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Group appointments can serve both patients and practices

A column about keeping your practice in good health

By Victoria Stagg Elliottis a longtime staff member. She covered practice management issues and wrote the "Practice Management" column from 2009 to 2013. She also covered public health and science from 2000 to 2009. Posted Sept. 19, 2011.

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Shared medical appointments are a small but growing part of primary care. According to the American Academy of Family Physicians, 6% of family physicians provided at least some care through group appointments in 2005, and that number went up to 13% in 2010. Group medical appointments also are a key component of the patient-centered medical home model.

So does that mean primary care doctors should start setting up group visits?

Shared medical appointments -- also called group visits or witnessed medical appointments -- vary widely but tend to have several core elements to ensure that patients get the care they need, confidentiality is not violated and the practice is reimbursed appropriately.

Advocates say such appointments may allow physicians to see more patients, provide more care and increase practice revenue if they are done well. Experts say they can be configured to care for just about any patient population, although they can be particularly effective for chronic conditions with a significant lifestyle component such as diabetes.

Group visits can be either a substitute for or an addition to a traditional appointment. Patients receive a limited amount of one-on-one care from a physician, but most of what they need is provided by the doctor in the group setting. Discussion among the group is usually run by a trained facilitator, such as a nurse or a medical assistant, who can deal with patients who dominate or complicate the visit, although physicians who run group appointments say that rarely happens.

"We've never had a disruptive patient," said Karen Cooper, DO, staff physician with the Cleveland Clinic's bariatric and metabolic institute who runs group appointments for her patients. "We have had talkative people or one person who wants all the attention. Sometimes I will say, 'It seems like you have a lot more questions about this particular situation. Why don't we talk about that when we go back to the exam room?' Sometimes I will turn the questions towards the group and ask if anyone wants to answer. Sometimes I use humor."

Experts say the first step for practices thinking about implementing group visits is to identify how the physical logistics might work. Where in a practice can five to 10 patients sit comfortably? Some practices have been able to use conference rooms, the employee break room or even the waiting room.

The next step is to consider which patients will be invited to a group visit. This will vary depending on the most common conditions in a practice's population. Diabetes is a frequent choice for the primary care setting, but this model has been used for many other chronic conditions.

After the patients have been identified, they can be invited to attend. This can occur during a usual physician appointment. Group visits also can be advertised on posters throughout the practice or on the practice's website. Patients should be given the option to switch back to an individual appointment if the group visit does not suit them.

Practices need to consider whether patients must make an appointment or just drop in. How long will a group appointment last, and how many patients will be seen in that time period? When will the visit be scheduled?

For instance, George Whiddon, MD, a family physician with Tallahassee Memorial Family Medicine in Quincy, Fla., has group appointments for patients with diabetes on Thursday afternoons, but that timing has limited the sessions to those who are retired. Some of Dr. Cooper's group appointments are early on weekday mornings, which means that those who work full time can arrange their schedules to make them.

Other key questions: What happens after a patient checks in? Will they see a medical assistant or nurse to have their vitals taken? When do they have one-on-one time with the physician? Who will facilitate the group? Will other clinicians be involved? Will the group session focus on a preselected topic or will this emerge from the needs of the patients in attendance?

For example, after patients check in at Dr. Whiddon's practice, his nurse weighs them and takes their blood pressure. Then Dr. Whiddon sees them briefly, listening to their heart and inspecting their feet, before they are sent back to the conference room for the group visit. Each patient is given a kind of "report card" of their relevant numbers to refer to during the group visit.

"We then spend about the next hour and a half discussing diabetes," Dr. Whiddon said.

Physicians generally bill for the individual services provided to each patient as documented in the progress notes. Because physicians don't have to repeat themselves as often, it is usually possible to deliver more services in a group setting. These visits are usually billed as level IV with a code of 99214 or a level III with a code of 99213, depending on the complexity of the actual care provided. Medicare generally pays for group visits if there is some one-on-one time with the physician, but practices should contact local carriers and other insurers about their policies.

"Check with your carriers to ensure they actually reimburse. Some carriers are still a little bit resistant," said Roland Goertz, MD, the outgoing president of AAFP. "You don't want to set all this up and then find out you don't get paid."

To comply with regulations of the Health Insurance Portability and Accountability Act, patients need to sign one form agreeing not to share the information of others who attend the shared visit and another authorizing the disclosure of their own information to the group.

Physicians who have set up shared medical appointments say they can work very well for patients, the practice and themselves. For instance, Dr. Whiddon likes that he can give advice to a group of patients, rather than to one at a time, allowing time to dive more deeply into relevant issues.

"I love it," Dr. Whiddon said. "My goal is to have 12 or 13 groups rotating on a three-month cycle so that every Thursday would be a group visit. It can be a lot of fun. Patients encourage each other. Sometimes they chastise each other."

Victoria Stagg Elliott is a longtime staff member. She covered practice management issues and wrote the "Practice Management" column from 2009 to 2013. She also covered public health and science from 2000 to 2009.

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