The community cure in integrative medicine

Photo Cred: Dylan Gillis/Unsplash

By Katherine Shagoury, Katherine Shagoury

There needs to be a stronger emphasis on community in healthcare, according to James Maskell, author of The Community Cure: Transforming Health Outcomes Together. Maskell said he believes group visits will change the trajectory of medicine, bringing integrative and functional care to the general public. The ripple effect of ready care access will result in prevention of lifestyle-related chronic disease, he said.

We sat down with Maskell to talk about community in medicine, group visits, and how support and empowerment can change the delivery of integrative healthcare and make it a feasible model for practitioners and patients.

Integrative Practitioner: What is the “community cure” as it pertains to the integrative healthcare community?

Maskell: The message that we really want to get across is that as long as we keep doing things the way we are, we will never get to the people who really need care the most, and that is poor people. And, ultimately, delivering functional medicine in groups is a lot more effective if you’re trying to change behavior. Historically, we’ve done integrative and functional medicine one-on-one because that’s the hangover of how medicine has always been done. We have a strong focus in the western medicine on privacy, and that drives everything. But if you look at something like Alcoholics Anonymous, what do alcoholics need? They need empowerment and support. They don’t need drugs and doctors. Ultimately, what we’re arguing is that lifestyle-driven chronic disease is more like alcoholism than having an infection. Therefore, we should look at the power of the group dynamic to inform how care should be delivered.

I’ve been fascinated with group visits since 2013. In 2015, I presented on community and group visits, and that really triggered my interest in group visits as a sort of way to make the delivery of functional medicine more cost effective and affordable, and able to do it on insurance. Last year, I went to the Cleveland Clinic Center of Functional Medicine and saw how they were doing it and heard some of the preliminary data. I knew this was going to change the world.

Integrative Practitioner: You’ve chosen to focus on communities in need. Why did you choose to emphasize that with this group structure?  

Maskell: If you look at all the practitioners in our community, and if you look at who’s getting integrative or functional medicine, it’s mainly the richest 30 percent of people in America. When I started researching this topic, and I started hearing from practitioners who are doing integrative and functional medicine in a group format, it was totally transformative to the communities of people it was serving. This was serving groups of, for example, uninsured immigrants. Suddenly, they were getting integrative care, and because their health level was quite low, when you infuse them with integrative medicine, the results are even more transformative. Then, when you put it in a group, you are solving the key social determinants of health.

One of the things that appealed to me about it is that, if you ask a functional medicine doctor to explain what they do, they’ll tell you they’re a root cause doctor. And yet, here is loneliness, showing us the most important root cause of all, and no one has a plan for treating it. If you treat loneliness by forming a group, and then you infuse that group with the principles of integrative and functional medicine, now you have a legitimate way, a new standard of care.

Ultimately, I think many practitioners are frustrated that we’re kind of playing around the edges of medicine. Cost and profitability are major challenges. However, group visits are very profitable because you can bill several peoples’ insurance for one visit. When I started to understand the implications of what it would mean to do this at a scale in groups, I realized that it solved a half-dozen of the biggest problems in healthcare simultaneously, and so I knew we need to really focus in on this.

Integrative Practitioner: What does a group visit look like in practice?

Maskell: it ranges depending on the different group in question, but ultimately, it’s about getting a group of people together and sitting in a circle and talking through different issues. There’s typically an education element or presentation. It’s much more effective because you’re educating a group at a time. Part of the visit is going to be didactic, but the biggest part, the most important part, is when you’re learning from each other. People interact with each other, sharing their experiences.

Chronic disease can be very isolating for patients. When it comes to behavior change, seeing other people who have had the same condition and experienced the change you are looking for is more impactful than being told that you have the potential to make change by a practitioner. It’s living proof that it is possible to change health outcomes. When I realized that, I started to understand that we’ve been doing everyone a disservice by hoping they would make behavior changes that we told them to do in isolation. That was a big a-ha moment for me.

Integrative Practitioner: What are some of the challenges that practitioners might experience with group visits?

Maskell: You have to have enough volume to recruit people into a group to make it work. The minimum number you probably need for a group to really have cohesion is about six people, with the maximum about 25. For an individual practitioner or private practice, recruiting 25 people into a group that can meet at the same time is tricky. Most groups start because of a sort of resource constraint. Many people want a service and there’s not enough time, so you need to consistently push people towards the group option. Finding space can also be an issue. For some practitioners, they leverage their waiting room and reception in their practice and make good use out of that. Lastly, the biggest concern that practitioners and patients have is privacy. There are waivers that patents can sign so they know that they’re going to be in a group environment. Some people have concerns about documentation, but patients can fill in most of their self-notes, making administration a lot easier.

Integrative Practitioner: How do you see practices starting to implement group visits in their own practice?

Maskell: The exciting thing is there’s a lot of different ways to implement them. For practitioners in private practice, a lot of times they’re using groups to deal with the inefficient task of running their day-to-day practice. Some practitioners are using it to do the intaking altogether. Rather than doing a 90-minute intake with every patient individually, they may do a 90-minute intake with a group of ten patients together, who are filling in their own timeline and are having a communal experience starting this journey together.

There are some doctors that are using group visits to do lab reviews, rather than having one lab review per patient, The majority of the information shared in a typical lab review is the same for everyone, and explaining what the ranges mean and what the numbers mean is beneficial in a group setting.

There are also some practitioners who do individualized care at the beginning, then get people into a group so that they can continue to adopt healthy behaviors that they’ve been taught in the one-on-one care setting. The group is designed to have ongoing support.

For some practitioners, group visits are an affordable entry-point into their private practice. Instead of paying $300 for one visit, they pay $300 for an eight or 10-week program, and then those patients who want to continue with one-on-one care have the option to do so. Groups can also be a good marketing tool.

The amazing thing about group visits is they allow the mainstream adoption of integrative and functional medicine into health systems. Some practitioners that work inside the system haven’t been able to do the kind of medicine they love because they have short visits and patient quotas. Group visits offer a solution that they can sell to those higher up in their organization and bring integrative and functional medicine to those who haven’t had access before.

I really want to show my fellow practitioners what’s possible with group visits, and over the next decade deliver integrative and functional medicine at a reasonable scale so that it can impact health creation, so it’s not just a thing a select few can afford.

Integrative Practitioner: What do you see is the future of community in medicine?

Maskell: The future, I think, is there’ll be a recognition that the group is the best way to deliver integrative and functional medicine for lifestyle-related chronic disease. That will take time to come into the health system, but I would say that when results and success stories are released to the public, people will stand up and understand that this is pretty powerful.

The most exciting models of delivery for group medicine are not inside the models at all. It’s just groups of people getting together to prevent their own disease. When we look at the potential, it makes sense to kick this off inside medicine, because unhealthy, lonely people end up in the medical system. The potential of this movement is really to stop people from coming into the system by executing groups in society and solving loneliness not in the medical system, but outside, as really where loneliness and, in turn, disease starts. 

Editor’s note: This interview has been edited and condensed.