Marcus Welby, with Computers

So at age 52, he realized that if he didn't launch his own practice and help develop a model for coordination of services for chronic care patients, "it was never going to happen."

He opened a small office, hired a nurse practitioner and a scheduler, put an ad in the paper noting that he did house calls, "and the practice came back to me."

The big opportunity to transform his practice came in 2005, when Family Medicine, Geriatrics and Wellness was the only practice in the state chosen in a nationwide demonstration project initiated by the American Academy of Family Physicians, which was seeking innovative ways to revamp primary care into a team-based structure.

"The chronic care model backs into the patient-centered medical home construct," Mambu says. "It's the key to healthcare reform and the transformational design for primary care growth for the next several decades."

Among other initiatives, such as installing an electronic medical record, Mambu filled out his practice not with other physicians, but with physician extenders. Mambu has two RNs who are "case managers slash health coaches slash office-based experts." Three nurse practitioners help Mambu and his part-time physicians with the caseload, and with managing patients' health and compliance so that they don't have to go to the hospital.

"I'm working myself into the ground," he says, "but I'm loving every minute of it."

What he thinks his practice is modeling is that patient centeredness will help cut costs by improving the patient-doctor relationship, "because that's the power of this model," he says. "Reestablishing that trust and guidance and having the time to guide and coordinate care, which has been lost for most physicians because we don't talk about value, we talk about volume."

Because of the demonstration project's funding, he was able to undertake much of the transformation. Other small practices clearly aren't as lucky because they weren't early adopters, he says, noting that producing outcome and performance reports is impossible "when you jot something into a chart and put it on a shelf. EMRs really don't make it easier to document—it's very burdensome to put in the data and make it good, but the beauty is that it can be retrieved and tabulated and analyzed. If you don't measure it, you can't manage it."