Letters to the Editor

Fort Worth Star-Telegram and Fort Worth Business Press, Fort Worth, TX
September 25, 2013
To the Editors:

Change is rapidly occurring in medical care. The rapid and universal acceptance of mid-level providers (such as physician assistants) has allowed for more care for more people. The new health care plan promises to bring health insurance to millions.

At the same time, not all people want the same things, and what is good for Joe may be different than what is good for Mary. We are patient, too. So we can choose urgent care clinics, big clinics, small clinics, big hospitals, bigger hospitals, as opportunities and preferences guide us.

But what if what I want is a board certified primary care doctor who will take care of me whether I am in the office, hospital, nursing home, or at home? Most of the elderly are offered different doctors at every level of care, leading to concerns. We believe it is better if the same doctor, circumstances permitting, follows his/her patient across the different levels of care. We think it is better if that doctor is always available using text, email, cell phone, or office visit in a way that best suits the patient's felt needs. We believe it is better if the doctor is available and has a direct relationship to the patient and the patient's family.

This type of practice is difficult to find, in our opinion, and we need to do more to encourage this type of care in our community.

If you would like to learn more, call us or go to our website,

Allan R. Kelly, MD FACP

Robert H. Kelly, MD FACP 817-336-3431

Annals of Internal Medicine, Philadelphia, PA
September 24, 2013
To the Editor:

Diana Pi brings to our attention a serious problem in her moving essay, Indian Summer (AIM, 158, 355-356): mature, intelligent, expert clinicians leaving primary care internal medicine. Dr. Pi suspects the problem is hospital and clinic management. We think the problem is much more fundamental than that. Being a good clinician cannot be measured by a CPT code, yet that is how our work has been defined and reduced.

Her work, and all clinical medicine, is valued by metrics of billing and productivity defined by the CPT guidelines. The need to conform to a 99213 code (office visit, intermediate), and all the other thousands of codes in the CPT system, leads to incentives and distortions in medical practice that cause too many good doctors like Dr. Pi to leave their clinics and patients.

For similar reasons, here in Fort Worth, every few months another primary care internist or family practice doctor in his or her 40's or 50's leaves the office/hospital practice of internal medicine. The widespread use of mid-level providers can take up the slack and patients are getting a good 99213 when they go to a provider. But neither patient nor physician sets out to provide or obtain a 99213.

Dr. Pi and doctors like her (including us) need to have a better choice than either being a provider of 99213's or leaving internal medicine. Patients, too, deserve a choice other than another 99213. Experience, loyalty, accessibility, even wisdom are what some people want and these values are not included in a CPT code or valued by RVU's.

Our take on this is that employment contracts and CPT codes are not working well for long term primary care internal medicine, especially in geriatrics. We do not advocate 'concierge medicine'. We advocate instead for internists and the elderly and chronically ill to have a choice in how they value medical care. We ask that AIM bring into focus innovative alternatives that will keep internists like Dr. Pi in primary care, working for the good of their patients. We describe one widely affordable and simple proposal at our web-site,

Allan R. Kelly, MD FACP

Time to Change

by Allan R. Kelly MD FACP

In all the public debate, we have been told that American medical care is the best in the world but at the same time that we need to change health care in America. As internal medicine doctors, we know both are true statements. Our concern is how to innovate and improve what is already working well.

There is opportunity to improve. Physicians complain of chaotic work environments and lack of time to be with, and think about, their patients. Many doctors add testing, imaging, and mid-level providers in order to meet volume goals. Many patients think their doctors are good, but too busy and too hard to reach. Patients also worry about high costs. Medical students, sadly, are turning away from primary care because of low reimbursement, long hours, and perceived lower prestige.

We believe that innovations will improve primary care. The current bureaucracy focuses on procedural terminology and equal pay for the same office visit, regardless of the quality of that visit. Innovation requires changing the models that have been favored by giant bureaucracies and government programs. The best innovations will come from focusing on the patients. Refocusing must be based in part on the quality of the patient’s experience. Importantly, if there is no connection between physician pay and quality, then quality will not improve.

Innovation to improve quality and reduce complexity is achieved by reaffirming the direct, personal, and reliable relationship between the expert physician and his or her patient. We call on the doctor to model his practice after the great physicians of the past and to embrace and adapt that practice to the 21st century. Provided care is affordable and represents value and improvement, we expect that patients will recognize that a premium practice is worth paying for. We want such innovation to be part of our practices and our community.

Our goal is innovation that improves value and quality. All doctors are challenged to improve medical care. One way to improve is not to focus on Medicare, insurance, CPT codes, and the government. We need to focus on our patients and their experience of medical care, their experience of each contact with their physician.

Different physicians will have different insights and plans. We hope yours will be better than ours! But, we simply cannot be satisfied with a good practice. We want to do better for each person who calls us Doctor.

Allan R. Kelly MD

PMH: What To Do Now

by Robert H. Kelly MD FACP

There is a book of aphorisms by Charles and William Mayo (1). Will Mayo wrote: “The glory of medicine is that it is constantly moving forward and there is always more to learn.”

We think it is time to move forward. We think there is something more to learn about providing good medical care, medical care that people want. I want to make clear what it is that we want to do for our patients.

We want to give definition to what it is that works so well. Leaving aside vaccines, penicillin, surgery and other wonders of medical care, the concern is the way we care for patients in and out of our offices. We have tried to define what it is in internal medicine practice that made many physicians want to be doctors. We have tried to define what is most important to our patients and colleagues.

We think this is expertise, loyalty and availability to the patient. The expertise is the professional and learned part, acquired through many years of training and practice and still ongoing. Patients expect and deserve this. But loyalty and availability makes the difference, makes the expertise desirable to colleague and patient alike. Loyalty and availability are the qualities that we think give our patients an experience like having a doctor in the family.

We are giving that expertise, loyalty and availability a name and a structure: the Premium Medical Home. We have identified expert care, optimal size, direct communication, focus on convenience, commitment to patient comfort, avoidance of intermediate providers, and expert records as the elements of a Premium Medical Home. In a Premium Medical Home, patients have confidence, comfort and convenience in addition to expert diagnosis and treatment.

All medical offices offer communication. They all have telephones and computers. But for the patient to directly, quickly and without obligation communicate with their physician, to get access to that valued judgment and thought can require an office visit or an emergency room visit. Many offices simply do not provide patients with direct communication to their physician: patient’s calls are directed, after various delays, to nurses or secretaries to arrange care. Staff prudently pass the information on to the doctor and often tell the patient to come to the office or emergency room to be seen, sometimes by a physician extender. But maybe the patient just needs knowledge, insight and good judgment. Maybe they just need communication: they need to talk with their doctor. We want patients to have access to that without an appointment. Whether by email, text messaging or cell phone, we want patients to have more choices.

With the Premium Medical Home Subscription, direct, unlimited, enhanced communication is immediately and always available. As a PMH Subscriber, you have paid for this communication and it is yours. Call the doctor. He will answer the phone, the email or call you back.

Today, when people call and I pick up the phone, they are often surprised that the doctor answers. No delay, no recordings, no “he’s really busy right now.” With a PMH Subscription, this direct and enhanced physician communication belongs fair and square to every person who joins. All individual charges for phone calls, refills and telephone care are covered. Expert medical judgment at your fingertips: that is a good deal.

We want to offer our patients good value. Concierge medicine promises convenience and comfort for its members, but for a fee often measured in the thousands. Also, in many concierge practices, the patient gives up the benefit of insurance coverage. In the Premium Medical Home, we work with your insurance.

We hope to represent these efforts with our logo which includes elements of a house, a foundation and a medical cross. The house is the medical home. The foundation is the direct relation of physician and patient. Its core is the medical cross.

The modern medical cross originated with the work of Swiss-born Henri Dunant. He was present at the Battle of Solferino in 1859 where 40,000 men died or were injured. There was no plan, organization or understanding about the medical care that was needed, especially on such a scale. In response, Dunant began the work that became the society of the Red Cross and its model of care. This was the first use of the symmetrical medical cross in such a secular medical setting. The symbol was moved out of the explicitly church-based hospital movement toward a humanitarian and non-sectarian model. For his work on the Red Cross he was awarded the first Nobel Peace Prize. Dunant was an innovator: the existing model of medical care needed to change to meet the needs of the sick and wounded.

The Premium Medical Home logo unites the meanings of the home with the medical cross, based on the one-to-one relationship of patient and doctor. It reminds us to strive to do better to serve those who are sick and to provide for our patients. The Premium Medical Home and PMH Subscription are devoted to expert medical care as well as your convenience and comfort. The Premium Medical Home represents innovation in patient care.

We want to know how we can do better in our work together, and we want to know what you think. Call or write. We want to improve medical care.

Robert Kelly, MD FACP
Aphorisms: Dr. Charles Mayo, Dr. Will Mayo
Edited: Frederick Willius, MD 1992
pp. 75, 11

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Your medical issues will be reviewed and summarized during your office visit or telephone consultation. However, there is much more you can and should do. Special interest groups such as the American Diabetes Association (1-800-Diabetes or can be a great help. Web sites contain much pertinent information (, Newspapers will also publish important information relative to your health and well-being. New information or questions you have are an important part of your doctor’s office visits. Your PMH physician encourages learning about your health and treatment in concert with doctor-patient communication. It’s always OK to bring articles or concerned family members to your appointments. To help guide your research, here’s a list of helpful links: