's diet, exercising and keeping one's diabetes under tight control:

As many as 80,000 diabetics lose vision each year, based on 2002 statistics.

Three million diabetics had heart attacks and 1 million had strokes; 3 million had impaired vision.

Eighty thousand had leg amputations, 100,000 had leg ulcers and 45,000 had to start dialysis for kidney disease.

Decreasing a person's average blood sugar significantly reduces eye, nerve and kidney damage. It also lowers the incidence of strokes, heart attacks and limb loss due to gangrene.

"We have to sell them on the idea that we have to treat them," Dr. Varma said. "Any complicating factors make it more difficult."

Her mission, she said, is convincing health-insurance providers that they'd realize the savings if doctors were reimbursed for bringing more diabetics within control guidelines.

Once her manuscript is complete, she said, she'll complete a module to be used with electronic health records to make her protocol available to physicians and healthcare officials in an international campaign to improve diabetic care.

"I'm hoping that someday health companies and employers will reimburse us for doing the right thing," she said. "I want to make this doable."