Support Patients Find in Group Visits Enhances Outcomes

Shared Medical Appointments Can Boost Practices' Productivity, Revenue

May 17, 2010 08:20 am David Mitchell

During the first year Byron Haney, M.D., of Ellensburg, Wash., offered his patients shared medical appointments, also known as group visits, to treat metabolic syndrome and diabetes, they lost an average of 15 to 22 pounds.

Those same groups of patients had gained an average of 10 pounds in the year before they started attending shared medical appointments, or SMAs.

"Patients are happier, and they are seeing better outcomes," said Haney, who presented his data in March at the Institute for Healthcare Improvement's International Summit on Improving Patient Care in the Office Practice and the Community. "I have increased patient access to health care, been rewarded with positive outcomes and found shared medical appointments to be a pure joy."

Haney said some patients experience better results in an SMA because they spend 90 minutes with a group of people dealing with the same problem compared to only 15 minutes during a traditional one-on-one visit with a physician.

In group visits, patients see the consequences of others' failure to manage their disease well, and they also hear the success stories of those who have made positive lifestyle changes.

"A big part of it is the support between people," said Gabriella Miotto, M.D., of Long Beach, Calif. "The people do not feel so alone in what they're going through. They're more likely to become more open about what their disease means to them."

A study( published in the Journal of the American Board of Family Medicine reviewed all group-visit articles published from 1974 through 2004. Researchers reported that treatment in group visits

  • reduced obesity;
  • reduced blood pressure and cholesterol;
  • improved quality of life;
  • improved health behaviors;
  • increased patient satisfaction;
  • improved doctor-patient relationships;
  • improved control of mean blood glucose;
  • decreased emergency and urgent care visits, as well as referrals to other specialists;
  • decreased HbA1c levels; and
  • led to better medication compliance and increased self-efficacy (i.e., judgment of their capabilities to carry out the specific tasks necessary to achieve a desired goal).
AIM-HI Offers Guide to Group Visits

The AAFP's Americans in Motion-Healthy Interventions initiative offers a free resource on shared medical appointments, or group visits.

"A Guide to Group Visits for Chronic Conditions Affected by Overweight and Obesity(16 page PDF)" is a step-by-step guide that covers such issues as scheduling, planning and billing. It also provides tips on how to conduct a group visit. And it has sample scripts for telephone calls to patients who might benefit from group visits, sample invitation letters, confidentiality forms, checklists for staff members, sample progress notes, and fitness inventory and fitness prescription forms.

Although insurance companies may not cover group visits specifically for obesity, most patients with obesity have comorbid conditions that are billable.

Miotto, for example, said she offers group treatments for patients with diabetes and depression. "A lot of the patients are struggling with being overweight," she added.

Brent Jaster, M.D., a Denver-based family physician and consultant who specializes in SMA implementation, said shared appointments can provide better access, outcomes and satisfaction for patients; lower health care costs for payers; and increase productivity and revenue for physicians.

"It's a win, win, win for all parties," he said.

Jaster said reimbursement is not a problem if a physician documents the individual care provided to each patient, and codes and bills accordingly.

"Group time is not billed for unless a payer specifically allows it," he said.

Jaster said that if a physician shares his or her enthusiasm for the process and personally invites a patient to participate, recruitment success is 80 percent or higher, and roughly 90 percent of patients are satisfied with SMAs.

"It might hurt some doctors' feelings, but a great majority of patients prefer an SMA to a one-on-one visit," he said.

Of course, achieving success isn't easy.

Kathleen Dunckel, M.D., of Harrisville, Mich., said patients and staff were excited when her community health center started offering SMAs in 2003, but that feeling eventually faded.

AAFP Partners With YMCA on Group Visit Model

Shared medical appointments, also known as group visits, often don't work for practices because the practice has inadequate meeting space. However, the AAFP is exploring a partnership to develop a group visit model with the YMCA of the USA.

Wilson Pace, M.D., director of the AAFP's National Research Network and professor in the family medicine department at the University of Colorado-Denver, said the organizations are seeking funding to study how local YMCAs and primary care practices can work together.

"We're trying to magnify the number of physicians who can successfully sustain a group visit process," Pace said.

According to Pace, the Academy needed a community partner with a message and approach similar to its own Americans In Motion-Healthy Interventions, or AIM-HI, initiative, which emphasizes fitness -- defined as physical activity, nutrition and emotional well-being -- in the prevention and treatment of chronic conditions. He said the YMCA's Activate America initiative fits the bill.

YMCA of the USA, which operates in nearly 10,000 communities nationwide, already offers a diabetes prevention program that is delivered in a group setting. That program is expanding through a partnership with UnitedHealth Group(

"We look forward to the opportunity to work with AAFP because YMCAs are intensifying their support to people who struggle to adopt and maintain a healthy lifestyle," said Jonathan Lever, national director of Activate America. "The opportunity to be part of group visits builds on our staff's expertise in motivational interviewing, facilitating groups and helping people with behavior change."

Pace said partnering with the YMCA could benefit physicians who don't offer group visits but want to deliver AIM-HI's fitness message. Such physicians could refer patients to groups at their local YMCA to receive education and support about obesity-related conditions.

"Patients started to think of it as kind of a class and not as a different way of delivering care," she said. "They weren't seeing it as an alternative to an individual visit because we weren't pitching it that way. It wasn't their fault. We weren't getting into that paradigm shift that this is a different way of delivering care."

Many practices using SMAs involve their nurses and physician assistants in the shared appointments. Dunckel said it's imperative that staff members support the process.

"You have to get your whole office understanding what you're trying to do," Dunckel said. "If you want it to be sustained and a redesign of how you deliver care, you have to get the whole office involved."

Dunckel said she offers SMAs once a month, ideally, with individuals expected to attend once a quarter. It's important that patients who are being treated for conditions such as diabetes or high cholesterol -- and, thus, who need to be seen periodically -- understand that the group visit for those conditions replaces their regular quarterly trip to the doctor's office.

"It's not an additional copay," she said.

Dunckel stopped offering SMAs for a time when renovations to her facility left her without a meeting room. But after construction was completed -- and the community health clinic experienced revenue issues -- group visits resumed.

"If you can see 10 to 15 patients in two hours and bill for them all, that's pretty good productivity," she said.

Like Hany, Dunckel said many patients tend to do better in the group setting, even if they don't lose a significant amount of weight.

"I couldn't say that everybody's numbers are terrific," she said, "but I still think that they do better. Their fitness, their emotional well-being, is improved. They're more positive, and that's very important. If you get discouraged, or if you take it even further and you're clinically depressed, you're not going to take care of yourself.

"I think it's very important that you stay positive and confident that you can do this. That's what keeps people on track."