America is getting older. The number of Americans age 65 or more rose by 15% between 2000 and 2010 and is predicted to rise by 36% by 2020.[1] The US Census forecasts that the number of older Americans will double in the twenty years between 2000 and 2020, from 35million in 2000 to 55million, and will double again in the ten years after 2020, to 72.1million in 2030.[1]
And Americans are not just aging – they are increasingly suffering from chronic medical conditions, many of them related to obesity.[2]
Just as America is getting older and sicker, it is facing a shortage of doctors due to the confluence of several factors – some demographic, some financial. Large numbers of Baby Boom-generation doctors are turning 65 and starting to retire. Steps taken years ago to cut federal spending and reduce healthcare expenditures are coming home to roost; in 1997 Congress capped the number of federally financed residencies under the Balanced Budget Act, an action that will cause a shortage of medical residencies by 2016.[3] Private and public payers are intensifying their response to market pressures and the incentives created by the 2010 Affordable Care Act to reduce the cost of healthcare.
The Association of American Medical Colleges predicts that this divergence of population trends and funding will result in a shortage of more than 62,900 physicians by 2015, 91,000 by 2020, and 130,000 by 2025.[4] The shortages will be in both primary and specialty care: by 2020 the nation will have 45,000 fewer PCPs and 46,000 fewer specialists and surgeons than it needs.[4]
This looming doctor shortage is especially problematic given that the 2010 Affordable Care Act (ACA) expanded the number of Americans of all ages who will be seeking care – the newly insured, those whose insurance now covers the expanded array of ACA-mandated benefits, and the large numbers who will enroll in Medicaid/CHIP as the ACA expands coverage.
How will America meet its future medical needs?
The answer to this question is going to involve a re-design of large parts of the healthcare system – including the definition of “seeing the doctor”.
One promising re-design has been in use only sporadically since the 1990s but has been picking up steam in the last few years. This model goes by several names, but it is most commonly called a group visit or a Shared Medical Appointment (SMA).
This re-design offers physicians the chance to improve their productivity by a factor of as much as two to three[5] while offering patients improved access to providers and better health outcomes.[6] Experience to date shows that SMAs are especially effective in providing on-going care to patients who have either disease or condition specific needs or who have multiple chronic conditions.[6]
What is a Shared Medical Appointments (SMA)?
While implementation varies across clinical settings according to the available provider resources and the needs of different patient populations, the model is generally defined as multiple patients being seen as a group by a multi-disciplinary medical care team for follow-up or routine care. [6] [7] The SMA supplements the traditional physician-patient appointment – it does not replace it.
How is a Shared Medical Appointment structured?
SMAs provide individual evaluation and disease management for each patient at the same time that it provides counseling to the patient within a group setting.
An SMA is a most frequently structured as a regularly scheduled meeting of between 8 to 20 patients who are living with the same condition or disease who meet with a multi-disciplinary team of healthcare providers who have expertise in that disease or condition. Each SMA generally lasts between 90 minutes and two hours. Family members and caregivers may attend with the patient.
While each SMA is structured differently depending upon site-specific resources and patient needs, meetings start with patients registering at the meeting site at which time a member of the SMA care team conducts relevant medical evaluations e.g., checks blood pressure, weight, blood sugar levels.
Once the patient group is assembled in the meeting room, a member of the care team, usually a behavioral health specialist, leads an educational discussion session with the patients, sharing information that is relevant to their situation.
After the educational component, the discussion then opens up to allow the patients the opportunity to express their specific concerns, to ask questions, and to share advice and experiences about coping with daily care management.
While these discussions are going on, the physician and other members of the care team bring patients into private examination rooms for one-on-one care. Since all members of the care team are present at the SMA, each one is available to provide care to each patient, to consult with other team members, and to coordinate care.
Following the meeting, the care team meets to debrief and to begin planning for the next SMA. Attendance at the SMA is recorded in each patient’s medical records in accordance with payer guidelines and billing follows standard medical and behavioral standards.
For which patients is an SMA most appropriate?
More than two decades of experience with SMAs has found that they are most appropriate for patients who are living with chronic conditions and diseases and for whom education, self-management and problem-solving skills are essential.[8] SMAs are currently used to address diabetes, asthma, ulcerative colitis, MS, cancer, HIV, menopause, insomnia and stress.[6]
SMAs are not appropriate for most medical procedures, initial evaluations, one-time consultations, treating acute or infectious illnesses, or for a rapidly changing medical condition.[8]
Who is on an SMA care team?
The core of an SMA team consists of a Medical Clinician (MD, RN, or NP), a Behavioral Health Provider (MD, psychologist, social worker, registered dietician,
medical educator, or an RN or NP), and support staff (nurses, medical students and assistants, a medical transcriber, and administrative support personnel). The consistency of this care team, their expertise in the specific illness or condition, and their commitment to the workflow flexibility that the SMA model requires is crucial for its success.[9]
What are the benefits of the SMAs?
While many factors impact the success of the SMA model, a significant body of research done over the past two decades has found that SMAs can be beneficial to patients as they:[6] [9]
-Provide one-visit access to multiple areas of expertise, shortening wait times and increasing access to care
-Provide peer support and build social networks necessary for disease management
-Reduce use of emergency rooms and outpatient facilities
-Improve quality of life
-Reduce feelings of shame and loneliness
-Result in increased satisfaction with their care
There are also significant benefits for staff, including:[9] [10]
-The behavioral health experts can elicit information from patients that the physician may not be able to access in a traditional office visit
-Are a more efficient and less stressful use of available staff resources
-Creating a strong sense of teamwork, camaraderie and a supportive work environment which leads to improved staff satisfaction
-Increases appreciation across disciplines for the work of team members
-Enhances the rewards of seeing patient outcomes improve.
What are the limitations for SMAs?
Many providers, especially those in individual or small practices, do not have either the staff or the office space to implement the model. While it is possible to hold an SMA outside of regular office hours to accommodate space limitations, an individual
primary care doctor or a small group practice is not likely to have on staff a mental health specialist, or clinical staff whose training makes them effective moderators, or the range of specialists required to run the SMAs.
Which providers are using the SMA model?
Given the staffing requirements of the SMA model, implementation of SMAs has been, for the most part, limited to large organizations such as Harvard-Vanguard, Kaiser Permanente, the Mayo Clinic and the Cleveland Clinic.[6] [11]
The Veterans Administration has been using SMAs since 2005 when it mandated their use as a way to improve the quality of care, reduce wait times, minimize costs and improve health outcomes.[9]
The Benefits of a “Medical Group Hug”
While the reasons why the SMA leads to greater efficiency for providers are fairly easy to see, the reasons why it leads to better health outcomes, especially for those patients who attend consistently, are less obvious.
Some providers who have experience with SMAs have found that patients are more open about the social, emotional, and psychological factors that impact their ability to follow their care plans in a group setting than they are in a traditional office visit. [10]
Some researchers think that the group setting – in essence, a medical “group hug” –allows patients to see that they are not alone in their struggle, to share advice and support, to find hope and, ultimately, better health outcomes.[10]
Here to stay
The combined pressure of the growing numbers of Americans who will be living longer and who will be suffering from a chronic disease or condition, the pressure to reduce healthcare expenditures from both the private sector and the ACA, and the influx of people into the healthcare system as they acquire public or private health insurance, means that the SMA model is likely to be adopted by an increasing number of providers and healthcare systems. These factors will continue to drive the healthcare system toward greater efficiency and value – the SMA has proven that it can deliver both.
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[1] https://www.aoa.gov/Aging_Statistics/Profile/2011/4.aspx
[2] https://www.cdc.gov/obesity/data/adult.html
[3] https://www.aamc.org/advocacy/campaigns_and_coalitions/fixdocshortage/
[4] https://www.aamc.org/download/153160/data/physician_shortages_to_worsen_without_increases_in_residency_tr.pdf
[6] https://www.massgeneral.org/stoecklecenter/assets/pdf/group_visit_guide.pdf
[7] https://www.aafp.org/about/policies/all/shared-medical.html
[8] https://www.clinicalmicrosystem.org/assets/toolkits/shared_medical_appointments/smasection1.pdf
[9] https://www.queri.research.va.gov/tools/diabetes/shared-med-appt.pdf
[10] https://www.managedcaremag.com/archives/0305/0305.sharedappointments.html
[11] https://www.mayoclinic.org/search/search-results?q=shared%20medical%20appointments