Marcus Welby, with Computers

If you read the tea leaves, they aren't falling in favor of small primary care physician practices. Squeezed by high overhead and falling reimbursements for years, many of these physicians have simply given up—retired—or moved on by selling their practices to larger institutions like large group practices or the local hospital. That's not a bad model, necessarily. There are lots of physicians who are relieved at the ability to leave behind the small business headaches associated with small practices of one to a few doctors.

But others want to improve as much as those in the big practices and hospital-based situations, yet remain independent, and they're finding that creating the elusive medical home for patients—a move that is as much about practice health, given the reimbursement climate, as the patient's health—does pay off, to a degree. Count Joseph Mambu, MD, 62, of Lower Gwynedd, PA among that group. I caught up with him recently as he was driving to a house call. Yes, you read that right. Mambu makes house calls, frequently because he's the only thing between his patients being homebound and hospital-bound.

He's the only full-time physician at Family Medicine, Geriatrics and Wellness, and although he has two part-time physicians to help him with his patient load, the key is computerized patient information, and the team of caregivers with whom he's surrounded himself. Critical to Mambu's practice, and to lowering healthcare costs nationwide, is the chronic care population. Mambu, who is also a geriatrician, says he's never been satisfied with the way healthcare deals with this highly expensive patient population, but he's never found a good way to coordinate that care until relatively recently.

He's been a family practice physician since 1976, and was in a group practice model for 22 years. Back in 1998, he sold that practice to a local hospital, thinking being part of a large health system would be a model to get coordinated care for his patients. In short, it wasn't, at least at that time.

He says the local hospital, which he wouldn't name, did a terrible job of human resources and micromanaged the practice to the point that he decided to leave after 2 1/2 years. He sees that bad experience as a blessing now.

"Had they not mistreated me, I wouldn't have had the gumption to start my own practice and would have never gotten involved with this [patient-centered medical home] movement," he says. "I always wanted to do this; it just took me 25 years."

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."

Next year, he's counting on bonuses from Medicare for e-prescribing and physician quality reporting which will translate to a "10% bump in Medicare next year, and $18,000 for meaningful use."

Some of the commercial plans he deals with are paying a little more for his services than for others who can't prove quality outcomes, but "I don't think it's enough," he says. "They might have to give a pay raise for primary care docs to help pay for the aggravation that goes on in switching to a value from volume basis. No one wants to volunteer to do this. It's something I had to do."

He hopes that other small practices won't despair that they can continue to exist under healthcare reform, because he sees small practices as an essential part of the continuum of care.

"I hope the smaller practices never go away, and I hope there's not large corporatization of medicine," he says. "I've had to exert a lot of leadership and we're struggling to keep current with the cost of having two nurses, three nurse practitioners and the cost of investing in an EMR. It's Marcus Welby with computers. It was expensive to do what we did, and there's no real reimbursement--salaries haven't gone up—but we're not in it for making lots of money."

Patient centeredness doesn't always mean doing what the patient wants, he adds. Instead, it's about having the time to re-establish a relationship and understand what's going on through the patient's eyes in the context of community and support systems.

"This is team medicine. It's a very difficult, time-consuming transition but it's one that docs are going to have to make."