The diabetes care program described by Philip J. Mohler, MD, and Nancy B. Mohler, RD, MS, CDE in our cover story (page 50) is an admirable example of what can be accomplished by private family practices who devote thought, time and energy to the care of chronically ill patients. Unfortunately, as you can see from the article and from the accompanying editorial by Roger Shenkel, MD (page 17), it doesn’t seem to be something you can make a living at. Most health care plans, happy with long-distance case management, aren’t prepared to pay for local, physician-mediated chronic disease care. Even with financial support from an unusually forward-thinking health plan, the diabetes care plan ends up costing Mohler’s practice more than $100 per patient per year. And this is in a 15-physician practice, better able than most family practices to distribute the cost of the extra staff needed.

So is the message of the article, “Stay away. Don’t try to improve your chronic disease care”? Not really. The chronic care model that the authors describe is a true improvement in care and one they remain committed to despite the financial challenges. It is the state of the art, and implementing it could well improve the care you deliver. If you can afford it, your patients will benefit. But if you can’t afford a full implementation of the model and can’t put one together by working with other local practices, keep in mind that the chronic care model is a constellation of good ideas, all of which work well together but many of which can be implemented piecemeal to good effect. If you can’t afford to hire a case manager, why not start with a patient registry instead? Several freeware registry programs are available online. As long as your practice can cope with the required data entry, you’ll have a low-cost way of managing visit-planning and improving follow-up, adherence and overall quality. Other relatively inexpensive parts of the model may also be useful by themselves or in limited combinations.

The piecemeal approach is certainly not the best approach to quality improvement, but it’s a viable alternative to doing nothing. And until the morning we all wake up and find that the U.S. health care system has miraculously regained (or gained) its sanity, piecemeal improvement may be the only kind that’s feasible for the small family practice.