The group visit model, in which physicians see multiple patients simultaneously, has gained much ground since it was first introduced in family practice circles roughly 30 years ago.
Medicare, and many major insurers now reimburse for group visits, and some actively promote wider adoption. Direct-pay practices are also embracing this model, given the positive experience it creates for many patients.
Dr. Edward Noffsinger, an early pioneer of the group visit model, who literally wrote the book on the subject—Running Group Visits In Your Practice (Springer)—estimates that this model can increase a practice’s productivity anywhere from from 200-600%.
By and large, the group visit model evolved in the context of conventional medicine, with a primary focus on management of end-stage disease. Doctors see groups of patients with the same diagnosis–say diabetes or asthma or atherosclerosis—provide education on self-care, proper use of medications, the importance of compliance, etc.
It improves the fiscal viability of primary care, but in terms of actually engendering better health, the standard group visit model has not necessarily been a game-changer.
Shilpa Saxena, MD, a family physician practicing outside of Tampa, FL, is attempting to change that by tailoring the basic group visit model to fit the principles and practices of functional medicine. Group visits have become a cornerstone of clinical care at her SevaMed Institute, and one of the most enjoyable aspects of practice. “The Group Visit is my favorite day of the week,” says Dr. Saxena, a featured speaker at Holistic Primary Care’s upcoming Heal Thy Practice 2013 conference.
A Remedy for Isolation
“Isolation is at the core of conventional medicine,” says Dr. Saxena. A person sees his or her doctor, is given a diagnosis and what little counseling the doctor can accomplish in 10-15 minutes, and then left on their own to figure out how to take care, how to adapt to whatever challenges the diagnosis presents.
Group visits make people feel less alone. “They learn from each other, and there’s a sense of “We’re all in this together,” which patients really like. They help each other more than I ever could. As much as I think I have great relation with my patients, there’s something special that comes from hearing from their peers.”
In keeping with the principle that a specific diagnosis is a net result of system-wide imbalances, and that lifestyle-based treatments should go well beyond the “chief complaint,” Dr. Saxena focuses her groups not on particular diagnoses, but on key aspects of healthy living: eating healthfully, restoring & maintaining gastrointestinal health, identifying and eliminating disease triggers, and the like.
As a result, her groups include people with a wider range of specific diagnoses. For example, people with hypertension, depression, diabetes and a handful of other conditions will all meet together to learn about the Mediterranean diet—a mode of eating that will ameliorate many different disorders.
“Its’ not about managing end-stage disease, its about teaching patients about the factors that trigger diseases. I modified the intention of the traditional group visit to fit the functional medicine approach.”
The Magic Number
There is an ideal size for group visits, generally in the range of 10-16 patients. “Fewer than that, and you won’t get the benefits of a group dynamic. More than that feels like a lecture—people become passive.”
Dr. Saxena’s groups run for 90 minutes. She begins with a Powerpoint presentation, and then takes questions. During the busier parts of the year, she’ll host them once weekly; in the summer—when many patients go away—the frequency drops to once monthly.
Being able to see 10 or more people at once has profoundly affected her time management. “I’m not having to repeat the same basic educational information over and over to each patient. By getting people together, I can go much more in depth than in a short individual visit. We allow lots of Q&A, so people can get help with their individual questions. But patients start to riff off of one another other, so we end up covering a lot more than we could individually.”
By discussing the basic health and lifestyle information in group sessions, she and her patients can make optimal use of individual visits. One-on-one time can be focused on specific issues that truly require individualized attention.
Dr. Saxena said that as long as one follows some basic guidelines, one can bill insurance for group visits. “If you see, say ten patients, you bill ten separate 99213 or 99214 codes. “The reimbursement depends on who you are and your practice setting. A solo FP gets less than someone in a multi-specialty group, but generally it ranges from 70% to 125% of Medicare. So, that’s about $75-$125.
She says insurers generally smile on group visits because they realize it’s more cost-efficient. “There’s no way I could teach lifestyle change to 10 or 15 patients in 90 minutes if I were seeing them individually.”
Dr. Saxena said she became interested in the group model out of necessity. “The PA I was working with was going out on maternity leave, so suddenly I was facing a double work-load: her patient panel and my own. I thought, “How am I ever gonna do this?” So I researched about the group concept, looked up the guidelines, and just started doing it.”
While most patients love the idea, there are occasional patients who are uncomfortable with it. Dr. Saxena says she and her staff do their best to explain the benefits, especially the time savings.
Patients can still see me individually, but it will require more visits. To get 90 min of time with me would be at least three one-on-one visits. So the trade-off is to get more time per visit in a group, or less time in an individual visit.”
The bigger issue is in keeping patients’ enthusiasm in check. “We have what I like to call group visit groupies—they love to come to groups, and sometimes they want to come to groups that are not really relevant for their conditions. I explain that these are not workshops or therapy groups. They’re medical visits. I do appreciate their enthusiasm, though, and sometimes it’s the patients that will suggest ideas for new group topics. “
Dr. Saxena believes group visits will become increasingly important for the future of holistic and functional medicine.
“Most of us were trained to believe the only way to have a meaningful patient encounter is in a face to face office appointment. In lifestyle-based medicine, the limitation is time. With reimbursement decreasing, doctors try to see more patients, which is counterproductive. The group visit provides a real solution. It doesn’t totally replace the individual visit, but it synergizes with it.”
Does it seem too easy? “Yes, it really is that easy!” Dr. Saxena concluded.