Angela Barnett, clinic supervisor, remembers her reaction when she saw the numbers.

"Shocked," she said.

"Dumbfounded," said Joanna Mauch, a medical assistant.

"Holy mackerel," said Dr. Bruce Kuhlmann, a family physician. "How can we be so dismal?"

In 2008, they discovered that only 5 percent of the diabetic patients at their clinic, CentraCare in Becker, Minn., were receiving proper care, according to state guidelines -- one of the lowest rates in the state.

The clinic was graded on, among other things, how many patients were able to keep key symptoms under control, including blood sugar and cholesterol levels.

That year, the average score statewide was 13.5 percent. But some clinics boasted success rates in the 40s.

Looking at the scores, posted online by a group called MN Community Measurement, Barnett says she and her colleagues made up their minds: "We need to do something to change this."

Two years later, the Becker clinic was rated second-best in the state for diabetes care, with a score of 60 percent.

The idea of rating clinics -- or individual doctors -- on patient outcomes has been hotly debated as more and more quality "scorecards" are made public. But in Minnesota, which has been on the leading edge of the movement, even skeptics agree these public ratings have sparked more change than many thought possible.

"When we first started this, some physicians were absolutely convinced that they wouldn't be able to do any better than they were doing," said Dr. David Tilstra, medical director for the CentraCare Clinic network. The Becker clinic proved them wrong.

The clinic, about 20 miles south of St. Cloud, is one of the smallest in the CentraCare system, with three doctors and one nurse practitioner.

Barnett, a nurse, said they started revamping the diabetes program after showing the embarrassing 2008 scores to the whole staff, including nurses and others. "This is on the Internet," she told them. "This is what patients see."

Five-point survey

That was, in fact, one of the reasons Minnesota started tracking diabetes care in 2003, said Jim Chase, executive director of MN Community Measurement, a nonprofit collaborative that collects and reports the data. At first, he said, the reporting system was voluntary; now clinics are required by state law to report a long list of measures, including a five-point diabetes survey known as the D5: Are patients controlling their blood sugar, cholesterol and blood pressure levels, taking an aspirin a day and not smoking?

If they meet those goals, experts say, people with diabetes can dramatically lower their risk of serious complications, such as kidney failure or heart disease.

From the start, the success rates were tiny -- the first year, only 4 percent of patients statewide met the diabetes goals, said Chase. But every year, the scores crept up, and some clinics far outclassed others.

Initially, he said, those that lag are often defensive. "The reaction is well, that must be wrong," he said. Or "I have a harder patient base." But when they look down the street and see a competitor with higher scores, that shatters some illusions.

"You never want to believe that you're at fault," said Kuhlmann, a Becker physician with 30 years in practice. But with such "dismal" numbers, he said, "We had to recommit to this and make it a priority."

Intensive follow-up

What Becker found, on closer look, was that many patients were long overdue for tests or checkups.

"Prior to this, we put a lot of the onus on the patient," said Patti Bruggeman, a CentraCare site coordinator. If they forgot to come in for diabetes checks, she said, "they just kind of fell through the cracks."

Now, staffers devised a new system: They made a list of all diabetic patients and routinely check to see who is due for tests or exams. If someone comes in for any reason -- a cold or broken toe -- they make sure their diabetes care is up to date. If someone skips a test, they send letters. And more letters. And phone calls.

Kim Warne, of Big Lake, calls it the "summoning." Both she and her husband, John, are treated for diabetes at the Becker clinic, and she says the staff has been relentless -- in a good way -- in helping them stay on top of it. "If we have blood tests or whatever and they don't like the results, they call us and say, 'OK, you need to come in,'" she said. "If [we] ignore them, then they pester, which is fine with me, because I'm really good at forgetting to do stuff like that."

John Warne, 48, said he's altered his diet, started exercising and lost more than 30 pounds with the encouragement of the clinic staff, and that's helped bring his blood sugar and blood pressure to more normal levels. "They don't just blow you off," he said. "They keep on track at their end, and if you start to slack off, they let you know ... and that makes a big difference."

Kuhlmann says it's been popular with most of his patients, but not all. "I'd say 85 percent love it," he said. "Five percent hate it, and they're gone. And 10 percent tolerate it."

Debate over scores

Dr. Richard Bergenstal, past president of the American Diabetes Association, credits the diabetes scores with prompting better care. "I think this has been a huge advance," said Bergenstal, who is also head of the International Diabetes Center at Park Nicollet Clinic. "We've seen the same thing at Park Nicollet; our numbers get better the more we have ... focused on them."

Dr. David Thorson, chairman of the Minnesota Medical Association and a family physician in White Bear Lake, said physicians have become more accepting of the ratings. "The skepticism has diminished," he said, and there's growing agreement they have improved care. Still, he said, doctors are concerned that they're held accountable for things outside their control -- such as patients who won't stop smoking.

And some experts worry there's too much focus on numbers. The danger is that doctors will "fire" uncooperative patients, said Dr. Victor Montori, a diabetes specialist at the Mayo Clinic; or that they will add expensive medications just to get someone past the goal line to improve their score. "Starting a new medication to get from 7.1 to 6.9 is very difficult to justify in terms of benefit for the patient," he said. But for the doctors, he said, it could affect their score, and eventually their pay. "So much rides now on getting good scores," he said.

Most, though, say the competition to raise scores is making care better. In fact, when the latest scores were released in June, a few new clinics had surpassed Becker.

But Joanna Mauch, who helps run the Becker diabetes program, wasn't discouraged. "We're going to be first next year," she said.

Maura Lerner • 612-673-7384