COVER STORY

Should you offer group visits?

You can't beat shared medical appointments for patient education and compliance, say proponents.

By Dorothy L. Pennachio
Senior Editor

"I used to go four miles without batting an eye, and now I can't even walk a block and a half without getting crushing angina," says the former runner.

Fellow patients nod sympathetically—all but one. A woman in her 60s sitting across the room offers some advice: "Why not get these nitro pills the doctor gave me? I take one before I go out dancing, and then, when I get chest pains from too much fun, I take another one. They work great!" Needless to say, her doctor had no idea she was abusing her nitroglycerin that way.

"This type of thing happens all the time," says Edward B. Noffsinger, a psychologist, director of clinical access improvement at the Palo Alto (CA) Medical Foundation, and a leader in the group visit movement. "Patients tend to deny symptoms when they see their doctor one-on-one. Or they may think their discovery of an innovative use for their meds, like that lady's use of nitroglycerin, isn't worth bothering the doctor about. But when they're among others, they get chatty and bring up previously undisclosed but significant medical information."

"The group setting is unexpectedly powerful," says internist John Scott, another leading proponent of group visits. He relates how a noncompliant patient once boasted, "I'm not going to let this illness take over my life. I'm going to eat and drink whatever I want. Sure, I go unconscious once in a while, but then I wake up and I'm fine."

Another patient two chairs away replied, "You know, you remind me of myself 20 years ago." Then he held up his leg so the group could see that his foot had been amputated.

"What better way to get across to patients the consequences of noncompliance?" says Scott, associate professor of medicine in the division of geriatrics at the University of Colorado Health Sciences Center. "Patients really get on board when they see evidence like that."

That's a key reason such group visits are catching on. They work as patient support groups, make for efficient use of medical resources, improve access, and help motivate behavioral change, say proponents.

But are group visits right for your practice? That depends on a number of factors. One is whether your staff has the appropriate capabilities. Although not all these jobs must be filled by specialists or even different people, the original model for group meetings requires the following staff:

A behaviorist to run the group while you're documenting a chart note or occupied with individual exams. The behaviorist might discuss stress reduction and generally help keep the discussion focused.

A nurse or medical assistant to help with exams and procedures, ordering meds or tests, and coordinating lab orders, referrals, and return visits. She might also promote the concept of group appointments to appropriate patients during office hours.

A champion to move the program forward throughout the system.

A program coordinator to supervise scheduling and prepare promotional handouts. The coordinator might prepare and follow up on questionnaires.

Another consideration is whether insurers will reimburse you adequately for the sessions. Although some physicians have found ways around the obstacles, others continue to stumble over them. We'll elaborate in a bit, but first here's an overview of the typical group visit structures.

CHCCs for the chronically ill

The cooperative health care clinic (CHCC) is one common type of group visit. "CHCCs are designed for patients with chronic illnesses or conditions that need extra care, such as adolescent pregnancy or geriatric medical problems," says John Scott, the architect of this model. "The group appointments are like extended office visits. They address patients' educational, social, and psychological needs as well as their immediate physical needs."

Typically, a CHCC begins with a few minutes of social time, followed by an educational segment lasting about half an hour. Next, the physician and nurse take patients' vital signs, update their records, write prescription refills, sign forms, and give immunizations. A question-and-answer session follows. During the final hour, the physician sees some patients one-on-one.

You can schedule CHCC appointments as frequently as every two weeks or as infrequently as every six months, depending on your patients' needs. Visits last about two and a half hours and should be limited to about 20 patients. Ideally, each patient should be seen individually four times a year.

Scott has been arranging such group visits for 12 years, and clinical evidence suggests that the model works well, he says. For instance, a 1997 analysis of the group appointments held during the previous year at Colorado Permanente Medical Care Program resulted in the following:

• An 18 percent decrease in ED visits.

• A 12 percent decrease in hospital use and readmissions.

• Delayed entry into nursing facilities.

• Fewer visits to subspecialists.

• More calls to nurses and fewer to physicians.

• Increased patient and physician satisfaction.

• A $14.79 decrease in the cost of caring for each patient per month. "A second study done two years ago showed overall savings had increased to $50 per patient per month," says Scott.

DIGMAs are for the worried well

Drop-in group medical appointments (DIGMAs), originated by Ed Noffsinger, aren't as structured as CHCCs, and each meeting is composed of different patients. DIGMAs are best viewed as a series of individual office visits with observers where each patient's unique medical needs are attended to individually. DIGMAs work best as follow-up visits for established patients, including those who are difficult and time-consuming. The worried well—depressed, angry, or anxious patients who tend to require excessive amounts of time—are prime candidates.

DIGMAs are typically held weekly and last about 90 minutes each. Like CHCCs, the groups can be disease-specific, but mixed groups are more common. A doctor and a behaviorist usually lead DIGMA sessions. The doctor or nurse gives routine injections, updates health maintenance, renews prescriptions, answers questions, and performs nondetailed exams, such as testing range of motion for a patient with Parkinson's. The behaviorist supplements the information provided by the doctor.

But in a DIGMA, the physician addresses each patient's medical needs while the whole group watches, listens, and learns. While examining each patient, the physician encourages group interaction by asking questions—for example, if others can explain how a patient succeeded in lowering her blood pressure. So patient education occurs during the individual visits. The last 15 minutes is reserved for brief physician-patient one-on-one encounters—private exams or discussions of a private nature—on an as-needed basis.

The ideal group size is about 13 patients—that's about three times the number who can usually be seen individually in 90 minutes of clinic time. DIGMAs have been shown to increase physician productivity by 200 to 400 percent.

"Seeing that many patients individually would often require four and a half hours," says Noffsinger. "That's a potential savings of three hours a week per DIGMA." Noffsinger recommends starting with one DIGMA a week, then going to two, and eventually aiming for one a day "if you have a busy, backlogged practice—or want to grow your practice and maximize your productivity."

Many patients and physicians say they prefer the group setting to the individual visits. "Patients say DIGMAs are like mini medical school classes—and better than watching ER," says Noffsinger.

Another group-visit structure originated by Noffsinger is the Physicals Shared Medical Appointment (SMA) model. It was designed for primary care but is now being used in many specialties for prenatal exams, well-baby checks, and school physicals. The model typically triples the physician's efficiency by grouping patients who need physicals by sex and age.

It's important to assure patients that their physicals during the SMA are private—nothing like a military-style exam where patients undress together or are herded en masse from station to station. How you should structure your group physicals depends on the size of your organization and the makeup of your patient population.

Private exams take place individually in exam rooms before the group discussion, while the behaviorist meets with the group, asking them what medical issues they want to discuss with the physician and handing out information. In the exam room, questions best addressed in front of the group are deferred to the session that follows.

"Patients often learn as much from the questions raised by others as from their own," says Noffsinger.

With staffing and coding, ingenuity is key

Although group visits are perhaps more feasible in large settings like Kaiser or Mayo, the two group-visit architects agree that they're becoming more common in small practices, too—even solo ones.

"You don't have to have groups of 20 patients; you can have groups of 10. You don't have to have behaviorists—your nurse can fulfill that function," says Scott.

"A small practice won't have the resources of a large group," says Noffsinger. "On the other hand, it will have more flexibility than an organization the size of Kaiser."

Noffsinger knows of a rural, three-doctor practice in Tennessee that runs DIGMAs. "The physician in charge uses his best nurse as a behaviorist," he says. "His MA helps, and he uses the lobby as a group room."

Getting paid for group visits may prove a bigger challenge than working them into a small practice. One reason: Medicare doesn't have payment rules or coding that directly address group settings, notes a spokesperson for the Centers for Medicare & Medicaid Services (CMS). That's a problem FP Mark Attermeier says his Midelfort Clinic in Eau Claire, WI, tried to solve.

"We wanted to offer group visits for our patients several years ago, even though we knew Medicare wasn't going to pay," says the FP. "The plan was to eat the cost temporarily while we worked with the AMA to get a CPT code worked out. After a year, a code was designated. Then CMS changed its mind and said, 'One patient, one doctor—that's all we're paying for.' "

Practices with non-Medicare patients—especially those that are capitated—are finding ways to get reimbursed, even without a CPT code specifically for group visits. "In a capitated system like ours, getting paid is not an issue, since we get monthly amounts from all payers," says Marlene McKenzie, research project coordinator at Kaiser Permanente in Denver. "But in small, fee-for-service practices, the lack of a CPT code might quash any decision to offer group visits," she notes.

"Unless you're capitated, what you'll get paid is based on a flip of a coin, if you get anything at all," says Kathy Pride, a coding consultant with QuadraMed in San Rafael, CA. "Group visits aren't covered services, and any insurance company will deny your claim on that basis."

Despite that, she suggests trying the unlisted E&M CPT code 99499 to report claims for services provided to an individual patient in a group setting. This code is designed for any service, and CMS gives carriers the discretion to assign a value to the service, even if only a history is taken. Send documentation with a detailed description of the services provided, how much time they took, and the resources involved. Indicate that the services were provided in a group setting. The carrier will review the claim and determine an appropriate payment amount based on medical necessity.

Noffsinger suggests another possible approach that some health care organizations are using: Bill DIGMAs and SMA physicals for what they are, a series of individual office visits with observers. As is the case with individual office visits, the focus from start to finish is on the delivery of medical care. Also like individual office visits (and unlike CHCCs) there are no structured warm-up, education, working break, Q&A, and planning segments.

"Billing and compliance officers in these settings indicate that nothing in existing CPT coding addresses the setting of visits," he says, "so they don't have to take place in individual exam rooms. There is also nothing that limits the number of observers you can have during a patient visit." Health care systems often bill for DIGMAs and SMA physicals as a series of individual office visits according to the level of care delivered and documented, using existing CPT codes.

You can't bill for counseling time, though, because it's impossible to determine how much time is spent on one patient when four or five benefited from the counseling. The behaviorist's time in a DIGMA or Physicals SMA is absorbed as part of the overhead cost of the program—which avoids patients being billed for two copayments during a single visit. "Most health care systems don't bill for the group discussion segment, only for time spent on individual histories, exams, and decision-making," Noffsinger says.

"Instruct your staff to offer your 90-minute DIGMA along with your first available individual office visit to every patient who calls about a nonemergent matter. Meet with those patients, take their vital signs, bring routine health maintenance current, give injections, talk with them face to face, and examine them if necessary. Have a meaningful, possibly compensated visit, rather than taking a shot in the dark on an uncompensated phone call at 7 p.m."

Forewarn patients to avoid HIPAA troubles

Before any group visit, tell patients what to expect. Make sure they understand that their medical issues will be discussed in front of others, and vice versa. Make certain that all patients understand not to identify other group members or to discuss their medical concerns with others outside of the session. They have to feel it's safe to speak freely in front of the group.

Some doctors have patients sign confidentiality releases prior to meetings. By signing, patients affirm that they will hold confidential anything said about other patients in group meetings, and not disseminate it outside the room.

"Here in Colorado, we're not so uptight about legal issues," says John Scott. "We haven't felt we needed a confidentiality form, and it hasn't been a problem."

Lucy Osborn, a retired pediatrician living in Salt Lake City, also says she sees no need for releases. Patients share what they're willing to share during group visits.

"People feel safe," she says. If something comes up that shouldn't be discussed, the moderator should stop it by saying, "It's inappropriate to deal with that here. Make an appointment to discuss that with the doctor in private."

"Confidentiality agreements may serve to inhibit unwanted disclosures, but as a practical matter they may also prove difficult to enforce," says Steve Ingraham, an attorney with Harris Beach in Rochester, NY. The Health Insurance Portability and Accountability Act (HIPAA), however, is another matter.

"HIPAA doesn't prevent people from voluntarily discussing personal health information with others. The intent is to protect patients' privacy," says Ingraham. "The focus of the privacy standards is on the doctor, whether he treats one-on-one or in a group. He has obligations under HIPAA with respect to permissible disclosures."

This means a doctor can't reveal personal health information acquired from a patient during a group session for nontreatment purposes, such as research, publication, or promotion—any more than he can reveal information learned during a one-on-one visit, unless the patient authorizes him to do so.

"Beyond that, there's nothing in HIPAA that precludes group appointments, provided the patients are willing and competent to participate," says Ingraham.

D'Arcy Guerin Gue of Phoenix Health Systems in Montgomery Village, MD, advises caution, though: "HIPAA's read on group visits hasn't been tested, but I suggest erring on the side of conservatism. If tested, a decision by HHS would come down on the side of the patient."

Power Points

CHCCs should last about two hours and provide care for about 20 patients.

The unlisted E&M CPT code 99499 can be used to report claims for group visits.

Make sure patients understand that their issues will be discussed in front of others.

HIPAA's read on group visits hasn't been tested, so err on the side of conservatism.

DIGMAs are typically 90 minutes, and the ideal size is about 13 patients.

Your nurse can act as behaviorist in a group visit.

Assure patients that their SMA physicals are nothing like a military-style exam.

You can't bill for the counseling segment of group visits.

Dorothy Pennachio. Should you offer group visits?.

Medical Economics

Aug. 8, 2003;80:70.