ORLANDO – Shared medical appointments offer an effective way to manage patients with diabetes, providing them with personal and professional interactions that improve clinical outcomes and self-care as well as fostering personal growth.
The programs, which usually include seeing 5-15 patients during a 1.5- to 2-hour period, allow providers to maximize their teaching and clinical care time and can actually be a lucrative way of managing this population, Mary Ann Hodorowicz said.
This newer method for managing office patients with chronic conditions allows providers to maximize their clinical care and face-to-face time with their patients. Diabetes self-management training or medical nutrition therapy is also offered during the visit by a diabetes educator or a registered dietician; patients interact with one another to help further their learning.
Shared medical appointments are not only cost effective but also much more profitable in terms of payer reimbursement, compared with individual visits, said Ms. Hodorowicz, a certified diabetes educator and registered dietician who specializes in reimbursement for diabetes services.
“I'm the queen of acronyms, and 'MORE' is a great one to describe the shared medical appointment for diabetes care. You and your patients get MORE results: Maximization of Outcomes, Revenue, and Empowerment of patients.”
Because Medicare and most private payers recognize the group treatment approach, providers can bill for individual patient follow-up visits for the evaluation and management services they deliver to each patient during a shared medical appointment (SMA).
“This is the good news. If you have 10 patients in an SMA that lasts 2 hours – 1 hour of which is with the physician – you can bill for 10 individual follow-up visits for evaluation and management services,” said Ms. Hodorowicz of Palos Heights, Ill.
For example, she said, if the reimbursement is $100 per patient, the physician will receive $1,000 for 1 hour of work. “Compare that to seeing 10 patients one on one in the traditional office setting, and spending about 20 minutes with each patient. It would take you more than 3 hours to make the same $1,000. In an SMA, this 1 hour translates to $17 a minute; the 3.3 hours in the office setting translates to 50 cents a minute. Do the math.”
But the SMA includes more than a clinical care component. Different programs have different formats, but evaluation, management, and medication titration are just part of a much more holistic package.
“Everyone who comes in gets a blood pressure check, a foot screen, and a retinal screen,” said Sharon Watts, a diabetes nurse practitioner who created an SMA program for the Louis Stokes Cleveland Veterans Affairs Medical Center. “The providers come in and give a brief talk on the importance of the [hemoglobin] A1c, blood pressure, and LDL cholesterol, and we go through the rest of the ABCs of diabetes care. And we get out of there,” and let the educators and patients take over. Registered dieticians, diabetes educators, and behavioral specialists can all be part of the team. A 1-hour lecture, however, is not the goal.
“It is all patient driven,” said Susan Cornell, Pharm.D, a certified diabetes educator and pharmacist who helped create the SMA program at Midwestern University in Downers Grove, Ill. “We know it's going well when the patients – not the health care professionals – are doing most of the talking. Allowing the patients to take the lead is key, because we stress the importance of self-management. We want to make sure they take ownership of their condition. The more they do, the better they can control it.”
Unlike Ms. Watts' program, which focuses exclusively on high-risk patients, Dr. Cornell's CHAT (Collaborative Health Advocate Team) program includes patients of other risk levels who have been referred by their primary care provider. She makes sure to keep the groups homogeneous. “You really can't have type 1s, type 2s and 'gestationals' all in the same group because they have very different needs,” she said.
This program includes some clinical care, such as blood pressure checks and blood glucose levels, but it focuses more on self-management tools. Topics might include nutrition, medical therapy, cardiovascular disease, depression, self-monitoring of diabetes, or how to deal with complications.
Because it's within a university setting, CHAT is run by students who are supervised by the preceptors in their specialty, whether that's nutrition, psychology, pharmacology, or medicine.
The VA program has a slightly different take on the SMA. For example, Ms. Watts' program is not open to all comers. “I populate these groups myself,” she said at the meeting. “I want to go after those who aren't being gone after by anyone else – those who are at really high risk of problems.”