Specialists fit in more care management time
THE NEED TO improve the accessibility and efficiency of healthcare has more providers adopting the emerging shared medical appointment (SMA) model.
While primarily thought of as an efficiency measure, there is mounting evidence that group visits also can improve the quality of patient care, particularly for those with chronic conditions such as diabetes and asthma, and, by doing so, lower healthcare costs.
A shared medical appointment is a physicianto-patient visit in the presence of other patients who benefit by hearing about the experiences of similar patients. During a typical 90-minute SMA, patients discuss their concerns in a forum and listen to strangers share their health concerns. Virtually everything-diagnoses, prescriptions, medical histories, treatment - is discussed in the group setting. An SMA is not a support group or psychiatry session, though it often does incorporate patient education. In addition to the physician and patients, SMAs usually are attended by one or more nurses or other clinical staff, who might act as facilitators.
'We are able to see two to three times more patients,' says Zeev Neuwirth, MD, chief of clinical effectiveness & innovation at Harvard Vanguard Medical Associates, a division of Atrius Healthcare, with 700 physicians in Greater Boston. 'It is a higher-cost activity, but you are able to see more patients.'
A backlog of patients and a phone ringing off the hook are among the reasons Holly Thacker, MD, director for the Center of Specialized Women's Health at the Cleveland Clinic, held her first SMA in July 2002. To reduce the appointment backlog, she scheduled several patients in a conference room and found it allowed her to educate everyone at the same time and address more common concerns.
Dr. Thacker says her first available individual appointment is typically eight months out, but she can see a patient within the week with an SMA.
'I can see a whole afternoon of patients in 90 minutes,' she says. 'IfI can do four hours of work in two hours time, then I can do other things, like writing and research activities.'
Dr. Thacker is likely on the leading edge of the trend.
In a survey by the American Academy of Family Physicians (AAFP), 8.4% of practices reported using SMAs in 2008, up from 5.7% percent in 2005. Among the institutions using group visits are: Kaiser Permanente Medical Centers at Santa Clara and San Jose, California; Borgess- Promed in Kalamazoo, Michigan; Sutter Medical Foundation in Sacramento, California; Parkland Health & Hospital System in Dallas; University of Virginia Health System; WellSpan Health in York, Pennsylvania, and the Cleveland Clinic.
A PricewaterhouseCoopers report on healthcare access in July 2009 cited SMAs as one way to ease the shortage of primary care physicians.
REIMBURSEMENT DOESN'T CHANGE
SMA visits are billed the same way as typical patient visits, based on the level of care delivered, and are documented in the patient's chart according to Current Procedural Terminology (CPT) criteria.
The Centers for Medicare & Medicaid Services (CMS) has not published official payment or coding rules for group visits for Medicare, says Cindy Hughes, billing and compliance specialist for the AAFP.
'Reimbursement is based on evaluation and management services provided to the individual patient - provided there is documentation to support it,' says Hughes, adding that payers reimburse SMAs at the same level as an individual office visit.
That's been the experience for Edward Noffsinger. The former director of clinical access improvement at Palo Alto Medical Foundation for the Kaiser Permanente Medical Centers has spread the mission of SMAs worldwide, helping implement group visits for more than 400 physicians and practices.
'Billing and compliance officers tell me the only thing different between my model for the group visit and an individual office visit is that it is happening in a group room rather than an exam room. But that is irrelevant in terms of CPT coding because what counts is the level of care delivered and documented,' he says. 'It doesn't matter if happens in a group room, an exam room, or the 'doc in the box' at your local Costco.'
Physicians are delivering the same care, if not more care, Noffsinger says. Although it is a group setting, it offers similar care value.
Time spent counseling is an exception, he says. He recommends physicians not bill for counseling time to avoid double-dipping.
SMAs have the potential for billing abuse, says Patrick Hurd, a healthcare attorney in Norfolk, Virginia.
'I caution providers not to 'game the system' by up-coding or billing at a level that neither the length of the office visits nor the nature of the services provided support,' he says.
He has spoken with CMS, and officials are concerned that doctors will be tempted to file fraudulent claims. Providing SMA service once with 10 patients could not be billed and additional 10 times for counseling.
'We just consider that overhead expense of the program,' he says.
In April 2009, Michigan insurer PriorityHealth added a separate reimbursement category for SMAs as part of its initiative to support primary care providers in becoming patient-centered medical homes.
The insurer sees SMAs as one way to increase the productivity and efficiency of the healthcare team and improve patient access. Additionally, PriorityHealth reimburses SMAs as a way to encourage quality through education and care management.
SMAs do save insurers money, says Kimberly Moreland, vice president at Rising Medical Solutions, a healthcare consulting firm in Chicago.
'Based on the requirements for an office visit code and the required time it takes for each component, it is very unlikely an SMA visit could ever qualify for even a mid-level visit,' she says. 'If the provider can see more patients, the medical community saves money due to the lower level of coding used for an SMA. This could be a win-win option for some medical treatments,' she says.
QUALITY AND QUANTITY
Though the initial appeal of SMAs was attributed largely to their potential to allow more patients to receive care in timely manner, studies continue to suggest they can deliver improved outcomes and lower costs.
A study of Hispanic patients with diabetes at a Dallas clinic found that those who attended SMAs were more successful in adhering to American Diabetes Assn. guidelines than those who had traditional visits.
A 2006 review of research on SMAs, published in the Journal ofthe American Board of Family Medicine, concluded 'there is sufficient data to support the effectiveness of group visits in improving patient and physician satisfaction, quality of care, quality of life, and in decreasing emergency department and speciahst visits.'
The improvement in outcomes has been attributed to patients having more time with their physicians as well as the group pressure on members to follow care directives.
PROTOCOLS FOR PRIVACY
Any practice offering group visits must ensure federal and local privacy rules are followed, however. Patients should always have the choice to opt out of group visits.
The AAFP recommends patients sign a confidentiality form and HIPAA disclosure form prior to the SMA.
At the Cleveland Clinic, SMA patients sign a waiver before the appointment, agreeing not to disclose other patients' personal information. Patients are referred to only by first names during the visit. HIPAA does not prevent patients from voluntarily discussing their personal health information with each other.
'HIPAA really doesn't apply to other patients, and there isn't a private right of action, 'says John Meyers, an attorney specializing in healthcare law in Beverly Hills, Calif.
'The challenge and liability lies within how the provider can ensure patients from the group remain compliant to their signed confidentiality agreement, and what recourse, if any, do they have should they become aware of a non-compliant patient,' says Moreland, of Rising Medical Solutions. 'That is a legal argument with possible exposure.'
Hurd cautions that healthcare providers should create protocols for protecting personal information in shared appointments, because that is the sole right of the patient.
Meyers says the best way to ensure HIPAA regulations are met is through consent and acknowledgement by the patient prior to the SMA, rather than a confidentiality agreement, which could be hard to enforce.
SMAs are not a good fit for all provider types, however. If group visits are not set up and run correctly, costs can increase.
Beginner mistakes often result in failure of the entire SMA program, says Noffsinger. One ofthe most common problems is starting an SMA with a smaller, homogenous patient population. He recommends SMAs incorporate a diverse group of patients to achieve critical mass.
'If only 15% of a panel is diabetic, physicians are going to have a hard time filling their groups,' according to Noffsinger.
Maintaining high patient volume is key to sustaining the program.
SMAs with fewer patients are less efficient and can be more costly than routine care, according to Dr. Thacker. She overbooks her appointments to account for no-shows in order to keep her SMA patient volume high.
'To eliminate billing/reimbursements concerns, SMAs would need to help reduce medical costs, not increase them,' says Moreland.
The AAFP believes small practices and physicians who don't practice full time are not good candidates for the SMA model.
But SMAs are an effective way to mitigate the shortage of primary care physicians, Noffsinger says.
'If you triple your productivity, physicians are doing 4.5 hours of work in 1.5 hours,' he says. 'That is a net gain of three hours of physician time.'
IT'S LIKE GAINING A DOCTOR
For every 12 scheduled SMAs, the result can be up to 36 hours of physician time saved. Essentially, the equivalent of a full-time physician is created from efficient use of current physicians' time without an increase in overhead expenses, Noffsinger says.
'The only thing the doctor is left to do is what the doctor can uniquely do, which is what they went to medical school for,' he says. 'They don't have to do the charting, they don't have to ferret out the reason for the visit. They just deliver high-quality, high-value medical care to each and every person in that room.'
SMAs can go beyond primary care. The opportunity for patients to learn from each other's experiences is one reason Neuwirth has spearheaded the launch of SMAs for Vanguard across a wide range of medical specialties, including pediatrics, dermatology, neurology and cardiology.
'If you add up the number of hours a day it takes for a primary care physician to practice medicine [according to best practices], it takes 18 hours a day. And it is just not doable,' says Neuwirth. 'We have some physicians that you cannot get a general appointment with for several months - at least you couldn't until they started offering shared medical appointments.'
With 18 SMAs a year, the savings could be more than $6 million within seven years, says Noffsinger.
'The physician is able to see three times as many patients in a 90-minute period because they are delegating non-medical tasks.'
[Sidebar]
MHE EXECUTIVE VIEW
* CMS has not published official rules for SMAs.
* Payers reimburse SMAs at the level of a typical office visit.
* Studies suggest the group settings save money.
[Sidebar]
MHE EXECUTIVE VIEW
* Patient privacy can be reasonably well maintained in shared appointments.
* Offer consent forms or confidentiality agreements.
* High volume is key to sustaining the model.
* Small practices are not suited for SMAs.
[Author Affiliation]
Amanda Brower is an Advanstar Communications Inc. senior editor.
