Ten patients smiled and waved out on the computer monitor, as Jacob Mirsky, MD, greeted each one, asked them to introduce themselves, and inquired as to how each was doing with their stress reduction tactics.
The attendees of the online session had been patients at in-person group visits at the Massachusetts General Hospital Revere HealthCare Center. But those in-person group sessions, known as shared medical appointments (SMAs), were shut down when COVID-19 arrived.
“Our group patients have been missing the sessions,” says Mirsky, a general internist who codirects the center’s group visit program. The online sessions, called virtual SMAs (V-SMAs), work well with COVID social distancing.
In the group sessions, Mirsky reads a standardized message that addresses privacy concerns during the session. For the next 60 to 90 minutes, “We ask them to talk about what has gone well for them and what they are struggling with,” he says. “Then I answer their questions using materials in a PowerPoint to address key points, such as reducing salt for high blood pressure, or interpreting blood sugar levels for diabetes.
“I try to end group sessions with one area of focus,” Mirsky says. “In the stress reduction group, this could be meditation. In the diabetes group, it could be a discussion on weight loss.” Then the program’s health coach goes over some key concepts on behavior change and invites participants to contact her after the session.
“The nice thing is that these virtual sessions are fully reimbursable by all of our insurers in Massachusetts,” Mirsky says. Through evaluation and management codes, each patient in a group visit is paid the same as a patient in an individual visit with the same level of complexity.
Mirsky writes a note in the chart about each patient who was in the group session. “This includes information about the specific patient, such as the history and physical, and information about the group meeting,” he says. In the next few months, the center plans to put its other group sessions online — on blood pressure, obesity, diabetes, and insomnia.
Attracting Doctors Who Hadn’t Done Groups Before
The COVID crisis has given group visits a second wind. Some doctors who never used SMAs before are now trying out this new mode of patient engagement, says Marianne Sumego, MD, director of Cleveland Clinic’s SMA program, which began 21 years ago.
In this era of COVID-19, group visits have either switched to V-SMAs or halted. However, the COVID crisis has given group visits a second wind. Some doctors who never used SMAs before are now trying out this new mode of patient engagement, says Marianne Sumego, MD, director of Cleveland Clinic’s SMA program, which began 21 years ago.
Many of the 100 doctors using SMAs at Cleveland Clinic have switched over to V-SMAs for now, and the new mode is also attracting colleagues who are new to SMAs, she says.
“When doctors started using telemedicine, virtual group visits started making sense to them,” Sumego says. “This is a time of a great deal of experimentation in practice design.”
Indeed, V-SMAs have eliminated some problems that had discouraged doctors from trying SMAs, says Amy Wheeler, MD, a general internist who founded the Revere SMA program and codirects it with Mirsky.
V-SMAs eliminate the need for a large space to hold sessions and reduce the number of staff needed to run sessions, Wheeler says. “Virtual group visits can actually be easier to use than in-person group visits.”
Sumego believes small practices in particular will take up V-SMAs because they are easier to run than regular SMAs. “Necessity drives change,” she says. “Across the country everyone is looking at the virtual group model.”
Do Group Visits Help Your Bottom Line?
Medicare and many private payers cover group visits. In most cases, they tend to pay the same rate as for an individual office visit. As with telehealth, Medicare and many other payers are temporarily reimbursing for virtual visits at the same rate as for real visits.
Not all payers have a stated policy about covering SMAs, and physicians have to ask. The Centers for Medicare & Medicaid Services (CMS), for example, has not published any coding rules on SMAs. But in response to a query by the American Academy of Family Physicians, CMS said it would allow use of CPT codes for evaluation and management (E/M) services for individual patients.
Blue Cross Blue Shield of North Carolina is one of the few payers with a clearly stated policy on its website. Like Medicare, the insurer accepts E/M codes, and it requires that patients’ attendance must be voluntary; they must be established patients; and the visit must be specific to a disease or condition, although several conditions are allowed.
Mirsky says his group uses the same E/M level — 99213 — for all of his SMA patients. “Since a regular primary care visit is usually billed at a level 3 or 4, depending on how many topics are covered, we chose level 3 for groups, because the group session deals with just one topic,” he says.
One challenge for billing for SMAs is that most health insurers require patients to provide a copay for each visit, which can discourage patients in groups that meet frequently, says Wayne Dysinger, MD, founder of Lifestyle Medical Solutions, a two-physician primary care practice in Riverside, California.
But Dysinger, who has been using SMAs for 5 years, usually doesn’t have to worry about copays because much of his work is capitated and doesn’t require a copay.
Also, some of Dysinger’s SMA patients are in direct primary care, in which the patients pay an $18 monthly membership fee. Other practices may charge a flat out-of-pocket fee.
How Group Visits Operate
SMAs are based on the observation that patients with the same condition generally ask their doctor the same questions, and rather than repeat the answers each time, why not provide them to a group?
Wheeler says trying to be more efficient with her time was the primary reason she became interested in SMAs a dozen years ago. “I was trying to squeeze the advice patients needed into a normal patient visit, and it wasn’t working,” she recalls. “When I tried to tell them everything they needed to know, I’d run behind for the rest of my day’s visits.”
She found she was continually repeating the same conversation with patients, but these talks weren’t detailed enough to be effective. “When my weight loss patients came back for the next appointment, they had not made the recommended changes in lifestyle,” she says. “I started to realize how complicated weight loss was.” So Wheeler founded the SMA program at the Revere Center.
Doctors Enjoy the Patient Interaction
Some doctors who use SMAs talk about how connected they feel with their patients. “For me, the group sessions are the most gratifying part of the week,” Dysinger says. “I like to see the patients interacting with me and with each other, and watch their health behavior change over time.”
“These groups have a great deal of energy,” he says. “They have a kind of vulnerability that is very raw, very human. People make commitments to meet goals. Will they meet them or not?”
Dysinger’s enthusiasm has been echoed by other doctors. In a study of older patients, physicians who used SMAs were more satisfied with care than physicians who relied on standard one-to-one interactions. In another study, the researchers surmised that in SMAs, doctors learn from their patients how they can better meet their needs.
Dysinger thinks SMAs are widely applicable in primary care. He estimates that 80% to 85% of appointments at a primary care practice involve chronic diseases, and this type of patient is a good fit for group visits. SMAs typically treat patients with diabetes, asthma, arthritis, and obesity.
Sumego says SMAs are used for specialty care at Cleveland Clinic, such as to help patients before and after bariatric surgery. SMAs have also been used to treat patients with ulcerative colitis, multiple sclerosis, cancer, HIV, menopause, insomnia, and stress, according to one report.
Dysinger, who runs a small practice, organizes his group sessions somewhat differently. He doesn’t organize his groups around conditions like diabetes, but instead his groups focus on four “pillars” of lifestyle medicine: nourishment, movement, resilience (involving sleep and stress), and connectedness.
Why Patients Like Group Visits
Feeling part of a whole is a major draw for many patients. “Patients seem to like committing to something bigger than just themselves,” Wheeler says. “They enjoy the sense of community that groups have, the joy of supporting one another.”
“It’s feeling that you’re not alone,” Mirsky says. “When a patient struggling with diabetes hears how hard it is for another patient, it validates their experience and gives them someone to connect with. There is a positive peer pressure.”
Many programs, including Wheeler’s and Mirsky’s in Boston, allow patients to drop in and out of sessions, rather than attending one course all the way through. But even under this format, Wheeler says patients often tend to stick together. “At the end of a session, one patient asks another, ‘Which session do you want to go to next?’ ” she says.
Patients also learn from each other in SMAs. Patients exchange experiences and share advice they may not have had the chance to get during an individual visit.
The group dynamic can make it easier for some patients to reveal sensitive information, says Dysinger. “In these groups, people feel free to talk about their bowel movements, or about having to deal with the influence of a parent on their lives,” Dysinger says. “The sessions can have the feel of an AA meeting, but they’re firmly grounded in medicine.”
Potential Downsides of Virtual Group Visits
SMAs and VSMAs may not work for every practice. Some small practices may not have enough patients to organize a group visit around a particular condition — even a common one like diabetes. In a presentation before the Society of General Internal Medicine, a physician from the Medical University of South Carolina warned that it may be difficult for a practice to fill diabetes group visits every year.
Additionally, some patients don’t want to talk about personal matters in a group. “They may not want to reveal certain things about themselves,” Mirsky says. “So I tell the group that if there is anything that anyone wants to talk about in private, I’m available.”
Another drawback of SMAs is that more experienced patients may have to slog through information they already know, which is a particular problem when patients can drop in and out of sessions. Mirsky notes: “What often ends up happening is that the experienced participant helps the newcomer.”
Finally, confidentially is a big concern in a group session. “In a one-on-one visit, you can go into details about the patient’s health, and even bring up an entry in the chart,” Wheeler says. “But in a group visit, you can’t raise any personal details about a patient unless the patient brings it up first.”
SMA patients sign confidentiality agreements in which they agree not to talk about other patients outside the session. Ensuring confidentiality becomes more complicated in virtual group visits, because someone located in the room near a participant could overhear the conversation. For this reason, patients in V-SMAs are advised to use headphones or, at a minimum, close the door to the room they are in.
To address privacy concerns, Zoom encrypts its data, but some privacy breeches have been reported, and a US senator has been looking into Zoom’s privacy vulnerabilities.
Transferring Groups to Virtual Groups
It took the COVID crisis for most doctors to take up virtual SMAs. Sumego says Cleveland Clinic started virtual SMAs more than a year ago, but most other groups operating SMAs were apparently not providing them virtually before COVID-19 started.
Dysinger says he tried virtual SMAs in 2017 but dropped them because the technology — using Zoom — was challenging at the time, and his staff and most patients were resistant. “Only 3 to 5 people were attending the virtual sessions, and the meetings took place in the evening, which was hard on the staff,” he says.
“When COVID-19 first appeared, our initial response was to try to keep the in-person group and add social distancing to it, but that wasn’t workable, so very quickly we shifted to Zoom meetings,” Dysinger says. “We had experience with Zoom already, and the Zoom technology had improved and was easier to use. COVID-19 forced it all forward.”
Are V-SMAs effective? While there have been many studies showing the effectiveness of in-person SMAs, there have been very few on V-SMAs. One 2018 study of obesity patients found that those attending in-person SMAs lost somewhat more weight than those in V-SMAs. 
As with telemedicine, some patients have trouble with the technology of V-SMAs. Dysinger says 5% to 10% of his SMA patients don’t make the switch over to V-SMAs — mainly due to problems in adapting to the technology — but the rest are happy. “We’re averaging 10 people per meeting, and as many as 20,” he says.
Getting Comfortable With Group Visits
Dealing with group visits takes a very different mindset than what doctors normally have, Wheeler says. “It took me 6 to 8 months to feel comfortable enough with group sessions to do them myself,” she recalls. “This was a very different way to practice compared to the one-on-one care I was trained to give patients. Others may find the transition easier, though.”
“Doctors are used to being in control of the patient visit, but the exchange in a group visit is more fluid,” Wheeler says. “Patients offer their own opinions, and this sends the discussion off on a tangent that is often quite useful. As doctors, we have to learn when to let these tangents continue, and know when the discussion might have to be brought back to the theme at hand. Often it’s better not to intercede.”
Do doctors need training to conduct SMAs? Patients in group visits reported worse communication with physicians than those in individual visits, according to a 2014 study. The authors surmised that the doctors needed to learn how to talk to groups and suggested that they get some training.
Will V-SMAs Have Staying Power Post-COVID?
Once the COVID-19 crisis is over, Medicare is scheduled to no longer provide the same level of reimbursement for virtual sessions as for real sessions. Mirsky anticipates a great deal of resistance to this change from thousands of physicians and patients who have become comfortable with telehealth, including virtual SMAs.
Dysinger thinks V-SMAs will continue. “When COVID-19 clears and we can go back to in-person groups, we expect to keep some virtual groups,” he says. “People have already come to accept and value virtual groups.”
Wheeler sees virtual groups playing an essential role post-COVID, when practices have to get back up to speed. “Virtual group visits could make it easier to deal with a large backlog of patients who couldn’t be seen up until now,” she says. “And virtual groups will be the only way to see patients who are still reluctant to meet in a group.”
Leigh Page is a Chicago-based freelance writer.
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