Working Smarter

Group visits are proving to be a valuable antidote to harried physicians. Would a 200 percent increase in productivity make you feel better?

Are you stuck between a rock and a hard place known as decreasing revenue and increasing payer demands for patient access? If you recognize any of the following situations, the answer is probably yes.

• You're seeing more patients in less time to make ends meet, and are beginning to hate coming to work.
• You're squeezing more full-length visits into each day, and find yourself working 100-hour weeks.
• You're thinking of hiring more physicians, but wonder if you're able to afford them.

All of this tells me that we need a tool for working smarter, not harder.

Here's a solution that helped Palo Alto (Calif.) Medical Clinic (PAMC) boost productivity by 200 to 300 percent while improving access, the bottom line, and patient and physician satisfaction: the "Physicals Shared Medical Appointment" (or Physicals SMA) model. It's a new way to handle time-consuming physicals -- largely in a group setting, but with appropriate privacy maintained.

Each person in a group of six to nine same-sex patients first gets a comprehensive private exam (typically just a few minutes per patient) in which only the hands-on tasks are completed by the physician. Then all patients gather for the rest of the appointment, where all discussions (except those that are truly private) are conducted in a group setting -- and everyone can listen and learn from what is being said.

The end result: Eight or nine physicals can be performed in the amount of time it would normally take to deliver two or three -- and each one is fully reimbursed.

Unlike other group visit models that focus predominantly on follow-up visits, such as the Drop-In Group Medical Appointment (DIGMA) or Cooperative Health Care Clinic (CHCC), Physicals SMAs, as the name implies, are specifically designed for complete physicals in primary care, and similar appointments.

The model has already successfully expanded beyond primary care into various subspecialties such as prenatal exams in obstetrics, well-baby exams and school/sports physicals in pediatrics, digital rectal exams in urology, foot exams in podiatry, cosmetic and acne exams in dermatology, and pre-surgery cataract physicals in ophthalmology.

Here's why it works

The fundamental reason that the Physicals SMA model works is that a relatively small portion of the appointment is dedicated to the actual physical examination. The vast majority of time is typically spent on the interactive component of the exam:

• reviewing symptoms;
• updating personal and family health histories;
• conducting risk assessment and reduction;
• educating patients;
• asking and answering questions;
• addressing health concerns;
• discussing treatment options and medication side effects;
• refilling and changing medications;
• reviewing health maintenance; and
• social chit-chat.

If all the talking were removed, complete physical exams could often be provided in just a few minutes' time -- four to six minutes for men, and a minute or two longer for women.

In Physicals SMAs, the physician only needs to say things once (but often in greater detail) to all patients, rather than repeating the same information to different patients in the exam rooms. Patients benefit even further by talking to one another and hearing the answers to questions that may not have occurred to them or that they may be reluctant to ask.

In short, Physicals SMAs provide complete physical examinations along with an interactive segment, maintain appropriate privacy, and deliver the same level of medical care and documentation as traditional physicals.

And because they achieve high levels of physician (and patient) satisfaction, Physicals SMAs -- which are meant to be voluntary to patients and physicians -- are embraced by physicians at the grassroots level. Why? Because of the dramatically increased productivity and the opportunity to do something different.

Scheduling with ease

While the length and frequency of sessions can vary, the most commonly used model is the weekly, 90-minute heterogeneous or mixed Physicals SMA -- for patients of the same sex, but from different age groups.

For example, physicals for male patients with a shared condition or issue may be commonly divided into two groups: male patients under 50 could be scheduled on the even weeks of the month, while males 50 and older are seen on the odd weeks. Female physicals could be similarly divided, for women under and over age 40.

Generally it is best to keep the sexes separate in primary-care Physicals SMAs. Many of the issues differ by gender, and patients are more likely to discuss some sensitive topics when only same-sex patients are present.

It's possible to consistently achieve the target group number of six to nine patients (with eight or nine patients being most common in primary care, and nine to 12 patients for medical specialties) by effectively promoting the program and by overbooking each session according to the expected number of no-shows and late cancellations.

Building the team

Physicals SMAs represent a team-based approach to care, with nonphysicians helping in all aspects of the visit, including identifying and rectifying any pre-existing problems in the system. The key to success is assembling a team that will enable the physician to delegate as many responsibilities as possible and appropriate to other, less expensive members of the team.

The critically important champion (used in larger systems), charged with overall responsibility for the entire Physicals SMA program, moves it from pilot study to organization-wide use, and helps the physician in the design and implementation phases and on an ongoing basis.

The program coordinator (also in larger systems) is responsible for assisting the champion, monitoring participants, managing the schedulers, coordinating with the physician, and handling both operational and administrative details.

The behaviorist (generally a specially trained psychologist or social worker) who, like the physician, is present throughout the entire session, assists the physician in multiple ways: by running the group when the physician is providing exams, distributing handouts selected by the physician, identifying what issues patients want addressed, and by keeping the interactive portion of the visit running smoothly and on schedule.

The nurse or medical assistant (typically the physician's own) rooms patients, takes vital signs, performs special duties, helps keep routine health maintenance current, and assists with documentation.

The scheduler is a clerical person trained to telephone patients whom the physician wants invited (typically from physicals wait lists), and charged with ensuring that each session is full.

Finally, documentation support personnel minimize the outlay of physician time in the extensive charting responsibilities that physicals entail before (abstracting and data entry), during (scribing and entering contemporaneous information), and after (entering updates and changes) each Physicals SMA session.

Getting paid

Physicals SMAs are a series of one-physician-to-one-patient encounters that address each patient's medical needs individually, focusing on delivering quality medical care from start to finish. They are billed according to existing CPT codes, exactly like individual physical examinations -- based on the level of care delivered and documented.

At PAMC, our billing strategy began with notifying all insurers as to why we were offering shared medical appointments -- to improve access, enhance patients' care experiences, offer patients more time with the physician, provide patients with more information. Next, we let payers know that we would be billing for these visits exactly as for traditional office visits.

All billings are reviewed for the first two months after starting each new Physicals SMA, and are spot-checked for compliance thereafter to ensure that they are supported both by the level of care delivered and by appropriate documentation.

Carefully designed, adequately supported, and properly run Physicals SMAs offer multiple benefits to organizations -- namely increased productivity and efficiency, improved access to care, enhanced patient and physician satisfaction, and a positive impact on the bottom line.

Edward B. Noffsinger, PhD, is a health psychologist and director of clinical access improvement at the Palo Alto Medical Foundation. He is also an independent consultant and a pioneer in group medical visits.

Noffsinger originated the Drop-In Group Medical Appointment (DIGMA) model for return appointments at the Kaiser Permanente San Jose Medical Center in 1996, and the Physicals SMA model in 1999. He can be reached at enoffsinger@physicianspractice.com.

This article originally appeared in the Spring 2002 issue of Physicians Practice.