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Group visits are a practical method of delivering medical care and coupling it with extensive group education. Most of the experience with group visits comes from primary care practices and has targeted chronic diseases, such as diabetes, chronic headaches, coronary heart disease, and osteoporosis, or specific patient groups, such as the frail elderly.1
Group visits are useful for patients with chronic illnesses such as diabetes because they improve patient satisfaction, quality of life and quality of care, and some indicators of self-care, as well as decrease medical use, including emergency room visits.2 Medical outcomes, however, do not always improve. With diabetes, for example, some studies (but not all) have shown improvement in glycated hemoglobin (A1C) and diabetic retinopathy in patients who have been seen in group visits compared with a group receiving usual care.3
HOW THEY WORK
In general, only patients enrolled in the practice are invited to attend. Usually, motivated patients will enroll and participate. Most research on group visits in the U.S. has occurred in large health maintenance organizations (HMOs), such as Kaiser Permanente or Group Health Cooperative at Puget Sound in Washington State. However, the model also has been applied successfully in non-HMO settings, such as private practice.4,5
The interest in group visits has arisen from the frustration of primary care physicians as they attempt to provide quality care within the confines of ever shorter office visits. While patients are living longer, they continue to suffer from an increasing number of coexisting chronic illnesses, most commonly obesity, hypertension, diabetes, hyperlipidemia, and arthritis. Office visits are becoming shorter, but are packed with more to-do items, leaving no time for patient-doctor interactions regarding patient understanding of illness and little opportunity for educating patients and teaching self-care. In addition, quality of care suffers because there simply is not enough time for the diligence needed to apply management guidelines pertaining to multiple coexisting chronic illnesses—say, hypertension, diabetes, and hyperlipidemia—in one visit.6
Most group visits are disease- or condition-specific, although several comorbidities and health maintenance issues are addressed frequently. Most commonly, target patients are identified through a patient registry and, more recently, through electronic medical records. The physician sends a letter of invitation, and attendance is voluntary. The same group of 8–15 patients attends one series—usually 4–24 weekly or monthly visits.
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Generally a physician or physician extender medically evaluates patients on an individual basis at each visit in a separate exam room or during the group session in a nonprivate manner. The latter method usually leads to more group feedback, but lacks individual privacy and undivided physician attention.
The group session usually takes place in a large conference room or waiting room and lasts 60–90 minutes. Education tends to be interactive, with a lot of patient participation. Ideally, there is a strong focus on understanding disease physiology, self-care, and skills building. Diabetes education would include classes on diabetes complications, pharmaceuticals, blood glucose monitoring, foot care, stress reduction, food label comprehension, exercise, cooking skills, and any other topics that are guided by patients' interests and questions.
The educators typically are physicians and nurses, but can be as varied as the practice can afford and may include dietitians, pharmacists, physical trainers, podiatrists, social workers, or psychologists.7 Lifestyle changes and other skills taught during these visits could benefit most comorbidities, not only diabetes. I believe that targeting depression and building exercise and fitness skills are key components of diabetes management and education, yet too often these are not addressed during individual and group visits alike.
REIMBURSEMENT ISSUES
At this time, Medicare guidelines allow billing for the individual medical visit only and not for the larger education component. Medicare will pay for education-driven codes for individual visits when half of the time is spent on education, but this cannot be extrapolated to group education. While some private insurance companies may allow additional billing for diabetes group education, Medicare does not unless the education is provided by a certified diabetes educator (see "FYI"), in which case it is possible to bill for both the individual medical visit (based on complexity) and the group education session.
A prepared and standardized intake form, together with appropriate chart review that includes recently ordered lab tests, will allow for billing of the individual visit at a level 3 or 4 follow-up based on the history and additional complexity of the decision-making process. The practice usually absorbs the group education component, and profit is maintained or increased by the number of patients seen within the 2.5–3 hours usually needed to complete the process from chart reviews to billing.
WHY DO IT?
In general, physicians enjoy the process of group medical management and education because it brings back creativity, fun, and humanity to their long hours of practice. Not all patients are comfortable attending group care, but those who choose this format love it, as it allows them time to ask questions, receive more attention and explanations, learn and share with patients with similar illnesses, and eventually feel more empowered and more in charge of their illness.
While we have had no problems at Stony Brook University Medical Center with confidentiality issues during our 5-year experience facilitating group visits and education, confidentiality is a concern because patients may share sensitive medical information in the group. To date, there are no HIPAA (Health Insurance Portability and Accountability Act) regulations regarding group visits. Several leaders in the field suggest that patients sign a privacy waiver and release in which they agree not to reveal personal information about other patients outside the group.
Group visits are an ideal format to provide patients with comprehensive
care, but emphasize important components of self-care. Group visits also allow
the necessary time to deliver quality care with personalized education that
empowers patients to acquire disease specific and general wellness skills in a
supportive and supervised environment. Comprehensive care is, at best,
difficult to provide under current scenarios, except within the confines of a
boutique practice. In addition, the group visit format provides modeling
reinforcement by other patients, as well as the power of the group dynamic in
supporting patient goals to improve self-care. Ideally, self-care education
should be linked to other self-care initiatives occurring in the community,
and patients should be given an individually designed resource map directing
them to dietitians, cooking classes, gyms, physical trainers, social workers,
life coaches, yoga teachers, and psychologists to continue their self-care
journey in the community. 
Footnotes
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More information on diabetes education eligibility requirements for Medicare reimbursements can be accessed from the National Certification Board for Diabetes Educators Web site at www.ncbde.org.
References
2. Jaber R, Braksmajer A, Trilling JS: Group visits: A qualitative
review of current research. J Am Board Fam Med 19: 276–290, 2006.
3. Trento M, Passera P, Bajardi M, et al.: Lifestyle intervention by group care prevents deterioratioin of type 2 diabetes: A 4-year randomized controlled clinical trial. Diabetologia 45: 1231–1239, 2002.[Medline]
4. Masley S, Phillips S, Copeland JR: Group office visits change dietary habits of patients with coronary artery disease. J Fam Pract 50:235–239, 2001.[Medline]
5. Jaber R, Braksmajer A, Trilling J: Group visits for chronic illness care: Models, benefits, and challenges. Fam Pract Manag 13:37–40, 2006.[Medline]
6. Boyd CM, Darer J, Boult C, et al.: Clinical practice guidelines and
quality of care for older patients with multiple comorbid diseases:
Implications for pay for performance. JAMA 294: 716–724, 2005.
7. Lorig KR, Holman HR: Self-management education: History, definition, outcomes, and mechanisms. Ann Behav Med 26: 1–7, 2003.[Medline]
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