The doctor, the nurse and the health behaviorist will see you all now," could become a familiar call at the doctor's office.
The waiting room might be filled with as many as 15 patients who have arrived for a follow-up visit with their personal physician, which they will experience together.
While health systems and medical groups face increasing pressure to contain costs and see more patients in less time, medical practices in California, Colorado and elsewhere are experimenting with 90-minute group visits that are designed to increase physicians' productivity.
National numbers for how many practices are using group medical visits for follow-up appointments are not yet available. But Mary Hobbs, project manager of group appointments at Kaiser Permanente's Northern California region, where group visits were born and have evolved, says roughly 200 to 300 such group appointments occur every month. And that number is growing among Kaiser's 3,750 physicians practicing in Northern California, Hobbs says. Advocates for group medical appointments claim that the quality of care is improved while both patient and doctor are more satisfied. They say consumers experience increased access and more time with their physician, and doctors can see as many as three times the number of patients in the same turn of the clock.
Too good to be true? Charles Kilo, M.D., former vice president and current fellow of the Institute for Healthcare Improvement, doesn't think so. IHI is an independent, not-for-profit organization based in Boston that seeks ways to improve healthcare quality.
"Innovations in the provision of care and the way we practice are necessary," Kilo says. "The one-on-one doctor visit is an outdated model." Kilo says his organization has been looking at numerous alternatives, such as scheduling visits the same day a patient calls and more robust out-of-office care, as well as group medical visits.
"We think all of these things are quite valid and are going to become an important part of the future of office-based care," Kilo says.
He does warn that group visits are not for everyone and should not be considered a substitute or a forced alternative to individual office visits.
"You just have to be sure everyone knows the boundaries, " Kilo says. "And be sure people have access to treatment in other manners."
Two schools. So far, two different approaches to the group visit have emerged as the strongest models for other practices to adopt. Edward Noffsinger pioneered his concept, the Drop-In Group Medical Appointment, or DIGMA, in 1996 after two dozen years working as a psychologist for Kaiser Permanente's San Jose and Santa Clara medical groups in California.
And in Westminster, Colo., near the Denver metropolitan area, John Scott, an internist and geriatrician at the Colorado Permanente Medical Group, created the Cooperative Health Care Clinic, or CHCC, a group model of care for patients more than 65 years old. Started in 1991, it has grown from an independent research project to a national program within Kaiser Permanente.
The major difference between Noffsinger's DIGMA and Scott's CHCC is that Scott's model focuses on patient populations either by diagnosis (a specialty CHCC) or utilization behavior. Noffsinger's model, on the other hand, focuses on the physician's entire practice, with the goals of increasing access and improving the physician's ability to manage his or her large practice. In the DIGMA, most any patient can attend, and a host of different ailments can be addressed and treated.
In the Cooperative Health Care Clinic, there is usually more consistent continuity of care, with the same group of patients seeing the same doctor and nurse at regular intervals. Both models often result in the formation of deep social bonds. Scott says the support network created by CHCCs can be "stronger than family." Noffsinger and Scott agree that their models can work well together in a complementary way.
Noffsinger has since retired from Kaiser and is a consultant to other practices, including the Palo Alto (Calif.) Medical Foundation, where he is helping set up nine DIGMAs in a pilot test of the new office visit. His model is basically an extended medical appointment with the patient's own physician that takes place in a supportive group setting. A mental health professional or other health behaviorist helps lead the group while the doctor takes care of individual charting duties. The behaviorist also can identify mental or emotional problems that a doctor might not always see, especially in a 15-minute visit.
"The role of the behaviorist is to assess both the needs of the patient and the needs of the doctor," says Gina Earle, a licensed clinical social worker on staff at the Palo Alto center. "If the doctor is uncomfortable with some of the mental health aspects, you can move in and play a larger role. It makes that seamless joining of behavioral health and physical well-being."
The DIGMA also addresses mind-body needs in what one doctor calls a "biopsychosocial" experience. Noffsinger says group visits work equally well for primary care and specialty care, and are especially apt to address the long-term educational and health maintenance needs of many people suffering from chronic illnesses, such as diabetes, asthma and congestive heart failure.
"It's a wonderful venue for working with patients who are noncompliant or fearful of treatment," Noffsinger says. Other patients can share information and personal experiences and give an individual the reassurance he or she needs. Laurel Trujillo, a general internist at the Palo Alto foundation and one of the champions of the DIGMA pilot project, adds that if a physician were to design a way to give patients chronic-illness education, individual visits would be the last thing a physician would choose.
Good business. With the DIGMA model, Noffsinger says the immediate cost savings come from maximizing the use of physicians' time. He typically advises a primary-care physician to see three times as many patients in a 90-minute group visit as he or she normally would in individual office visits during the same amount of time.
Specialists could see even more because they typically see fewer patients during the same time frame. The ideal group size is 10 to 16 patients, Noffsinger says. Too many more can become tiresome for the physician and result in less bonding between the patients.
"By leveraging the doctor's time by 300% to 400%, a 90-minute group translates to a net savings of three hours, or about one-twelfth of a work week," Noffsinger says. If a medical group schedules 12 DIGMAs in a week, it is saving the cost of one full-time employee, he says, plus associated office space and support staff.
Each doctor's DIGMA is open only to his or her patients, who should be personally invited by the physician to attend for follow-up care. A different mix of patients at each visit can be present. Noffsinger says those interested in implementing a group visit program should have a champion, either a physician or a mental health professional, who has a good working knowledge of the DIGMA model.
A one-time start-up investment of about $1,000 should include high-quality marketing materials, such as framed posters and fliers to be handed out by the doctors.
"Running a document off your PC and taping it to the wall isn't going to attract patients," Noffsinger says.
Invitations also should be sent to patients who frequently visit their physicians by a designated scheduler who is committed to the program. Often this can be someone already on staff who is willing and able to meet the DIGMA appointment needs. If not, a group might have to hire someone, but that would require enough DIGMAs to justify the added expense, Noffsinger says.
Visits are billed using the same criteria and codes currently used for individual visits. "There are separate codes for group education and group therapy, but this is neither of those," Trujillo says. "It is a medical visit. My primary interaction is with each patient, and there are other people present as well."
Thomas Hopkins, an internist at the Sutter Medical Group in Sacramento, Calif., has been conducting drop-in group visits every Monday since December 1999. Like Trujillo, he bills for the services he provides during the visit.
"I'm going to code it the same way I do a one-on-one visit because I take care of the same problems and conduct the exam the same way as I would in my practice," Hopkins says. "There should really be more that you're able to code for, because (in a DIGMA) you're able to do more for the patient."
Hopkins echoes Noffsinger's concern that drop-in group appointments are not for everyone and should always be offered to both patient and doctor as a voluntary alternative, not a required substitute for one-on-one medical appointments.
Thomas Atkins, M.D., chief medical officer at the Sutter Medical Group, helped establish four pilot DIGMAs last winter and plans to add six to eight more. He says each is different and is tailored by the individual physicians.
"That's also true in the financial analysis," Atkins says. Whether he has a large or small patient panel, the DIGMA should make each doctor's management of those patients more efficient, more productive, more open and more satisfying.
"From the business perspective, we have to figure out what helps pay for the program and be sure we don't spend more money in the process of seeing patients and capitalizing on physician and patient satisfaction." Atkins says he expects to break even on the model and that the DIGMAs have produced a better healthcare product.
Measurable differences. Scott says the Cooperative Health Care Clinic already has produced measurable outcome improvements and cost savings. The results of a randomized trial comparing the impact of Scott's CHCC group visit model to traditional individual visits were published in an article in the May 1997 issue of the Journal of the American Geriatrics Society. The study concluded that, after one year of follow-up care, the older, chronically ill HMO members who participated in the CHCC had fewer emergency-room visits, fewer visits to subspecialists and fewer repeat hospital admissions per patient.
The group participants also made more visits and calls to nurses, and fewer to physicians than the control group patients. A greater percentage of group participants also received influenza and pneumonia vaccinations. Cost of care per member per month was calculated to be $14.79 less for the group participants.
"We know the stuff works, and we have the hard data that's reproducible," Scott says. "All the big-ticket items are down, and yet you've got happier patients that are doing better."
Scott notes that more-extensive outcome improvements and cost savings have been observed in a larger, two-year trial; the results will be published later this year.
The first 15 minutes of the CHCC are spent building community. In early sessions, Scott says a psychiatrist also attended the group, as in the DIGMA approach. But because of the tightly knit group that results from his format, the mental health professional is not required to help manage the group.
An educational segment follows the opening chat for more formal discussions of a core set of topics, such as use of the emergency room, routine health maintenance issues and Medicare policies.
Next comes the "break," when the nurse or medical assistant starts down one side of the U-shaped gathering and the doctor starts down the other; they take vital signs, order routine tests and write and renew prescriptions. Then there's time for questions and answers on any subject, medical or otherwise. One-on-one consultations are reserved after the group meeting, which only about half of the group usually needs, Scott says.
Pitfalls, problems. "One pitfall we fell into and almost didn't climb out of in time was, at the beginning of our second study, we did not monitor the groups to be sure they were doing it right," Scott says. Half of the doctors had turned the group visit into a lecture.
"The doctors are much more comfortable being professors than facilitators," Scott says. "They're mostly used to working on patients, not with them."
Raj Bhandari, a neurologist at the Santa Teresa Medical Center, a Kaiser affiliate in San Jose, began offering DIGMAs in the fall of 1997. The program has since been picked up in the neurology departments of Kaiser practices in Oakland, Calif., and Santa Clara, and more are being established in Sacramento and San Francisco.
Bhandari says before implementing the group visits, he had a backlog of appointments stretching as far ahead as six months. Patients were complaining, and scheduling clerks often had to change 60-minute first-time visits to 15-minute appointments. Since using group visits, he says the backlog has decreased and not a single new visit has been shortened.
The increased number of new appointments now available presents another potential problem that should be discussed by doctors and administrators. With the time physicians save, there is a temptation to simply bring in even more patients.
"We're struggling with increasing our patient panel," Bhandari says. "The goal is not to make the physician's professional life harder, but to make it easier and to improve quality."