Docs Dig the DIGMA

Putting in long hours and still facing a crowded appointment schedule and complaints about access? Drop-in group medical appointment (DIGMAs) can help. These group appointments - which include an average of 10 to 16 patients meeting for up to 90 minutes at a time - are designed to improve patient access without adding resources, appealing to patients and physicians alike.

Like any new process, however, DIGMAs require careful planning, and may mean changing perceptions among patients, physicians, and payers.

How to DIGMA

Despite some initial raised eyebrows, practices of all kinds are now experimenting with the model, in which patients' family members may also participate. "More people are doing group appointments as a replacement for some one-on-one care," says Elizabeth Woodcock, director of knowledge management at Physicians Practice.com. Patients like group appointments because it gives them a chance to meet and share with others, Woodcock says. "Think about the power of the Internet in terms of Web sites centered around disease states: People are desperately trying to find [other] people in the same condition, and that's what group appointments can do."

Physicians benefit as well: DIGMAs make physicians more productive, aid patients with compliance, and - despite fears to the contrary - can actually help diagnosis and treatment.

"In the DIGMA, doctors see a different type of information. We've picked up life-threatening situations in a DIGMA because a patient brings up a concern as an afterthought - someone who needs glasses turns out to be a diabetic with blood sugar over 900," explains Ed Noffsinger, PhD, who formerly ran DIGMAs for Kaiser Permanente and now works as a consultant, helping others use the technique.

The models that are commonly used include

• Homogeneous model. Patients share a specific diagnosis. One week's meeting might focus on hypertension, the next on asthma, the next on diabetes; the cycle can repeat monthly.

• Heterogeneous model. Any patient with any diagnosis can drop in to a weekly DIGMA.

• Mixed model. Each week, the DIGMA focuses on one of four major groupings, for example, cardiopulmonary, then weight management/diabetes, then chronic pain, then gastrointestinal matters. However, patients may drop in to the group at any time.

The appointments are ideal for patients with chronic diseases that demand a lot of self-management, such as diabetes. Sessions offer an opportunity to educate patients and do simple check-ups. Usually, several providers help at each session. The physician speaks to patients and answers questions; a nurse might handle routine care such as blood pressure checks; and a behavioralist - instrumental to the DIGMA's success - facilitates patient participation. The right person for the facilitator role will have strong interpersonal skills and experience working with large groups, allowing physicians to concentrate on diagnosing specific clinical problems, modifying medication schedules, and other medical decision making.

When assembling your DIGMA team, keep in mind that "behavioralists tend to be listeners," notes Mark Attermeier, MD, a family practice physician at the Mayo Clinic in Luther, Wis. "In this setting, the behavioralist must be a time manager and literally butt in to the conversation, which isn't what their training teaches them."

Making sure DIGMAs pay off

From a management perspective, the DIGMA should be treated as a regular patient appointment. Applicable co-pays should be collected, and patients should be instructed to call in a cancellation if they cannot attend. Payers, however, may not recognize DIGMAs as regular appointments. Group visits began within the Kaiser Permanente organization, then moved to heavily capitated physician groups - two situations that minimized compensation concerns. Today, most health plans do not offer coding options for group appointments, so practices must develop strategies to receive payment.

"Sit down with payers and talk about it," Woodcock advises. "Show them the literature proving it is helpful, and ask if it's a possibility. Payers now pay for e-mail consults - those kinds of advances are driven by some physician taking the time to ask if it's possible."

Thomas Hopkins, MD, an internist in a multispecialty group at Sutter Medical Group in Sacramento, takes a practical approach. "I code for the work that I do, simply. The DIGMA is another appointment format, and it offers a lot more value to the patient that I don't think the coding is able to encompass. If I carry on the same things I do in a one-on-one visit, I code for the work I do."

Others are more philosophical. "We're entering a new phase of healthcare delivery," says Attermeier. "We're going to go through a period of time when compensation doesn't match with the codes we have. That doesn't change the fact that we have to give care to [patients] in a way that works."

Plan and persevere

As with any new treatment method, practices should consult an attorney beforehand to discuss potential liability using DIGMAs. "Doctors often worry, 'what if I miss something in the group?' But physicians often miss something in individual visits, because time is short - the average visit includes eight minutes of patient contact," Noffsinger notes, compared to nearly 10 times that amount during a DIGMA.

As a precaution, Noffsinger recommends confidentiality waivers for participating patients. "We tell patients they can take home everything from the group, but they can't identify anyone from the group," he says.

Patients also need to be educated about the purpose of DIGMAs - and must be invited to participate. To attract patients, physicians can invite them during regular appointments or send brochures. Woodcock notes that explaining the DIGMA's purpose is critical. "It's different, so you want to explain why the practice is embarking on it and how it is valuable to patients."

A DIGMA's success does not depend specifically on the size of a practice's patient panel, but on how the practice promotes group visits, so enthusiasm is important. "This isn't a slam dunk," Attermeier concludes. "You have to have a good behavioralist who's willing to partner and be an active participant, as well as a physician who has - or is willing to learn - good communication skills and is fairly tolerant of ambiguity. You have to be willing to effortlessly change gears. You're not directing what's happening, and you have to adapt."

Overall, patience is key in establishing DIGMAs. "Don't quit," advises Attermeier, whose group appointments are still evolving after nearly a year. "It's a good idea. It will take time to learn, and it isn't going to go right, right away. It will be uncomfortable, but it's worth the effort, and in time you will get comfortable with the process."

Susanna Donato is a freelance healthcare writer based in Denver, Colo.

This article originally appeared in the May/June 2001 issue of Physicians Practice.