Primary care providers have less time with patients who are presenting more frequently with complex chronic conditions. Group visits provide an innovative approach that moves care from the traditional patient-provider dyad into a dynamic group.

In group visits, patients, typically with similar health concerns, receive regular care and education and gain self-management strategies from a team of healthcare professionals. The approach has been used for a range of high-risk chronic conditions including diabetes, chronic obstructive pulmonary disease (COPD), asthma, osteoporosis and lipid management.

Despite the positive outcomes from group visits, several key barriers exist. To provide more comprehensive healthcare, especially for patients with chronic conditions, providers must embrace group visits and integrate them into practice. The following provides some information on the benefits and current barriers to establishing group visits.

Benefits
Research into the value of group visits has revealed high patient satisfaction, improved clinical outcomes and greater self-efficacy.^1,2,3 Patients also gain valuable self-management tools in an environment with peer support.⁴  Overall, group visits allow for comprehensive preventative care and greater adherence to clinical guidelines.

The benefits also extend to providers. After implementing group visits, healthcare providers felt they were better able to meet patient needs.⁵ Increased provider satisfaction is an excellent reflection on improved clinical outcomes, greater patient satisfaction and a more efficient care delivery system.

One study assessed the use of group visits facilitated by nurse practitioners for patients with COPD. The results revealed improved health outcomes and increased exercise tolerance, as well as positive responses from both patients and providers.⁶ An evaluation of group visits for uninsured or poorly insured patients with uncontrolled diabetes reported increased patient trust with providers and better community orientation compared with those who received typical care.⁷

The Future of Family Medicine Project estimated a potential increase of more than $15,000 in revenue per provider each year with group visits.⁸ Other savings include fewer disability days and hospital admissions, as well as emergency department, subspecialty and primary care visits.^1,8

A randomized controlled clinical trial assessed the feasibility of group visits for patients with type 2 diabetes who were inadequately insured and found statistically significant reduction in outpatient charges.⁹ The fiscal benefits should be expected considering the greater patient compliance and involvement in self-care as well as providers' ability to adhere to clinical guidelines.

As awareness has increased, so has the implementation of group visits programs. The Cleveland Clinic reported an increase in the use of group visits in many large medical centers to more effectively manage chronic disease.¹⁰

Challenges
Despite the many benefits, the "buy-in" of healthcare providers to participation and the appropriate direct reimbursement stand as roadblocks. Providers are reasonably concerned about the quality of care, their ability to maintain patient privacy, the feasibility of initiating group visits in practice, and adequate reimbursement. Another considerable barrier to keep in mind is the lack of randomized controlled studies. There are many articles in the literature describing personal experiences of practitioners establishing group visits; however, there are only a handful of randomized controlled studies published.⁹

Quality of care is always a concern when making changes in practice. This concern initiated a study that assessed the perceptions of providers before and after their participation in a group visit. Providers who participated in a group visit had significantly improved attitudes toward the program after their involvement.¹¹ Greater opportunities for providers to observe established group visits would help ease concern.

Integrating group visits into practice can be time consuming. Providers should look at the implementation of group visits as an investment. Another critical point is that no one should go into this venture alone. Efforts should be made to enlist support from office staffers, and other clinical professionals within the facility or geographic area, who can become part of the team.¹² The support of other providers and staff members is vital to the initiation and maintenance of the program.

Another concern is maintaining patient privacy, especially considering the Health Insurance Portability and Accountability Act. While healthcare providers need to remain conscious of privacy, it has been suggested that health information sharing between patients may encourage others in the group to take a more active role in their care. Confidentiality statements should be used to establish expectations among the participants. Examples should be provided as to appropriate content to share with people outside the group. Patients should also understand that while sharing of health stories is allowed, it is not required for participation. This permits individual patients to decide what information they would like to disclose to the group.

Currently, reimbursement stands as a significant deterrent to group visits. An article from 2003 was hopeful that a Current Procedural Terminology (CPT) code would be established for group visits.¹³ Five years later, reimbursement continues to be a challenge. Providers are required to manipulate the current coding system in order to be reimbursed.

Successful group visit programs have found coverage through consulting with their local insurance companies.¹⁴ There are two methods of coding that have been used by other programs for group visits and are reported in the literature. The first is as an expanded problem-focused visit (99213).¹⁵ The second is a detailed visit (99214).^15,16 Some practices using group visits have documented in each patient's chart and coded according to the CPT criteria, using the standard procedures to bill payers with the criteria and codes to bill for individual visits.¹⁷ A summary from the 2006 AAFP Scientific Assembly stated that the Centers of Medicare and Medicaid Services (CMS) requires one-to-one private care with patients for reimbursement of group health visits.¹⁸

Reimbursement will also be determined by the patient population, depending on diagnosis or health state, and the goal or intentions established by the health center for the visit. A family physician published a descriptive article on implementing group visits for patients who were "high utilizers" of services. Billing was based on the content of the visits for each patient, and appropriate documentation was completed for each patient.¹⁹ It is critical that the level of services that is billed corresponds to the documentation.²⁰

These solutions tend to involve the use of multiple CPT coding mechanisms. Establishing reimbursement through individual insurance companies does not stand as a practical means of billing for busy practices. Additionally, providers believe that the patchwork of coding takes time away from practice and does not adequately reflect workload credit that goes into the visits.²¹ Providing a clear and approved means of reimbursing for group visits, which also accounts for the preparation time, would help to eliminate this barrier and increase healthcare provider interest in establishing group visit programs.

Caring for patients with chronic conditions will continue to be a challenge if innovative ideas and approaches are not used. Group visits have significant potential within primary care to increase patient and provider satisfaction and improve clinical outcomes. For group visits to be successful, however, more providers need to welcome the concept and advocate for appropriate reimbursement and billing codes. It is time to spread the news and make this unique approach to care a standard in practice.

 Kathryn King is a graduate nursing student in the family health program at the University of Pennsylvania, School of Nursing. She is a registered nurse in the medical intensive care unit at the Hospital of the University of Pennsylvania. As an undergraduate at Bates College in Lewiston, Maine, she completed a senior thesis on group visits, which included organizing a group visit at B Street Health Center in Lewiston.