American College of Physicians: Internal Medicine — Doctors for Adults ®


Group visits help patients, but are costly to solo practices

From the March ACP Observer, copyright 2007 by the American College of Physicians.

By Jessica Berthold

When word got around that solo general internist Michael Hennigan, FACP, was holding group visits at his diabetes and lipid center in Decatur, Ala, people started showing up who weren't his primary care patients. Dr. Hennigan, who lives in an area of the country with high diabetes rates, was glad to see them. But some of his colleagues around town felt differently.

"We teach the patients what kind of care to expect, and if they don't get it, to ask for it. This has gotten a few people upset at us," Dr. Hennigan said. "We had one physician call and say 'Stop telling my patients to take off their shoes. I don't have time to look at everyone's feet.' "

Mike Hennigan, FACP, of The Diabetes & Lipid Center in Decatur, Ala., speaks to a diabetes group about nutrition and health issues at ECM East Diagnostic & Rehab in Florence, Ala.

Group visits, in which education is mixed with clinical care, have been touted for years for their ability to increase patient knowledge and satisfaction, improve certain health indicators, and save money for practices. Studies have shown that for some populations, they are more effective than individual visits. (See sidebar). Yet they also pose certain challenges, from angry competitors to financial struggles, particularly for solo doctors and those in smaller practices.

Will patients come?

Sharad S. Swami, FACP, a solo general internist in Clinton, Okla., originally planned to have four separate groups of six to eight diabetics come in for monthly visits, but was only able to get enough patients for two groups. Still, at six patients per group he figured he would break even.

Dr. Swami started the meetings last March, and everything went very well for a few months. Then people started missing meetings or dropping out altogether. By the fall, he had to combine the two groups into one.

In theory, group visits help save money for practices by using a doctor's time more efficiently. Instead of repeating the same individual conversation about diet and weight, for example, a doctor or nurse can deliver the message once to a group then pull patients aside individually for quick one-on-one exams.

In reality, some solo and small practice doctors are struggling to make group visits pay. The main problem is simply getting enough patients to show up to make setting aside a chunk of time worthwhile.

"We were blocking a whole afternoon when Dr. Swami could have seen 15 individual patients, but only four or five were showing up for the group," said Ashley Rodriguez, Dr. Swami's secretary and part of the three-person team running the group visits.

Dr. Swami said he believes part of the problem is practicing in a rural area, where it is difficult for some patients to come in for monthly meetings. Many of his working-class diabetes patients have trouble taking time off from jobs during the day, while his retired patients sometimes need to find rides in areas that lack public transportation.

Another problem for the solo practitioner is burnout. Without a nurse practitioner or certified diabetes educator on hand, much of the work falls on the physician, Dr. Swami noted. These frustrations, he said, have led him to consider stopping his group visits altogether.

"I still want to do it, but if I don't get enough people, what can I do?" said Dr. Swami. "Group visits are definitely a good idea, but for a solo practice it may be too much."

Competition stalls referrals

Marc Shalaby, FACP, a general internist and assistant professor of medicine at Lehigh Valley Hospital in Allentown who has run diabetes groups since 2004, said most of his group visit patients are either people who work within the hospital network and can pop in for a two-hour visit, or retired folks.

"I invite all diabetics to come, but if you are 45 years old and working, you can't come during the day," Dr. Shalaby said.

Dr. Hennigan, who has conducted his diabetes group visits since 2000, said it took two years before he broke even on group visits.

"The first year we started, we probably invested more than $50,000 in getting the program set up," said Dr. Hennigan, who estimates he has 2,000 patients. "At this point it is a little more than break-even, but that's mostly a volume issue. We've not had the level of referrals in the community we need."

Specifically, said Dr. Hennigan, local hospital referrals haven't been forthcoming. "We have noticeably decreased the number of admissions to hospitals," he explained, "which hasn't enamored us to them."

As well, said Dr. Hennigan, other doctors in the community are reluctant to refer patients to another practice for group visits, perhaps fearing that the patients won't return to the referring doctor for primary care. Dr. Swami reported similar issues, and sees it as a consequence of living in a sparsely populated area where competition for patients among doctors is keen.

"Some doctors will send a patient 100 miles to Oklahoma City for a clinic but not a half a mile for a group visit," Dr. Swami observed.

Such fears on the part of colleagues may be justified. Dr. Hennigan recalled an incident where he gave a diabetes presentation for a local chapter of Kiwanis International, and an audience member stood up and pronounced he'd had diabetes for years and had never once gotten a foot exam by his physician—who was also the man's friend of 30 years.

"So, unintentionally, what did we do but undermine the credibility of this man's doctor and friend?" asked Dr. Hennigan. "And the phone call I got the next day wasn't a mea culpa from that doctor for not doing adequate care. It was 'Why are you telling my patients I'm not doing a good job?'"

Patients who show up benefit

While medical competitors may object, group visits benefit patients, physicians said. In general, they make it more likely a doctor will closely monitor patients, and are likely to improve performance measurement and compliance, said Michael Weisz, FACP, program director of the internal medicine residency program at University of Oklahoma Health Sciences Center in Tulsa.

"It's easier to keep track of people if you have a focused area that you are looking at and thinking about," he said.

Patients report learning more from the staff who might help run group meetings, because these people are more approachable than doctors, said Dr. Hennigan. They learn more from one another, too, noted Marty Levine, MD, who organized a senior group visit program at Group Health Cooperative in Seattle, where he is Medical Director of Senior Care.

"When patients hear other people ask the same questions, the answer sinks in," Dr. Levine said. "Hearing someone talk about how exercise changed her life is more convincing than hearing a doctor tell you to exercise."

Plus there is the fact that patients gain a support system, said general internist Dawn E. Clancy, MSCR, ACP Governor of South Carolina, who holds diabetes group visits as a faculty clinician at University Internal Medicine clinic at the Medical University of South Carolina. "You can see that they are calling each other, meeting for lunch, driving in together."

Learning about the pathology of diabetes, and how it relates to other conditions, gives patients a deeper understanding than would memorizing a list of rules on diet and exercise, said Dr. Swami. And the benefit may extend beyond the patient to family members, such as children who are educated and exposed to healthful habits by their diabetic parents, he noted.

One of the most important side effects of group visits, said Dr. Shalaby, is that it makes people better patients … and it makes physicians better doctors.

"It gives me a more relaxed, personal relationship with them, one I might not get while wearing the white coat and stethoscope," Dr. Shalaby said.

The bottom line

Group visits are commonly held for diabetes, asthma or COPD, but there are also primary-care groups for seniors who tend to seek care often, and even drop-in group medical appointments for the stable chronically ill or "worried well."

While Medicare typically pays for disease-specific group visits, it doesn't pay for those that are more general, like geriatrics, noted Dr. Levine in Seattle.

"At Group Health, we do the visits for free because it's in our business interest. For a small practice doctor who is billing fee-for-service, they will have trouble doing a non-disease specific group," Dr. Levine said.

Even for those visits that are paid by Medicare, providers need to have a "critical mass" of patients in order to make it financially worthwhile, said Dr. Clancy.

"For us, it was 13 people in a 90-minute period," Dr. Clancy said.

And yet some doctors actually opt for keeping their groups small, even if it takes a toll on the pocketbook or wallet. Dr. Weisz, in Oklahoma, after doing a trial last summer with 13 patients, felt that it was too many for a complex diabetes group visit. He reduced the group to nine when he started with a new group in November.

"It takes time to do individual care because there's so much to deal with, like blood sugar, lipids, blood pressure, foot exams … especially if you are dealing with a group that isn't well-controlled," said Dr.Weisz.

As a result, Dr. Weisz acknowledged, the cost of doing group visits may not quite equal that of holding individual visits.

"You know, I'm not realistically thinking this is going to pay for itself yet. We're still figuring out the best way to do it," Dr. Weisz said.

Dr. Shalaby, in Allentown, said he probably loses a little money by seeing eight patients in a two-hour meeting as opposed to individually. Still, he said the group visits are worth doing, because it improves the care he gives and his patients love them.

"The quality of the visit is superior with this group of patients. They know what I'll be asking and looking for, so it allows us to be more focused on other issues," Dr. Shalaby said. "Financially it's a wash, but for me it's mostly a patient care issue."


Searching for evidence: Do group visits lower HbA1c levels?

Anecdotes abound about how effective group visits are. Marty Levine, MD, chief of geriatrics at Group Health Cooperative in Seattle cites two examples from the group visit program that he organized for seniors and a variety of other populations:

  • A hard-working, aggressive lawyer with diabetes who started with an HbA1c level of 9.8 and dropped to 6.1 after joining a group has maintained that level for two years.
  • An elderly woman who had chronic headaches but wouldn't listen to her doctor about increasing her exercise found a walking buddy in one of her group visits—and the pain disappeared.

Examples like these are plentiful, as are accounts of satisfied patients and doctors who say the group visit format is more efficient, effective and humane. Yet research on medical gains from group visits has yielded mixed results.

Published studies have shown that group visits for seniors result in fewer ER visits and less hospitalization—and higher patient satisfaction—but not necessarily a change in health status.

As for diabetics, a study by Trento et al published in Diabetes Care in June 2001 found that HbA1c levels remained stable, while BMI and fasting triglyceride levels were lower and HDL cholesterol levels higher, in patients who participated in groups for at least a year. Meanwhile, the control group's HbA1c levels rose, and the other indicators stayed flat, over the same time period.

Yet a similar July 2003 study in Diabetes Care by Dawn E. Clancy, ACP Governor of South Carolina, found no significant difference in blood sugar or lipid control for patients who participated in group visits vs. individual visits over six months.

Dr. Clancy, who called Dr. Trento's team in Italy to try to determine why the results differed, said she believes that medication plays a role in whether or not group visits can change health indicators like glucose levels.

"In Italy they give medication for free to those with diabetes. Our patients, meanwhile, are disadvantaged and don't always have access to medication," Dr. Clancy said. "If they had medication, they could get their blood sugar and blood pressure under control."

Dr. Clancy's study did find, however, that 76% of group visit patients were up-to-date on at least nine of the 10 standard-of-care items recommended by the American Diabetes Association, compared with 23% of control patients. Those standards included up-to-date HbA1c and lipid profiles, annual foot exams and pneumonia immunizations.

Doctors assess their results

Results from the group diabetes visits of Sharad S. Swami, FACP, a solo general internist in Clinton, Okla., have been mixed. Out of 10 patients who were tracked and who completed at least one group visit, five saw their HbA1c levels decline, three saw HbA1c increase, and one saw no change. Declines ranged from the dramatic—one patient's fell from greater than 13% in June to 8.6% in October—to the mild, with two patients seeing a 0.3% drop after more than four months. Meanwhile, one patient's level increased from 5.9% to 7.2% between January and March; another's rose .7% in a six-month period.

All but two of nine patients tested saw no change in urine microalbumin before and after group visits, while all five tested for LDL saw their levels drop 9.8% to 46.7% after at least three months.

Marc Shalaby, FACP, a general internist and assistant professor of medicine at Lehigh Valley Hospital in Allentown, Pa., found that the percentage of his 12 patients who reached their LDL and blood pressure goals increased by double digits after participating in group visits for a year, from 64% to 84% at goal for LDL and 44% to 60% at goal for blood pressure. Those who reached their HbA1c goal rose from 20% to 28%, with the average HbA1c dropping to 7.12 from 7.56. The average LDL dropped from 90 to 89 and blood pressure from 138/73 to 128/69, Shalaby said.

For his data analysis, general internist Michael Hennigan, FACP, of Decatur, Ala. narrowed down his 316 group visit patients by pulling the first 29 charts of those who had levels of HbA1c, blood pressure, cholesterol and weight taken at baseline (April-August 2005), at six months and at twelve months.

Five of the 29 dropped out of the program between the sixth and twelfth month. Of the remaining 24 patients, two-thirds saw overall declines in HbA1c after a year, though levels after six months were often lower than after 12 months. One-third saw an increase in HbA1c after a year. Averaged out, the HbA1c drop was .9 over a year, Dr. Hennigan said. Results were roughly equivalent for blood pressure, with 59% showing some decrease after a year.

Diabetes group visits organized by Michael Weisz, FACP, director of Internal Medicine Student Programs at University of Oklahoma Health Sciences Center-Tulsa, led to significant improvement in meeting management standards. After three visits, 100% of the patients had appropriate testing of HbA1c, urine for microalbumin, and a monofilament foot examination. Patients whose LDL cholesterol was at goal of less than 100 increased by 12% and appropriate aspirin use increased from 75% to 100%.


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