To Our Colleagues PMH Reports

Summer 2018

We have medical students in our office on a regular basis, and Journal Club Is where we all sit down together and talk about the big journals and new research. These students are young and impressionable, of course, but often are brilliant, devoted, and idealistic. We always review the New England Journal of Medicine, and the June 21 lead article was chosen: “A randomized trial of family support intervention in intensive care units.” 1 The article basically asked how we can better support patients and families in ICUs. They added substantial resources for education. Nursing leaders, quality improvement specialists, a large team, and a standardized protocol. It was meant to supplement and improve the outcomes over what the physicians could provide through their own work with patients and families. But for us at Journal Club, the intervention appeared to be a failure. Also, interestingly, death rates were higher in the intervention group. People died faster. But it was the lead editorial by Daniella Lamas that engendered the strongest conversation.2 She starts her editorial as follows:

“We examined them each day – the elderly patient, intubated, sedated, with a bewildered wife at his bedside. We should sit down with his wife before we ask her to make hard decisions about her husband’s care, but the unit is so busy that we find ourselves scurrying by, pausing only to offer rushed updates that do not allow for the exchange of meaningful information.”

Dr. Lamas holds a prestigious position at Peter Bent Brigham Hospital. She teaches at Harvard Medical School. The person who must make decisions for the man she describes is the wife. In some fashion, the wife’s voice is the patient’s voice, and the wife’s judgment is the patient’s judgment. How can this patient be cared for if he is not advised, knowledgeable and understanding of what is happening? How can the patient, through his wife, make reasonable decisions? One of the best hospitals in the world, published in one of the best journals in the world, gives us an image of medical care that comes across poorly. Does Dr. Lamas have any control of her practice and her profession? Dr. Lamas’ complaint seems common today. Why is it that doctors don’t find time to talk to their patient and to understand their patient and to protect their patient from bewilderment and confusion Our response to doctors who feel they are not doing their job: find a better way to get the work done. How we organize our day, how we approach our patient and their families are choices that we make. We can choose to run our offices and our hospital practices in a way that avoids what Dr. Lamas laments. That is why almost ten years ago we changed the way we practiced medicine in our offices and on our hospital rounds. We determined that for our sickest patients, routine medical care as expressed in Dr. Lamas’ editorial is not what patients want. We started a program we call “Premium Medical Home.”

We think that Dr. Lamas could improve her situation by adopting our business practices:

Directness. Direct communication with cellphone, text message or e-mail with the patient and the patient’s family.

Continuity of care. The doctor promises to follow the patient at patient’s various levels of care, whether ICU, ward, emergency room, home, etc.

Professionalism. There are different levels of professionalism, and we will provide the best.

Not too busy. We will run our offices and practices so that if we need to sit down with a patient or a patient’s family and explain things, we will not be too busy to do so. If a patient calls and needs to be seen, we must run our offices so we are not too busy to see them, the same day.

Affordable. Doctors will take on responsibility for the affordability of care. We will be a direct responsibility, not put off on others. If patients are having trouble paying for their medical care, we will help them find a way.

These changes in the way we practice medicine have been helpful to us, our staff, our patients, and our patients’ families. When we make rounds on our patients at the ICU, we do not think to ourselves that we are “scurrying by, pausing only to offer rushed updates that do not allow for the exchange of meaningful information.” Dear colleagues: Are you experiencing the problem that Dr. Lamas is experiencing? Our colleagues are wonderful individuals, loving, professional, experienced, and outstanding. Just like Dr. Lamas. But here is Dr. Lamas, whose own concepts and ideals appear to be overtaken and lost in some fashion. We know that Dr. Lamas sees to the care of her patient. I expect that she is an excellent doctor. We believe she would like to organize her practice so that she feels and recognizes that she is doing a good job, caring for patients and families, working with her nurses, colleagues and the whole medical team. This individual responsibility will make her stronger. Taking on this individual responsibility will improve the joy of her work. We want doctors like Dr. Lamas to do a better job, to improve their lives, their practice and the experience of their patients and their patients’ families.

We think Premium Medical Home is an affordable, straightforward, understandable way to improve how we care for our patients and families.

Allan Kelly, M.D., F.A.C.P.
Robert Kelly, M.D., F.A.C.P.

1. Douglas B. White, et al, “A randomized trial of family-support intervention in intensive care units.” New England Journal of Medicine 2018: 378:2365-2375. Sincerely,
2. Daniella Lamas, “Editorial: Nurse led communication in intensive care unit,” NEJM 2018, 378:25:2431-2432.

April 08, 2017

Pamela Wible, MD, A Physician in Private Practice.
Recently asked colleagues to share experience with her as she prepared to speak at a medical school commencement - here are her topics and our responses

Dr. Robert Kelly's Response:

What is the most inspiring thing you have done for a patient?
There were inspiring times when I have told a patient that, no, I am not just going to let them die, but will help them live: the blood was given, the ventilator placed, the surgery completed, and years of life with joy and happiness followed. But, there were times when I cared for a patient who I could not help live.

The 91 years old gentleman was frail. Admitted after poor health and acute heart failure from a dilated cardiomyopathy and aortic stenosis, he was transferred to a nursing center for conservative care, to regain independent ADL, and hoped for return to his home in a retirement village. His mind+ was good, for 91: Smiling, friendly, and glad to see me. He slowly made progress over a week to ten days. I was rounding early Tuesday morning at the nursing home, before hospital rounds. A facility nurse called me on my cell phone. He had suddenly become weak, barely responsive and had been put in his bed.

I was 40 feet from his room, so went directly to his bedside. There was an agonal breath. I called his name. I held and pressed his hand. There was no movement, no breath, possibly an agonal beat, then gone. He was not a DNR, but code status was not updated daily, of course. The nurse who had called just a moment before brought the crash cart into the room. She was surprised to see me already there. I told her that the emergency cart would not be necessary, but she was concerned about proper order and documentation. I asked that she not call a code, and hand me the AED (an emergency automated heart monitor and defibrillator). I broke the seal and applied the leads. No shock advised. Quiet, he was gone, and he remained at peace. There were no cracked ribs, no lights and siren to the emergency room, no naked body and pointless tests, but a dignified death of a wonderful man who had come to his natural, undesired, and unplanned end: I called the family. I have thought of that day often. I decided I had done what a good doctor would do: I had given kindness and gentleness to this elderly man.

What is the most inspiring thing a patient has done for you?
A patient will follow my advice. I recommend surgery. Please take this medicine. Put down the cigarettes. See me in one month. The simple decision, so often made, to follow my recommendation is the most inspiring thing a patient has done for me. It fills my heart and mind with a profound sense of responsibility. Sure, I engage the patient with the decision. We collaborate. I offer alternatives. The patient 'chooses' to proceed with what I think is best, but the patient, in the end, trusts my recommendation, and so proceeds.

One Hippocratic statement that I long used as a motto for my office touches on this: "In whatsoever house I enter, I enter to help the sick." Not everyone is sick — some houses are filled with perfectly healthy people. Some persons who see me are healthy. However, the inspiration is that I am here to help the sick. That is a strong tonic, and I pray to return it as a soothing balm to help the sick, to follow this ancient tradition of the physician. This inspires me every day.

Dr. Allan Kelly's Response:

Most Inspiring thing I have done for a patient:
Responding to a request for help. A physician colleague, sent home on hospice. The wife called me as I had cared for him in the past. She asked, "We are not ready; can you help?"

I knew his doctors: leaders, wonderful, my peers or frankly better than me. Though the doctor and his family lived on the other side of the county I went out that night. We had a good talk, I called my colleagues, and I admitted the Doctor to the hospital that night as his new attending.
He responded well to our efforts, and he lived another 12 years. I was asked to speak at his funeral.

I am still inspired from this experience. You can bring hope to the hopeless, courage to those who are sick. A physician's skill knowledge and insight can change the lives of others. I recognize my averageness. I recognize and applaud my opportunities of time and place to serve and support the sick and those who love them, to be a physician to those in need. As this physician devoted to the moment at hand to the needs and wishes of my patients and those who love them.

Most Inspiring thing I have done for a patient:
I am still inspired from this experience. You can bring hope to the hopeless, courage to those who are sick. A physician's skill knowledge and insight can change the lives of others. I recognize my averageness. I recognize and applaud my opportunities of time and place to serve and support the sick and those who love them, to be a physician to those in need. As this physician devoted to the moment at hand to the needs and wishes of my patients and those who love them.

An elderly father showed me respect and appreciation. Yesterday an old man stood up when I walked in the room. I said "You don't have to stand for me." He said "I have to show my respect." Now 85 years old, at age 60 he biought his son ravaged by AIDS and hopeless, through my door. He said "I remember coming through that door and meeting me. I will never forget what you did for my son and family."

Yesterday, it was the same son, still my patient, strong and vigorous, bringing his ailing father to a first consult looking for help. The father was and is a good man. I had gained his respect 25 years later he was anxious to show that he remember. This is the life of a physician, dedicated to patients and their families, dedicated to colleague physicians and nurses. I am daily inspired by the people I work for and with. Their respect inspires me and guides me.

March 30, 2016


Cathy Schubert's wrote an essay published in Annals of Internal Medicine (2015; 163, 10, 803-804), "What Adoption Gave Me”. In this, she tells the story of her pregnancy at age 20. She resolved to complete the pregnancy and allow her child to be adopted at birth. She was at peace knowing that for the nine months of her pregnancy she would do everything she could to assure having the healthiest baby possible. The baby was born and happily adopted. Afterwards, Cathy completed college and medical school and become a doctor. Eighteen years later, Dr. Schubert met her daughter. It was a lovely story of a mother's love and courage. But it also said something about Dr. Schubert as a physician.

The decision Dr. Schubert made for birth and adoption became her touchstone of love for others. Just as her unborn child was loved, Dr. Schubert discovered that she too was loved. In time she came to realize that as a physician she had similar commitment: What she felt as love for her patients. She writes:

"This profound and amazing love has transformed me into who I am, and being a physician has become my way of sharing that same love with others, my patients, and their families, by serving them to the best of my ability. Love is what informs and motivates every physical examination, every progress note, every family meeting, and every medical decision I make as I do my work."

We see her essay as a reminder about something important about life and about being a doctor. In life, children change their parents. The change begins in pregnancy and labor, followed by work, worry, and hope. Dreams, commitments, and disrupted sleep: Beneath these is always the hope that the future will be bright and good for the child. Likewise in medicine we experience work, worry, disturbed sleep, hope, and commitment. Doctors hope that the future will be good for their patients.

But today, the spirit of love and commitment that a physician has for the patient, seems to be contested by the newer models of medical care. There is less room for love in practices dominated today by guidelines, EMR, meaningful use, ICD-10 codes, rules prohibiting care of family, and contracts mandating productivity goals and a promise to not compete. These new guidelines become a form of restraint on doctors who would put the principled emotion that Dr. Schubert describes into their daily work.

Contracts, guidelines, and regulations seem to dictate what doctors should do or not do. The old constraints on medical practice were patient choice and a physician's ability. The new constraints on care are formal, artificial, and imposed from afar. These new restraints are not demanded by patients. The new restraints are created by bureaucracy, regulation, and technology.

I commend Dr. Schubert's decision to allow her child to be adopted, and for what she says about being a doctor. Her story is a metaphor for medical cares it should be. Medical care that is not described in any HMO contract or employee doctor's job description. Medical care that is more fit and effective than any CPT code.

I wrote Dr. Schubert a letter telling her I was glad she was a doctor. She responded:

"I agree that it is often difficult to show love to our patients in the current healthcare ‘system' as we rush them through visits, clicking check boxes in the EMR along the way to prove to the powers that be what ‘good care' we are providing. But when we are able to stop for an extra moment with a patient, to hold her hand and hear about her grandchildren, or listen while he tells what he is growing in his garden this year – there is no higher reward. I cannot find time for the extra moments every day, but I do my best to sneak them in as often as I can."

Her response shows that something is being lost by the profession as it responds to new pressures, such as the Affordable Care Act. Like Dr. Schubert, we don't want to ‘sneak in' the extra moments, the extra commitment and love for our patients. We want them to be a part of everyday medical care. At PMH we are committed to the ideals expressed by Dr. Schubert.

Robert H. Kelly, M.D., FACP

March 31, 2016

Premium Medical Home (PMH) has been up and running for six years in our practices in Fort Worth, Texas. This way of running our business is successful. It is successful from the patient's point of view because we believe people, especially those with complex or difficult problems, can turn to a Premium Medical Home practice and find what they like and value.

We believe Premium Medical Home is valuable to our colleagues. For example, we see doctors as patients in our practices. We see their families and their children. We get phone calls, “I have a difficult patient and I need to find someone who can help me take care of them.” The patient may already have a diagnosis and treatment, but other needs are not being met even in a good medical practice. Many of our colleagues are looking for something different that Premium Medical Home can offer.

Part of PMH is continuity of care. Our community values doctors who still make rounds at hospitals and nursing homes, and run a busy clinic. A colleague, Dr. Greg Phillips, became President of the Tarrant County Medical Society in 2016. One of his qualities noted by the speakers at his installation is that he “still makes rounds at the hospital.” Our community appreciates and values those internal medicine doctors who not only work in their clinics, but also make rounds at the hospitals, providing continuity of care.

Our employees value our Premium Medical Home office. A Premium Medical Home office should be run so that the employees perceive a difference in their work. They will be more connected to the patients and their families. They will have more time to troubleshoot problems and resolve difficulties. They know that the success of the office does not depend entirely on insurance CPT codes, but depends equally on providing services of value to patients, families, and community. This is good for our employees.

We read in major national journals about physician burnout. The Mayo Clinic Proceedings has published research showing increasing physician burnout at the Mayo Clinic over the past 10 years. Dr. Pamela Wible and her work at have targeted physician suicide and physician burnout as something that must be addressed. In The New England Journal of Medicine (2016, February), Dr. Suzanne Koven wrote about burnout, describing in the paragraphs below her visit with an emotionally distraught woman with complex unresolved diarrhea:

" The dilemma I face most often as a primary care physician, however, is not one that [others] anticipated. The commodities I struggle to ration are my own time and emotional energy. Almost every day I see a patient like the woman with diarrhea and I find myself at a crossroads: Do I ask her what is really bothering her and risk a time consuming interaction? Or do I accept what she is saying at face value and risk " missing a chance to truly help her?

" Often the situation is not so dramatic. Say I walk into an exam room and find the patient waiting for me reading a book. Do I ask what book she is reading?... [If I do] pretty soon we'd be having –horrors! – a conversation, precious minutes wasted on useless chit chat. But is chit chat really useless? Such conversations can generate the trust that . . . improves health outcomes . . . indeed that is essential to healing. "

" I have been meeting with groups of doctors and nurses to discuss brief works of literature relative to clinical practice. Before the meetings, I always ask whether there is a particular theme they would like to address, and the answer, alas, is always the same: Burnout . . ."

" In 1985, free from the shackles of the computer screen, [the doctor] faced only one obstacle in engaging the troubled [patient]: His own willingness to do so. Leisurely conversations with [the patient] seem as quaint to us now as black bags and glass hypodermics. "

" [If we make chit chat] we fall hopelessly behind in administrative tasks and feel more burned out. If we don't ask about the [small things], we avoid the kind of intimacy that not only helps the patient but also nourishes us and keeps us from feeling burnt out. "

" I order the cultures, prescribe an antidiarrheal drug and some dietary modifications, briefly mention psychotherapy again, and leave the room. And I sit at my work station to document and bill for our encounter, perched at the edge of my seat, on the verge of despair. "

We encourage the reader to read Dr. Koven's entire essay. She is an attending physician at Massachusetts General Hospital and a professor at Harvard. She represents the pinnacle of medical practice and the medical education system. And yet, a Harvard professor, she characterizes herself as a slave: shackled to the work station. She says that she is on the verge of despair.

We believe this doctor's dilemma is that she is forced to give importance to things that she knows are not important. She is forced to give preeminence to things that are perhaps meaningless to the patient, meaningless to the patient's family and meaningless to those who love the patient. She is forced to meet the criteria for the CPT code, to find the right ICD-10 code, to make sure that her documentation meets all the criteria to justify the code lest she be found to be up-coding, miscoding or otherwise committing crimes or misdemeanors. These various demands on Dr. Koven mean that she apparently feels she does not give preeminence to the complex needs of the person who is seeking a physician's help.

Dr. Koven reports that she cannot allocate her time, her energy, and her resources as she thinks best, but submits to standardization or even indoctrination of medical care. Her labor and capital are not hers to employ as she thinks best, it seems. She is not alone.

Dr. Koven's shackles and despair are found in many physician essays in 2016 in the United States. We encourage our colleagues facing such trial to read our website, to call us on the phone, and to come to Fort Worth and meet with us. We believe that primary care internal medicine can be beautiful, liberating, professional, personal, and better than it is today. Better primary care is good for patient, doctor, and community.

We are committed to several principles, as expressed elsewhere on our PMH website. The first is directness. The doctor's relationship with the patient and family must be direct and communication must be modern and convenient. Secondly, we are committed to professionalism. People have a choice of who they can turn to for their medical care. We think there is value in turning to a Board Certified physician, a professional trained in the tradition of Osler. Thirdly, we are committed to continuity of care across phases of care. We make rounds at the hospital, the Emergency Room, the clinic, the nursing home, or the private home. And finally, we think doctors benefit by having time: Time to think, reflect, and care. Doctors help their community if they have time to see sick patients in their time of need, and time to reassure those who are healthy.

We applaud our colleagues everywhere who care for the sick. Here in Fort Worth, there are so many men and women of great intelligence, sensitivity, insight, and dedication working as physicians. But our observation is that the current process of internal medicine practice often represents an undue burden patient and doctor. We should address ourselves to improving the way we run our offices. We know that our colleagues are as committed to the care of the sick as we are. We encourage all to learn more by reading through our website and calling us if they wish.


Allan R. Kelly, M.D., FACP

Robert H. Kelly, M.D.,FACP

August 17, 2015

A Letter to a Colleague Encountered on Hospital Rounds

It was good to see you and meet your son at Baylor All Saints. I wish you and your family the best. You asked whether or not I was still going to the hospital. I thought I would give you a brief rundown.

Approximately five years ago I decided that I would commit myself to primary care. The ID world seemed well staffed, but primary care I thought might benefit from innovation, and I wanted to offer a different type of primary care practice. With this in mind my brother and I began a project we call Premium Medical Home (PMH).

You can read more about this at or The point was to create a primary care office that emphasizes 1) a more direct relationship between the doctor and the patient, the patient's family, and patient's loved ones; 2) Offering a primary care where we choose not to use physician extenders; 3) continuity of care between hospital, nursing home, rehab, etc: Where the same doctor will take care of you at whatever level of care is best for you; 4) Always have time: in our office there is always time to see a sick patient, there is time to see a worried family member, and there is time to make rounds at the hospital or go to the emergency room. The office will be run in such a fashion that the doctor will always have time.

These 4 characteristics are not part of CPT codes, insurance requirements, or state board expectations. We think these 4 characteristics add to the value and character of a primary care practice.

I know my colleagues are working hard and taking excellent care of their patients. But I feel that primary care is particularly challenging for doctors and patients right now. PMH is our model for offering something that may be different.

See you around the hospital.

April 21, 2015

Dear Colleagues:

From the simple to the complex, from the minor to the life-threatening, our work as physicians often has great value for our patients, ourselves, and our communities.

Our particular work is in Primary Care and Internal Medicine, especially the care of aging people, and doctors in this field need help. One of our young internists just retired or, more properly, quit. He had excellent education, training and an outstanding reputation. Five or six years ago he stopped hospital rounds. Four years ago he left a specialty group and started a private practice. He has closed shop this month and will take a few months off – burned out and feeling that his patients were taking advantage of him. He couldn't figure out how to make it work. Now we are all worse off. One fewer doctor to care for the sick and aging. Our neighbors have increasing trouble finding a doctor.

We read that burn-out is getting worse. A young female doctor left an allergy practice. She tells me that she is the last of a group of women friends from medical school to keep working. The other four have already given it up, and now she also will join them. All five no longer caring for patients, no way to make it work apparently, giving up on caring for the sick, on living the professional and work life they sought in their youth.

It is no wonder. Increasing government and organizational regulations seek to eliminate – or even punish – variation, as if there were only one way to practice. It seems now there is no room for these young doctors to create a practice to match their dreams and plans. How likely is it to be successful when we expect everyone to be the same? Our work must meet certain CPT descriptors. We strive to provide a CPT code. Our diagnoses and care must match the ICDM template. We try to fit our observations, thoughts, and our conclusions into an International Classification of Diagnoses. We write down our observations and thoughts electronically, in a certain format: the ultimate achievement now called “Meaningful Use”. We are regulated how to interview, examine, think about, describe, write, and communicate. Is it possible that CPT, ICDM, and Meaningful Use will create better doctors than existed in the era before this triumvirate? We don't think so.

We believe that the rule of CPT, ICDM, and Meaningful Use is essentially bureaucratic and inefficient. These three force out or diminish more useful and variable qualities, such as loyalty, commitment, curiosity, reflection, and brotherly love. And they limit or preclude what might be new or better.

Working for CPT, ICDM, and Meaningful Use does not inspire. It does not inspire the medical student, the intern, the resident, or the attending. It does not inspire the young doctor or the older doctor. Working for CPT codes and RVU's is anti-professional.

We believe that private physicians working directly for patients and their families will experience professional and personal satisfaction not found in a CPT/RVU relationship. We do not expect all patients and all doctors to want such a direct relationship. We see that many colleagues, for example, seek out Emergency Room or Hospitalist careers where such relationships cannot reasonably develop over months and years. However, we believe patients and families want long-term, professional, personal, and loyal care from their Internist or Geriatrician. We call this practice model Premium Medical Home.

Premium Medical Home allows patients and doctors to create professional relationships in medical care that go beyond CPT codes. Its simplest parts are comfort and convenience. We recognize and value comfort and convenience and so do our patients! Let's make patient comfort and convenience important to our work every day.

We believe such a model encourages longer-term commitment and involvement by Internists. Patients like it. Doctors like it. It is better to care for patients and family you know. Recent research shows that involving an outpatient doctor in the Emergency Room and hospital care of his patient reduces cost and improves quality – but there is no CPT for that. We are foolish when we delay or omit doing something good simply because there is not yet a CPT, or because the CPT is poorly reimbursed.

We believe that a vibrant, fulfilling, and professionally optimized Internal Medicine practice must go beyond CPT, ICDM, and Meaningful Use. We call it Premium Medical Home. Review our website,, and call us if you would like to talk.

Allan R. Kelly, MD, FACP

Robert H. Kelly, MD, FACP

September 24, 2013

Dear Colleagues:

Like some of you, we have worked for decades in Tarrant County. Growing up in the 50's and 60's, we were taught daily by our father, Gordon Kelly, M.D., of the obligations, joys, and rewards of a physician's work. We made rounds with Dad at Harris Hospital about the same time we learned to ride bicycles. Despite wage and price controls for doctors, and the re-definition of medical care by CPT coding, access to excellent medical care has improved. Like patients, physicians benefit from the innovations and progress in our medical community. But progress is never finished. There is a need for progress in the experience of patient and doctor in internal medicine. Today, patient encounters are defined by CPT codes. Yet CPT gives no weight to experience, loyalty, or continuity of care, to mention just three qualities that can provide a very different experience in medical care. It is common today that physicians no longer continue to care for patients across different levels of care. Complex and difficult transitions from home to hospital to rehabilitation and long term care and, for some, hospice can leave patient, family and physician unsure about what happened or what it all means. More physicians' names than a person can remember, sheaves of hospital discharge instructions and education, are the results. And while costs sky-rocket, we are told, payment for an office visit has fallen. The market price of a 99213, the CPT definition of a common office visit, has fallen in 10 years, adjusted for inflation. And who goes to a doctor's office seeking a 99213, or at dinner that evening tells the family about the 99213 she had today? What student follows in his mentor's footsteps, hoping some day to provide a 99213 to anyone? And yet that is what is measured, billed and bought. We are writing today about what we think progress can look like for internists and family doctors, especially caring for the elderly and chronically ill. We propose a model that we have found improves the comfort, convenience, and experience of medical care. This model is based on the truth that a doctor's care of a patient is not summed up by a CPT code, even a 99215. The model is based on the value of loyalty, experience and direct relationship between patient and physician. It is based on the idea that this experience can be offered by providers and purchased by patients who also value this. Our model is called Premium Medical Home, or PMH. People deserve a choice in health care. The model generally offered is the medical care defined by CPT codes, provided in part by mid-level providers in a high volume practice. What alternatives are there? One is the concierge model, but the costs are high, insurance benefits are often lost, and the doctors may not be available outside the outpatient clinic. Another choice, the urgent care clinic, focuses on acute symptoms and complaints, and staffing is inconsistent. PMH offers another choice, where a person can pay a subscription for comfort and convenience services not covered by insurance or Medicare. These services have no CPT value, but are what some people and doctors think make for an excellent experience in medical care.

  • Direct relationship to the physician. No mid-levels, no intermediaries, no phone trees. All concerns can be directed to the physician as best fits the felt needs of the patient.
  • Continuity of care from clinic to hospital to long term care. Collaborating with the full medical community, the physician cares for the patient in select hospital, nursing homes, hospice and assisted living.
  • Communication between patients and physician will be based on the technology that best meets the patient's needs: cell phone, email, text messages, office visits. Direct communication between physician, family and patient saves time for everyone, alleviates anxiety and can improve understanding.
  • Limited practice size. Doctors and patients want more time to discuss patient complaints and follow up on the doctor's concerns. Worried families often need more time. Fewer appointments, more time – patient and doctor both have a better experience. You and your patients will be better served if your door is open every workday

These basic concepts of PMH – direct relationship, continuity across levels of care, open communication, limited practice size – improve the comfort, convenience, and experience of both doctor and patient. PMH is valuable and good. Not everyone would choose a PMH clinic. We think doctors willing to provide the care and patients who need this deserve to have a choice. It is a matter of choice. PMH is not free – the practice is limited to a maximum of subscribers, each of whom pays a non-refundable annual fee ranging from $100 to $600 per year. We want other doctors to become a part of this model. Doctors willing to be primary care providers to the sick and elderly across different levels of care. Doctors able to work in the office, the hospital, and the home. Doctors who will help their patients with living, healing, and at the end of life. Doctors who have confidence that, working with colleagues, they can accept such broad primary care responsibility. With our model, these doctors will be comfortably, even generously compensated. The fee is affordable and based on age, family and demand. Premium Medical Home is a valuable and good choice at a fair price.

June 14, 2012

Everyone wants improvement in primary care and change is under way. Accountable care organizations are forming. Physician extenders are popular. The electronic medical record is favored by many. We wish the proponents of these changes success, success in improving medical care delivery that yields benefit for doctor and patient alike.

We have had success with another model that focuses on improved medical service and experience: Premium Medical Home. The concept has three parts: the physician as an individual doctor caring for the individual patient; the direct and immediate communication between patient and physician; a subscription for services not covered by insurance.

But first, consider the situation we work in and see patients today. Patient and physician relationships today are routinely defined by, or reduced to, CPT codes. A patient comes in to see the doctor to receive a specific service, defined by a CPT code. A doctor takes time and accepts risk to see a patient, knowing in part that she will submit a bill for payment of a CPT code. CPT codes are what the primary care physician delivers and are what the primary care physician is paid for, whether by Medicare or insurance. Yet no patient knows of or cares about CPT codes.

Doctors understand elements of CPT coding. We fill out billing forms; we study American Medical Association copyrighted books; we even listen to CME tapes or attend breakout sessions at conferences. All this is done so that we can then complete, for example, four page electronic note about a visit for bronchitis. We assume the time is well spent: many are anxious to complete these notes so that a compliance review or payor audit will find that the CPT code billed was justified. Some offices depend on computers to figure out what code is right for the service performed.

Patients and doctors need no books, forms or consultants to explain the basic exchange: “I have a problem,” on the one hand, and “I will take care of your problem,” on the other hand. The patient brings the need. We offer attention, expertise, collaboration and diligence. To the extent that we allow the doctor-patient relationship to be reduced to a CPT code, we artificially limit that relationship and compromise the experience of primary care for both doctor and client. The individual doctor accepting personal responsibility for her patient is not the same as a 99212.

Much that is good in medicine has no CPT code. For example, as doctors, we know what it means to be able to call a trusted colleague for advice if we or our family are sick. There is no CPT code for this. At times we, as physicians, have received special consideration and thoughtfulness in medical care because of our relationships; and there is no CPT code for this. A family member needs help and they reluctantly call us, their doctor in the family, and ask for help “if we are not busy”; there is no CPT code for this direct access to a trusted physician, but it is a helpful and good thing. A patient who has a long established relationship with a provider has a different experience from a patient who has visited the doctor only once before, but the CPT code is identical in either case: an identical code number for dramatically different service and experience.

Consider that the chairman of the internal medicine department at any University Medical Center will be paid the same fee as a doctor who is one week out from a State Medical Board suspension for drug abuse. Insurance companies and Medicare make no distinction between providers within a single medical group. Isn't this irrational, by all ordinary measures? None of this experience is captured by a CPT code or otherwise counted in the business of medicine.

Premium Medical Home is our effort to address this problem and move forward. What is the value of comfort? What is the value of experience, attention, diligence? What is the value of direct and immediate access, convenience, confidence, and loyalty? These have value: men and women spend a lifetime developing these skills. But these qualities are not valued in the current CPT based system, none has a code or a -25 modifier. Their copyrighted CPT value is zero, though they can be important in the lives of all patients and in the medical community. What are they worth? In this era of wage and price controls, no one knows but their CPT value is zero.

At Premium Medical Home, we want to create a value for comfort, convenience, and experience. Here are four examples:

  • Direct telephone or E-mail consultation about medical problems unrelated to a recent office visit: In our CPT world, there is no code for such care, and rationally patients are directed to an office visit to discuss these questions or possibly a quick appointment with a physician extender. We think that some patients will value knowing that their doctor will help them by phone or by E-mail if that is more convenient to the patient than another office visit. If we charge for phone calls separately, then we discourage important communication.
  • Medication refills based on comfort and convenience of the patient. Occasionally patients misjudge prescription medications and find themselves needing a refill before a scheduled follow up. Emergencies may find them out of town or otherwise out of the needed medication. We consider these understandable misfortunes and an opportunity where direct access, convenience, and experience can make a big difference for a patient. At Premium Medical Home, fixing this kind of problem immediately is not a favor or a privilege, but part of the subscription that patients own.
  • Helping our subscribers' out of town guest, family or friend, who becomes ill. Some problems will be addressed in the emergency room, but it is a value to a person to know that his or her doctor also can and will help, to discuss the complaint and the needs of their friend or family member, before the patient begins expensive testing in an emergency room or other clinic.
  • A medical practice that is a part of our model is kept small. Many complain of practices being too busy and of doctors not spending enough time with each patient, or feeling hurried through a long awaited appointment, or even specifically restricted to only one or two questions even though there may be eight or nine questions on the note brought to the visit. It would be helpful to have practices where that environment is avoided; where the size of the practice is optimized from the patient's point of view, and where volume is not the principle route to success.

Because of wage and price control, doctors must accept the CPT system, as we do at Premium Medical Home. With the Premium Medical Home subscription, we have created a qualitative alternative. Not better care or better doctors; but an alternate model that features comfort, convenience, and direct access that many people see as desirable and valuable.

Our subscription fees range from $100 to $500 per year, based on age and family status. Our offices were successful before Premium Medical Home, based on “CPT based” practice. However, we were concerned about the bureaucratic drift of primary care into the CPT model of care. We felt, at some level, that this CPT model devalues comfort, convenience, loyalty, and experience. There appeared to be insufficient interest in the impact of patient volume on the patient experience. We created Premium Medical Home to offer an alternate model. We believe that Premium Medical Home is compatible with insurance, Medicare, or the non-insured. It is a specific bundle of non covered services that a patient can own if they wish to pay the subscription fee.

Our goal is to create a primary care model that will run differently and where that difference can be easily understood by any patient or doctor. Whether patient, family member, or physician, we want this concept to improve the experience of primary care. After 24 months of developing and working within this model, we know that Premium Medical Home is one way forward.

March 22, 2010

Physicians visiting our site are well aware that the common Medical Home model is a mainstream effort to better align outpatient office practice with the complicated needs of patients. Through the use of physician extenders, educational settings and physician-directed coordination of care, providers focus on the goal of improved patient care and reduced overall cost of care.

However, we think the Medical Home is more.

As an expert dedicated physician, you know what it is like to be able to call a colleague when you are sick or injured. Despite the great strength and comfort of such communications, we call on our colleagues for our own care once every ten years or even less often. But we know the door is always open and that help is always first-rate. In a Premium Medical Home, the physician wants his patients to experience that same level of communication and service and the same sense of connection. For the patient and for the doctor, it is direct communication and commitment that make all the difference.

We began the project of the Premium Medical Home because primary care is failing to attract new graduates from medical schools. At the heart of this failure to attract new physicians is a failure to reward physicians in primary care. With our model, we seek to restore this balance and provide a Medical Home for patients that simply leaves the nurse practitioner-staffed retail clinics and often chaotic twenty first century medical offices behind. PMH promotes innovation and improvement not available in a CPT-only medical practice.

We welcome our physician colleagues' interest. We hope that you will call, write or e-mail us if there are questions that we could answer. Our hope is to establish the success of this model in the years ahead. For those who would like to explore this model for their own practices, we believe that we can help. Please see and

Our Premium Medical Home doctors, expert in their fields, seek a different experience for their patients by offering them direct, immediate access by cell phone, internet, and text messaging within a smaller practice. We believe our patients will experience this as if the doctor were a member of their own family. The Premium Medical Home doctors also maintain an expert modern office that works with insurance providers to get the insurance benefit that our patients have paid for. A PMH physician maintains staff privileges at Joint Committee for Accreditation of Healthcare Organization approved hospitals. The PMH doctors follow their patients in rehabilitation and long-term acute care, and even in selected nursing homes. PMH doctors are committed to continuity of care and direct access for their patients. Such doctors with this style of commitment are uncommon and make a Premium Medical Home possible.