It was a sense of mission, a desire to help people that led the young George Guthrie to set his sites on medical school. In
fact, he and his two brothers were following in their father's
footsteps as, each in their turn, chose to become physicians. Their
father's worthy example along with their faith propelled each along a
similar path. Profoundly touched by his sister, who died of cystic
fibrosis at age six years of age, George entered medical school with
"the goal of helping people." In 1981 he earned his Doctor of Medicine
at Loma Linda University in California and completed his Master
of Public Health in 1993.
Dr. Guthrie's awareness about the
importance of lifestyle and health relates back to his teenage struggle
with weight and the impact of lifestyle choices. His passion for
lifestyle medicine emerged while working at a Mission Clinic on the
island of Guam. He recalls one patient in particular who refused
standard medical treatment yet was willing and able to make significant
lifestyle changes. Dr. Guthrie was amazed at the business man's
resulting improvement in weight, blood sugars, blood pressure and
lipids. The presenting diseases were apparently gone in only one
year. Witnessing that patient's efforts and success was a turning
point for him as a physician.
"Chronic
disease can only be effectively dealt with by addressing the underlying
lifestyle causes," he says. "The challenge is that doctors are used to
being 'in charge' when in truth the individual patient needs to take
responsibility. What we have to offer is simply 'grace,' i.e. education
and coaching regarding lifestyle management of their own disease.
Patients can, if willing to take charge of their health, even reverse
disease."
In May 2007 Dr. Guthrie was hired by Florida
Hospital Family Medicine Residency to focus on teaching Lifestyle
Medicine as a component of their medical program. Tandem with the
education of medical residents is the importance of modeling lifestyle
medicine care in the hospital. Therefore he is involved in expanding
the availability of lifestyle intervention in the acute care hospital
setting.
Dr. Guthrie currently utilizes the DIGMA model in helping patients with Diabetes at the Florida Hospital Family Medicine Residency.
(DIGMA = Drop-In Group Medical Appointment; see feature story in the March, 2009 issue.) "Medical
Practitioners tend to think that Lifestyle Medicine cannot be done in
the office because no one pays for it," says Dr. Guthrie, "but that is
not true." Payment is not the real limitation. It is really people's
willingness and readiness to change that is the biggest barrier to LM."
He feels strongly that "Physicians need to have a relationship with
their patients; often it's in a crisis that a willingness to
change surfaces."
Integral to his understanding of both the
value and the details of group medical appointments was Dr. Guthrie's
and his wife's experience with the Coronary Heart Improvement Project
(CHIP). "We experienced the power of group process in bringing about
change. Many participants adopted most of the recommended behaviors;
all considered themselves to be better off."
Also key to his
work was an invitation to Lifestyle Center of America back in 2001.
Data demonstrating the amazing progress of patients even one year after
participating in their programs, was inspiring. Dr. Guthrie then
developed his own medical office based program for Diabetes appropriate
lifestyle change utilizing the Lifestyle Center of America educational
videos designed for a group process in making lifestyle changes.
"Diabetes is the flagship disease for chronic lifestyle disease," says Dr. Guthrie. "It has more,
more medications required than many other diagnoses and, sadly, more
complications." This makes it an ideal disease for intensive Lifestyle
intervention. And when dramatic lifestyle changes are made the
improvements are very encouraging to both patient and physician.
Team Approach
Patients
interested in being seen as part of the DIGMA are invited to view an
introductory DVD provided by the Lifestyle Center of America that they
can watch at home or in a "Free Informational" visit. Once they sign up
for a DIGMA appointment they are asked to commit to the full 2 months
of the program.
A "nurse" takes vital signs--BP, pulse, weight, and a record of
blood sugars of the previous 48 hours. A "medical recorder" enters
appropriate records. EMR templates streamline documentation of
medications, ROS, and other items. An optional "behaviorist" handles
the psycho/social and behavior change needs of the group when the
caregiver is doing medical records.
The Group Process
Groups
meet 2hr/2x's week for 2 months; 13-20 participants in a group.
Special HIPAA Confidentiality forms are signed by each person in the
group -- each one promising to not share information outside of the
session.Viewing of Video: While viewing an
educational video, patient data is entered into the EMR system.
Medical records can be kept on paper forms designed for the process as
well. A Question and Answer session generally lasts 3-10 minutes as issues from the video program are clarified for the participants.
Recommendations for individuals, prescription writing, and the encouragement of positive behaviors are done as appropriate.
Dr.
Guthrie finds that 90% of patients really like the group visit process.
He finds it to be cost-efficient as well as an enjoyable way to do
healthcare. Many large health care systems are implementing variations
of this model of healthcare.
Billing
Dr.
Guthrie highlights clarification from the Centers for Medicare and
Medicaid Services (CMS), as noted on Medline, regarding billing for
patients seen in a group visit:
"...under existing CPT codes
and Medicare rules, a physician could furnish a medically necessary
face-toface E/M service (e.g., CPT code 99213 or similar code depending
on the level of complexity) to a particular patient that is observed by
other patients. From a payment perspective, there is no prohibition on
group members observing while a physician provides a service to another
beneficiary."
The Medline statement continues: "CMS goes
on to explain that Medicare will not pay for the observation of any
services or for any subsequent group counseling or discussion of the
observed services. Also, the services provided to the group should not
influence the level of history, exam and counseling, instruction or
medical decision making used to determine the E/M code for the
individual patient service. In other words, medically necessary
services provided directly to the patient during a group medical visit
are reimbursable and should be reported with the office or other
outpatient CPT code that reflects the level of service provided."
As outlined above, Dr. Guthrie is clear that billing must be as an "individual
visit in group setting," not billed or spoken of as a "group visit."
This is important for billing purposes because it is indeed the reality
of what is taking place: personal disease issues are being addressed
individually while others witness and benefit from the scope of
education, clarification, and support that invariably happens among the
individuals collectively.
Proper medical records and
transparency to insurance companies is essential for any viable
practice and of utmost importance to Dr. Guthrie. "I believe that I am
doing what is ethically appropriate for my practice with diabetic
patients. It is essential to be able to justify one's process, not only
for insurance and other professionals, but for one self.
relevant, valuable and viable for both patient and physician is the
goal. For many, the DIGMA model offers all of that, and more. 