Numbers Game

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In the battle to keep costs down,group medical visits are growing

Sacramento Bee

As Dr. Chu Kwan Lau bent to examine a patient’s swollen calves on a recent Wednesday morning, it sounded for all the world like a typical, routine visit.

“Margaret, your weight’s gone up quite a bit. You need to work on that exercise and eat less now that the holidays are over,” he said.

She nodded. At 78, after burying a husband with heart troubles and a sister with diabetes, Margaret Brennan knows exactly what she needs to do to keep her health.

This time, she said, the advice sunk in. It hit home because in this unconventional exam, Brennan was one of a dozen patients trying to manage diabetes or avoid its onset.

“It’s been 10 years I’ve been dealing with this, and it’s good to look around this room and know you’re not alone in the world,” Brennan said.

Buoyed by those around her, Brennan headed home determined to do more walking and yard work, just the outcome doctors at Woodland Clinic had in mind when they started optional group medical appointments here three months ago.

It’s one of several that have sprung up in the Sacramento area in the past three years. And as physicians search for new ways to treat patients and stay in business, more medical practices are looking into whether group visits might be appropriate for their patients.

For doctors paid a flat monthly amount by health plans to treat each patient – a system known as capitation – optional groups at Woodland Clinic and elsewhere are a way to achieve economies of scale lacking in one-on-one visits.

Physicians also hope group dynamics will pressure patients to follow doctors’ orders. Increasing patient compliance can improve health and save money by reducing the need for hospitalization, drugs, and repeat visits.

As the financial rigors imposed by managed care continue to spread, some wonder if these group visits will be one more California export that changes the world of modern health care.

In substance, the groups very much resemble traditional one-on-one appointments most people have with their physicians. There’s a trip to the scale, a blood pressure check and other lab

Conversation, led by a doctor and therapist, tailors treatment to individuals while at the same time, offering advice to the group.

For some, this may conjure distasteful images of military health clinics or 12-step programs.

The American Medical Association, while largely unfamiliar with the groups, is concerned that such meetings could threaten the doctor-patient relationship.

“About 80 percent of complaints people have my grandmother could treat with chicken soup and Tylenol,” said Dr. Edward Hill, an AMA board member. “But in the other 20 percent, people often need complex, individualized care they might not get in a group.”

To date, no one has studied groups to see if they save doctors time or improve patient health. Nobody knows for sure where group medical appointments originated or how many exist. And there are no standard billing codes for doctors to charge health plans for care provided in groups.

But as doctors with time and money constraints search for new ways to treat patients, fewer ideas are being rejected out of hand.

“For years we’ve been trying to make the system work better with all the money drained out,” said Dr. Thomas Atkins, chief medical officer for Sutter Medical Foundation’s group practice program. “The cost pressures are not going away. We have to change how we deliver care, and groups are a way to do this.”

Beyond cash concerns, physician practices rely on groups to satisfy people’s demand for fast and frequent access to care.

Two thirds of Americans rate their health plans based on how easy it is and how long it takes to see doctors and specialists, according to a recent study by the Kaiser Family Foundation.

In response to patient demand, groups designed to reduce waits and increase face time with doctors have sprung up in recent years all over Sacramento.

A three-year-old diabetes group at Kaiser Permanente’s medical offices in Rancho Cordova may be the oldest locally. Since then, the idea has spread to Sutter Health as well as to Woodland Healthcare, which is part of Catholic Healthcare West.

Sutter started with four groups just over a year ago and intends to have 21 weekly sessions by summer. Woodland Healthcare has two groups and plans more.

These local groups treat everything from chronic conditions such as asthma, diabetes and hypertension, to more vague medical concerns, such as fatigue and foot pain.

For Sutter rheumatologist Dr. JaNahn Scalapino, two weekly sessions have made all the difference in handling a patient load that doubled when one of her colleagues left.

In groups, Scalapino sees about 12 patients in the time it normally takes to treat six. But there’s a cost: She often works through scheduled breaks, including lunch.

“I would be tearing my hair out without the groups,” Scalapino said. “It has really been a good release valve for working all my patients in.”

On a recent Thursday, Scalapino’s group dealt with lupus, arthritis and other ailments. Patients debated the merits of various anti-inflammatory drugs and discussed ways to improve their sleep quality.

“It’s weird,” patient Darcy Littlefield said of the session. Still, she regularly drives 60 miles from Jackson to Sacramento to attend Scalapino’s group.

“I was nervous the first time because I’m a private person,” Littlefield said. “But it’s really good if you need to get in quick.”

At a time when the health care industry and the federal government are increasingly vigilant about protecting privacy, group appointments challenge doctors and patients alike to take on faith that nothing personal will leave the exam room.

Patients typically sign confidentiality waivers, a practice carried over from physician-run therapy groups.

Waivers not withstanding, consumer advocates question the medical necessity of the sessions – especially those that put people with a wide range of health complaints into the same exam room.

“It’s certainly in the financial interest of doctors and HMOs to have group appointments because it can push patients towards a standardized treatment, but it’s a terrible violation of patient privacy,” said Jamie Court,executive director of the Foundation for Taxpayer and Consumer Rights.

Privacy concerns and the lack of scientific evidence clearly linking groups to improved patient results may keep some from participating, but Stephen Shortell, a professor of health policy and management at the University of California, Berkeley, said effective group models should stand the test of time.

“To meet the health care needs of people in the 21st century, we can’t be wedded to the idea of the individual office visit when, in fact, a lot can be accomplished through group or even e-mail visits,” Shortell said.

Consumer Watchdog
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