Group Visit Series Part 6: Lab Review In A Group

Welcome to the Evolution of Medicine podcast! In this episode, we talk with Christopher Mote, DO, DC, IFMCP, a practicing physician and owner of Cornerstone Health Community in Centennial, CO. Dr. Mote has not only mastered the art of group visits in his practice, but also lab reviews in those group health appointments. He finds great joy in teaching and learning more about his patients and their health struggles in this setting, and he shares some great insight into how you too can find both personal and professional fulfillment with group visits.

In this motivational 30-minute episode, Dr. Mote discusses his innovative practice model that blends functional medicine and primary care, how he uses lab testing, and how he makes functional medicine affordable and accessible for his patients. If you’re thinking about implementing group visits in your practice, but don’t know where start, this is the episode for you. You’ll feel a new level of motivation and confidence to pursue this innovative model for patient care. Highlights include:

• How to blend functional medicine and primary care in practice
• Focusing on practice efficiency and avoiding burnout
• Implementing the Group Visit Toolkit and other resources to run successful group visits
• How to share lab results in a group format
• How to effectively recruit patients for group visits
• Insurance considerations for group visits
• And so much more!

Resources mentioned in this podcast:
goevomed.com/LMRC
goevomed.com/gvt
www.cornerstonehealthcommunity.com

James Maskell: Welcome to the Evolution of Medicine podcast, the place health professionals come to hear from innovators and agitators leading the charge. We cover the latest clinical breakthroughs and health technology as well as practical tools to help you transform your practice and the health of your community. This podcast is brought to you by the Lifestyle Matrix Resource Center, who provides a range of options to help you deliver successful, effective, functional and integrative medicine. To find out more and to get started, go to goevomed.com/LMRC, that’s goevomed.com/LMRC.

Hello and welcome to the podcast! This week, we continue our Group Visit Series and this week we talk with Dr. Christopher Mote. He is a physician, he has been practicing for decades, practicing functional medicine and has one of the most innovative practice models that we’ve ever seen. In this podcast, we talk about that model, how he blends functional medicine and primary care, makes it affordable and accessible to different people, no matter what kind of care they’re looking for. And in this podcast, we’re going to talk specifically about how he goes about using lab testing, and specifically doing lab testing and sharing lab results in a group format.

If you’d be wondering ways about how to use groups or just looking at a way that it could work in your practice, I think you’ll get a lot out of this session today. Tons of tips on how to run an efficient practice from one of the most innovative clinicians in the space. I think you’ll really enjoy it. Enjoy!

So, a warm welcome to the podcast, Dr. Christopher Mote; welcome, Doc.

Dr. Mote: It is a true pleasure to be with you, James. Thank you.

James Maskell: So great to have you here on the podcast. This has been such an incredible series that we’ve done on group visits and I’ve heard you speak about the work that you’re doing in groups. I’m super excited to just share with our audience just some of the sort of cutting-edge structures that you’ve put in place to make functional medicine affordable and accessible. But let’s just, I guess, start at the beginning. I know that you have a, the name of your practice is Cornerstone Health Community, I love that name. What led you to come up with that name and how does that name transfer into the kind of care that you deliver?

Dr. Mote: Yeah. For me, James, it started about 20 years ago when I was a chiropractor. My mentor helped me to understand functional medicine at its core and he said this can and should be the standard of care. And that’s when I first got the notion that the current medical model has become obsolete and we really need to change it. So everything we’ve done in this practice has been to try develop a model that could be a forerunner or something to advance the profession, one that would make functional medicine the standard of care in our country. So as you like to say, to disrupt the way of medicine.

And so what we’ve done is we’ve blended primary care and functional medicine, we take insurance but we collect additional revenues. And then we also make extensive use as you said, of group health visits. And that is the backbone of our clinic, Cornerstone Health Community, because we know that people who have poor health, those who need to transform their chronic illness into ideal health, they need to do so not in isolation but in a tribe. And so, we pull them in sometimes reluctantly, but by the time they’re done, they’re full-fledged members of our community and advancing their health and pulling together with others.

James Maskell: Beautiful. So just give us an example. Obviously you have as a certified functional medicine doctor, you probably get patients who come in who have been everywhere and are really chronically ill, and you probably have also patients that just come to you through their health plan if you take insurance. So do you want to just give us sort of an idea of the patient flow arc for each of those two different cases?

Dr. Mote: Yeah, sure. So if we’re going to be a model practice that others could look at, we needed to both accommodate the patients who are happy with their health and just need an annual wellness visit or the occasional sick visit. So in our practice they could call up even as a new patient, and get right onto the schedule and see our physician assistant for all primary care needs. We will simply bill the insurance as any other practice would and they’re back out the door.

But what our real forte is, is transforming health. And so for that, when a patient identifies on the phone that they are looking for health transformation or they’re looking for functional medicine, we would pull them into a free one-hour orientation. In fact, they are required to come to the orientation before they can schedule with me. And at the orientation, I’ll be very detailed in terms of setting expectations for how we practice functional medicine, what they might expect in terms of out-of-pocket costs and then how we utilize group health visits. And so we set as many expectations of that visit as possible and when they’re done, those who are excited and that’s the vast majority of them, will schedule their first appointment with me.

Once they have that, we have two appointments that are necessary in order to build their plan. The first one is a initial intake visit. It’s only 40 minutes in length. We utilize something called the LivingMatrix extensively to get the health history or their health story, and at that visit we can efficiently extract the information we need. At the second visit, I sit them down in our conference room and I present them with a written plan of care and further testing. That is the functional testing they’re going to need as well as an estimate of the office visits, what insurance will pay, what they would have out-of-pocket, even right down to how much they might spend on supplements over the course of their plan.

And we give them the opportunity at that second visit to go ahead and sign their plan and get started. And if they do that, then we would begin by handing them test kits for stool, digestive cases or hormones for…saliva testing for hormone cases, et cetera. And as they get their results back, they’ve been told on two or three occasions that they will get their test results at a group health visit. And that’s where we really start to pull them in, because we can have 90-minute discussions around hormones and stress and sleep at one class and give people their test results and their individualized treatment plans, and bill insurance for a 15-minute office visit for each of the people that are there.

And then they can come a week later and get their stool test results and hear about their digestive concerns and have an individualized treatment plan again at a 90-minute class talking about leaky gut, talking about SIBO, whatever the topics are that we need to discuss for that class. And then again, billing everybody’s insurance for a 15-minute office visit. I’ve had two patients out of about a thousand in the last three years who have ever said, “I don’t want to do that again, Dr Mote.” It has been universally popular amongst patients.

James Maskell: Yeah. How do you sell patients into wanting to do it and obviously once they’ve done it, I mean, my experience is similar as that once people do it, they’re like, “Oh, this is great.” But it’s not normal at this point for people. So how do you sort of recruit effectively into these groups?

Dr. Mote: Sure. Well, James, I have to say that we did an orientation for all of our prospective new functional medicine patients out of necessity, because there was so many times in our program where people were not understanding how we do things and they were complaining and it was really bogging down the practice. So we started these orientations out of necessity to set expectations. But what it’s really become is an opportunity to really presale people on the idea that they’re going to come to a class to get their test results. That’s the first time they hear it.

At the second visit, when I lay out their treatment plan, they hear it again and it’s right there in writing, “You’re going to get your test results at a group health visit.” So it’s assumed. And when that test results come back, occasionally we’ll have people that balk. Most of the time they’ll come anyway. And like I said, only two have ever said, “I don’t want to do it again.” So it’s a very…it’s ingrained in our culture and if you want to be a part of what we’re doing here and you want our help, you’re going to have to fall into step to some degree.

James Maskell: Beautiful. Yeah, I love that. So one of the reasons why I wanted to share here today is how exactly you work with groups and lab results. Because I think that a lot of practitioners out there would love the idea of doing a group, but they just don’t know how to make it easy to take best advantage of the group. And typically lab interpretation is one of the things that I think really bogs down the delivery of functional medicine. And I know that you care, like I care, about how can we deliver this efficient enough for it to be the standard of care. And I think you’ve got some really incredible answers that have come out with the way that you’ve done it, so I’d love for you to share that with our audience.

Dr. Mote: Sure, sure. So, about every Thursday night at six o’clock we have our group health visits because it suits our office scheduling and seems to be good for patients, too. And two days prior, my staff will hand me test results if it’s a hormone class on Thursday nights, Tuesday night I’m looking at six, eight or maybe as many as 12 different hormone test results. And I have a template that I can pull up within each of the patients’ charts. And the template gives results and a summary and then even the product protocols and next steps, things we want them to change. And it takes me about 15 minutes, excuse me, maybe more like 10 minutes for each of the test results and I will populate their template and print it. I will then attach that to their test results. And when I’m done with my class notes, I’ll hand them to the staff and they will pull together products that are necessary to support the test results.

When all of the participants come into the class on Thursday night, my medical assistant stays late that evening and takes everybody’s vitals, seats them in the class, we collect copays, we get them situated within about 15 or 20 minutes. And then I start with a video that I’ve obtained through Lifestyle Matrix Resource Center that kicks off the notion of hormones and stress, that’s one class, and digestion in another class. So we’ll start with a four or five minute video while people are checking in. And then I begin, and really what happened for me was I created a set of slides based on the points that I was making with almost every patient. So again, I used to do these in individual one-on-one appointments. It’s probably the least efficient way to deliver healthcare and especially that which requires lifestyle change.

But then when I saw myself saying the same things time and time again, we simply made a set of PowerPoint slides around those points and now I make those same talking points in front of the group. So I say it once instead of 12 times a week. It’s a lot more enthusiastic when I deliver it and patients seem to receive it a lot better. At the end of the class, having gone through all the markers and answered questions, even discussing a bit about the products that they might be taking home with them, we encourage them to make sure they have a follow-up visit with me or with the other providers in our office so that they can follow up on what they’re starting. And then we send them out. It’s pretty much all done within 90 minutes and it’s probably some of the most fun I have, the most fun 90 minutes I have all week. It’s just a fantastic time.

James Maskell: Yeah. Could you go into that a little bit further? Because that’s another thing that I hear consistently, is that practitioners of all varieties who do the group visits really enjoy that part of their practice. And I know you said that on the Functional Forum recently. What is it that’s enjoyable about it and what do you think practitioners who don’t do it and we’re just doing it sort of one-on-one appointments, what are they missing out on by not running these kind of groups?

Dr. Mote: Yeah. Well, hey, even if you don’t like to speak publicly, these are not large groups and these are people who are known to you. So it’s really a very casual environment to be able to sit in, and people who are already there because they’re interested in what you’re about to share with them. So you have a captive audience who wants to hear what you have to say, they are people who are known to you. And if you’re like some of us who actually do like to get in front of others and to teach, this is the one chance I have to actually pretend and fulfill some of my dreams of being a high school teacher when I was younger. It’s a fantastic environment.

The questions are coming quickly. The discussions are lively and what was really, I didn’t anticipate is, that patients at some point not only are respectful, I haven’t really had any instances where patients took over the encounter, and I anticipated that but it’s never really happened. But there is sharing, there is sharing between each other. And so when I bring out a point you’ll have somebody else add to that and the entire group collection, the sum is greater than the individual parts. It’s amazing.

James Maskell: How much value is there? Like I could imagine if I’m doing a group and we’re all looking at the same labs, ultimately obviously the lab test might be the same, but people’s data is the same. How much value is in there to people learning from numbers that aren’t their own? Because it seems that like obviously that’s one of the things I think mentally holds back practitioners. They’re like, “Well, my work is so individual. There’s no way I could do it in a group.” But are there side benefits from other patients hearing about lab ranges or lab panels that aren’t theirs?

Dr. Mote: Yeah. Well, James, I’m really glad you brought that up. To get away from going marker by marker through the test results, because we do not do that and I explain that to patients. I say, “If you’re a linear learner and you hope I’m going to go through every marker in sequence, you’re going to be frustrated.” What we’ve done is we’ve taken the topics, the key points that I’m stressing.

So let’s say it’s a hormone class and I know I want to make sure I talk about the quality of sleep. There are three key things that really interfere with sleep, like low progesterone, altered melatonin and bedtime cortisol is too high. Well, I’m going to talk about sleep as a topic and then when I introduce those three hormone changes that can interfere with your sleep, everybody can hold up their test and say, “Oh yeah, I have cortisol that’s out of range and a melatonin that’s low.” So they’re looking at their own test results, but I’m speaking topically and covering the topic of sleep or low blood sugar or menopause. And so we’re not going through the markers one by one and they really don’t hear much that does not pertain to them.

James Maskell: Beautiful. Yeah, no, I can see that and I can see that that topic. So what is the range of, just on a practical level, what are the different classes that you hold, who teaches them and how often are they?

Dr. Mote: Sure. Well, it started with the hormone class based on a salivary hormone test that most of our patients would get. And I teach the class and we build a level two, one, three and nine, nine, two, one, three, which is a 15-minute office charge for everybody who attend. And by the way, many people have come back on subsequent testing, we don’t charge them. We let them sit in as alumni and they seem to appreciate that. Then we’ve got other classes based on digestion. We’ll run a stool test and again I teach that. We have a Core Restore Detox class that we obtained through [Ortho Molecular Products], and that is where patients get a two-week intensive detox. We provide the supplements and there’s a two hour class to kick that off. That is taught by my nutrition therapist. We don’t bill that one back to insurance, at least not yet.

We also have a PA who’s interested in cardiovascular, so she’ll be introducing a class on cardiovascular health and we will bill that to insurance because again, that’s a provider who’s spending their time teaching. And then we have a group of, a series of six classes, we call Next Level Health taught by our nutrition therapist and it was to address the need that we had amongst patients who could not afford an individualized plan for themselves, but we wanted to put in their hands the most powerful lifestyle change. Whether it was regarding eating habits, circadian rhythms, sleep, exercise. And so, we’ve got this series of classes that are just $25 for every two-hour class and those are taught by my nutrition therapist. We have others that we’ve talked about, but it really, it comes down to how many can we accommodate in our current practice, and so I think right now we’re topped out at about five.

James Maskell: Yes. Yeah. It’s really interesting you say that. I mean, one of the things that I thought of when you said that it’s just access to this kind of care. And I know that that’s a big thing for everyone in our space, thinking about how could we give access to functional medicine for people who aren’t going to pay out of pocket? What are your thoughts on that?

Dr. Mote: Yeah, group health visits are the way of the future. And for three reasons, real practical. For a physician, it’s additional revenue. You can say the same things to 12 patients and collect for 12 patient visits. And it frees up appointments on your schedule, it’s enjoyable time, it’s highly profitable, so it’s great for the physician. It’s also been very popular with patients because they get time with their physician. They’re learning complex ideas and able to assimilate them, ask questions, and it’s been truly transformative in their health. But perhaps one of the other reasons that’s beneficial is for the system, the delivery of medicine.

As I said earlier, there’s no more inefficient way to deliver medical care than to put one doctor and one patient in a room and to repeat that process repeatedly. It comes at great expense. If you can pull people together who have similar problems, groups who don’t sleep, those who have hormone concerns, those who have digestive problems, and you bring them together and you teach them principles and you do that in a group, you create a tribe for the patient so they don’t feel isolated. But that’s the most efficient way to make use of the limited resources in our medical system. You don’t have physician burnout because they’ve had to increase their schedule. You don’t have to completely tax the system, whether it’s private insurance or Medicare. And so I just don’t see that we’re ever going to meet the needs of a growing population if we don’t find more efficient ways to deliver it. And group health visit to me seems to hit on all of the key pain points.

James Maskell: Absolutely. And yeah, very well said. Well, what are your thoughts about which practitioners can do what, because I know you started your career as a chiropractor and now you’re a DO and practicing as a physician. So how do you get the right people in the right seats on the bus and what role does the chiropractor have in all of this?

Dr. Mote: Yeah. Well I’m really glad you brought that up because our model is one that divides the labor. We tell people in your initial orientation, we have a practice that could be one stop shop if that’s what you want. And I’d say 90% of our patients come here for all of their needs. We can do your primary care and bill your insurance. We can do functional medicine on the highest level. But which provider provides which service could be individualized by the practice.

So if you’re a physician practice that’s looking to bring functional medicine in, but it isn’t something that you can dive into as quickly as you would like, then that is the ideal role to bring in a chiropractor, naturopath or another allied professional who is already steeped in the understanding of functional medicine, and you let them do the functional medicine for the practice. And then you have other providers who specialize in primary care. I thought I could set up a practice where I would do all of that. I would recruit a few hundred patients and we would all grow old together and that was a complete failure.

There were too many patients demanding functional medicine and then wanting to stay in the practice. My schedule filled out two months and when somebody calls for a urinary tract infection, it doesn’t really sit well with them when they tell them they have to wait two months for their appointment. So you can divide the labor, but it doesn’t have to be the physician does the functional medicine. You could absolutely bring in a chiropractic physician to do the functional medicine and in collaboration with a supportive DO or MD, then you actually have a real winning team to deliver the full spectrum of care in the same office.

James Maskell: Yeah, that’s great. Obviously it takes a lead physician to pull that kind of team together. What does your team look like right now and where do you see it moving in the future?

Dr. Mote: Yeah, I’m the 10th employee that draws a salary. We have two medical assistants and my medical assistant as a scribe who stays in the room with me, which also lowers my stress greatly. I have currently one physician assistant and she’ll see 12 to 15 patients a day for primary care. I’ll see eight patients three days a week for functional medicine, and we’re already busting at the seams in terms of our capacity. We also have a nutrition therapist. We’re looking to actively expand, we’ve secured additional space. I believe we’ve identified another physician assistant to do the primary care. I’m looking for a physician MD or DO preferably, to join me in delivering the functional medicine because we are actively expanding and we’re starting our third year. I anticipate this to grow quite a bit.

James Maskell: Yeah, that’s great. So any practitioners listening or doctors listening, if you’re looking to work in a practice that is on the cutting edge of delivery of functional medicine, look no further than Cornerstone Health Community. Yeah, really, are there other things that you do in the practice that help with efficiency? Because ultimately efficiency obviously you identified as one of the key reasons why we want to do functional medicine. But I know that there’s technology, you already mentioned LivingMatrix. Are there things that you’ve done in the practice as you started to think through, “How can I do this in the most efficient way,” that have been really valuable that other people might benefit from?

Dr. Mote: Yeah. I can’t say enough James, about this orientation. It’s so critical to our practice that I don’t charge anybody for it, but I insist that they come or we won’t take them as a new patient. And that’s where the pushback can start sometimes. But again, in three years I have never, at three or four times a month, I have not once had a patient, perspective patient, come up to me at the end of it and say that was a waste of my time. And it’s the one thing that sets the stage for everything else we want to do with the patient, from the collection of some of our additional fees to the scheduling of the group health visits, to the timeframe. When I can set expectations for patients and reality lines up with those expectations, you have very happy patients and your staff is better served as a result of it. So the orientation is a very big deal.

We’ve been doing the LivingMatrix now and it’s what allows me to collect the health story from patients before their first visit. And it’s taken us from two and three hour first appointments to just 40 minutes, and we can get everything accomplished in a short window of time and stay within the insurance model of 40 minute appointments. And then because it is an intensive day and there’s a lot of transference of ideas and communication, I have to talk a lot. We have a scribe in the room with me who captures everything and makes that office visit note into something that’s billable to insurance. And I think those are three of the most important things that we’ve done that allow us to stay within the insurance framework and still do excellent care for our patients.

James Maskell: Yeah. I know one of the things that practitioners and doctors have told me about being in insurance, is that sometimes you could be questioned by the insurance company by what you’re doing because of the lengthy visits. What have you found to be able to steer clear of that?

Dr. Mote: Yeah. Well the group health visits has really helped me because if I’m seeing most of my patients for 40 minute visits and I’m billing it some of the highest level of E&M codes, and that would certainly put me on the radar screen with the insurance companies. I’ve actually gotten one letter in three years on that, largely because our group health visits are all billed at the nine, nine, two, one, three, and that certainly offsets and gives me a better average for my office visits and makes me look more typical on paper.

About the only time I take any flack anymore from insurance companies, and we just finished a re-credentialing and actually had all of our rates increased, so our reimbursement levels have gone up. But we do about twice a year, I’ll hear from some insurance company United, Blue Cross, and they’ll say, “Dr. Mote, you’re using a lot of out-of-network labs.” They send me a letter and they say, “We’d like you to work with one of our representatives to try to find in-network options.”

And usually is not the case. I work with them, they can’t find anything. They leave me alone for another year. So I really have not faced threats yet at least from the insurance environment. And eventually my hope is they’ll see that we have a low cost of care, we’re not referring to a lot of specialists. We prescribe almost no novel or expensive brand name drugs, and we run fewer tests, the more standard tests. And so, we truly have a lower cost of care, but the only thing we ever get beat up on is the out-of-network lab use that we have. And yet that has not stood in the way of us getting credentialed.

James Maskell: Beautiful. Yeah, I love that. Well, Doc, look, I really appreciate you coming on the podcast and sharing all of this with us and it’s been great to get to know you and see you lecture. And obviously, one of the things about this Group Visit Series has been able to showcase doctors and practitioners on the cutting edge of functional medicine delivery. Obviously you have in a certain way the attention of the functional medicine community in this podcast now. Is there anything that you feel like you’d like to share based on your experience about how we can all take this industry forward as a parting note?

Dr. Mote: Yeah. I really appreciate the opportunity. I want to say with conviction that we absolutely have the right mission. To take a patient’s health and to start with their environment, their circumstances and their habits is truly the most effective medicine that we have. I believe though we have to work carefully on our models. This is why I’m so supportive of what you’re doing, James. If we can work on our model and it better suits the patients, but at the same time keeps providers in the system.

Every year of Medscape does their position pole and primary care providers are bailing out and 48 to 50% of us are looking to leave the profession. So we need a model that actually allows for physicians to enjoy what they do, capture a nice income and provide the patients with the kind of care that they’re not going to get in the current model. And there are others like mine out there that are doing that and I really want to highlight them whenever we can and say, there’s a way out of this. There is a way to put functional medicine as the standard of care and I’m not going to quit until we do.

Listen, James, if there are any interested providers who would like to send us a CV, can I just tell them where they could send it?

James Maskell: Sure.

Dr. Mote: Sure. It’s info@cornerstonehealthcommunity.com, that’s info@cornerstonehealthcommunity.com and I’d be happy to call anybody back who thinks they might be interested. And I really appreciate the opportunity, James.

James Maskell: Wonderful. Well, look, thank you so much for being part of it. This has been part of our Group Visit Series, but there’s certainly a lot to unpack here about how you’re delivering the care. Obviously dealing with the major stumbling blocks in functional medicine is a huge piece and I hope that through this series and everything that comes on that, we’re able to get more and more physicians looking to use group visits in all different ways that it can. The group visits themselves, the introductory classes, just efficient delivery of care and getting these concepts out in a way that is good for the patients, good for the doctor, and good for the community itself.

So, if you want to know more about the group visits, you can go to goevomed.com/gvt and we have the Group Visit Toolkits. There is one there on stress that Dr. Saxena put on. But if this the first podcast you’ve heard in this series, you can go back. We’ve had five before and we’ll continue to have a few in the future. Dr. Mote, thank you so much for being part of the evolution of medicine. This has been part of our series here. I’m your host James Maskell and we’ll see you next time.

Thanks for listening to The Evolution of Medicine podcast. Please share this with colleagues who need to hear it. Thanks so much to our sponsors, the Lifestyle Matrix Resource Center; this podcast is really possible because of them. Please visit goevomed.com/LMRC to find out more about that clinical tools like the Group Visit Toolkit. That’s goevomed.com/LMRC. Thanks so much for listening and we’ll see you next time.