Welcome to the Evolution of Medicine podcast! This episode continues our series on group visits and the pioneers who are bringing this practice model to the masses. We sit down with Dr. Mikhail Kogan, integrative medicine leader at the George Washington Center in Washington, DC.

In this 45-minute episode, Mikhail Kogan shares his experience and incredible insight on running successful group visits, specifically focusing on shifting the mindset of big medical organizations and payers toward this powerful method of delivering medicine. Highlights include:

  • Challenges he faced with the insurance-based and cash-based models, and how he tackled them
  • What the ideal group visit space looks like
  • Tried-and-true strategies for recruiting patients to group appointments
  • How to create cohesiveness in your groups so patients want to participate ongoing
  • Why vulnerability and mindfulness are key components in a successful group visit, and how to encourage them in your groups
  • The potential for trauma resolution in group visits
  • And so much more!

Resources mentioned in this podcast:
www.functionalforum.com/podcast-group-visit-series-part-1-lessons-from-two-decades-of-group-visits/
www.goevomed.com/LMRC

James Maskell: Hello and welcome to the podcast. This week, we check in with Dr. Mikhail Kogan, integrative medicine leader in the George Washington Center in DC. He has been on the cutting edge of many things to do with integrative medicine and delivered an incredible insight on how to deliver group visits, best practices for recruiting patients, for doing the groups, for gelling the groups, and for convincing big medical organizations and payers that this is a powerful way of delivering medicine for some of the toughest chronic conditions. It was a really transformational 45 minutes. Enjoy.

James Maskell: So warm welcome to the podcast. Mikhail Kogan, welcome.

Mikhail Kogan: Thank you. I’m happy to be here.

James Maskell: So very excited to have you here on the podcast. We’re going to be talking all about group visits and some of the work that you’ve been doing on that end, but recently I read an article from John Weeks who’s a great chronicler of the industry, and he referred to you as the hardest-working man in integrative medicine. So I know that you’re involved in a lot of things to take toward the industry and the movement. So maybe we can just start there. What are some of the things that you’re involved with that most people will know about or might not know about?

Mikhail Kogan: Right. So I’ve been at the George Washington University for actually more than 10 years at this point. But five years ago, we also started a nonprofit called Aim Health Institute, which is designed to try to bridge this issue of underserved populations on Medicaid, not having access to integrative medicine. So we’ve been growing steadily for past couple of years, especially in the last 12 months, and a couple of years ago, I think two years ago, G.W. started Office of Integrative Medicine and Health as well as the program in integrative medicine, it’s an online curriculum and fellowship. So I’ve been involved in all those parts, and somehow through all of this, I also managed to write a book. Well, I didn’t write it, I edited it, called Integrative Geriatric Medicine, and it that was one of the Andrew Weil volumes for the Oxford University Press.

So I think that’s why John called me the hardest-working man because somehow I managed to get all this done while having two small kids and lots of hobbies like beekeeping and skiing and taking lots of leisurely walks with my dog and long-distance running. So somehow I managed to do all this.

James Maskell: It’s a great sort of Renaissance man it sounds like.

Mikhail Kogan: Well, I think I feel like we have to practice what we preach, and I think when you’re healthy and vibrant and you have all this energy, I think the energy can be spent on good projects, on family, and things one likes to do. So I feel like, knock on wood, that energy component in my life has been not diminishing despite mid-40s.

James Maskell: Yeah.

Mikhail Kogan: So I don’t know. I’m still waiting to hit that block.

James Maskell: That’s beautiful. Well, look, long may it continue. So yeah, obviously this series that we’re doing here is on group visits, and we’ve had a chance to interview some of the leading minds in the group visit world. And obviously it solves a lot of problems with behavior change and accessibility and obviously some of the things that you’re interested in. So maybe let’s just start at the beginning of that. What was sort of the initial impetus for the group visits, and the two things that I really want to focus on is how do other clinicians and other people around the country convince either their medical group to go in this direction, support it, and obviously you’ve got a lot of support there at GW, and then how do you actually do it in a way that has the potential to resolve chronic illness? And that’s where I’d like to focus on. So wherever you’d like to start on that journey.

Mikhail Kogan: Right. Right. So I think in 2014 when we started nonprofit it became pretty clear to me that the only practical way of delivering mass integrative medicine to masses is to somehow do it in a group format because not only is it not insurance-covered, things like acupuncture and massage, but even when they are covered by some insurance, the sort of payment structure is such that it’s really hard to make a living on that. However, if you put multiple people in the same room and you do the billing, insurance will cash and suddenly, you can lower the prices, and your income is significantly higher per unit of time. So I think in terms of logistics, it was obvious to me back then. And I’ve also been following, for us who work very closely and Jeff Geller and lots of other clinics, Cleveland Clinic, where the group visits have been run for quite some time.

So summer around the same time, we started running the groups. And very quickly became obvious that there was such a high demand both from university side and also from our own for-profit Center for Integrative Medicine and nonprofit that we started experimenting with different kind of sub-models. We tried insurance run, that didn’t go exceedingly well because there are a bunch of issues with copays. Then we tried a low cost, something like $30 a visit on a group, which we are still running. And now the most recent iteration is that we are now trying to secure very large Medicaid contract through the DC Department of Health and Finance to literally fund multiple groups for chronic pain and chronic conditions like depression, anxiety, insomnia, and others.

So that’s been kind of our evolution, and we, sort of through all this, we also managed to apply for a bunch of grants. We only got one. So we have an internal grant from Cancer Center at GW, which we finished a year ago, and we now just got accepted. To John Weeks’ journal, we just need to do a bunch of revisions, and that’s looking at our model for chronic insomnia. Unfortunately, we didn’t get our grant funded. So we wanted to compare our model to current cognitive behavioral therapy for chronic insomnia. They didn’t really…came close but we didn’t get the money. So we’re still probably going to continue trying to research this, but I think we’re now shifting more towards increasing the volume and really doing it through the insurance. And I think the further next steps is to start expanding conditions.

And I think our uniqueness is really we’re going to concentrate on a complex to treat problems. So I think there are a lot of great examples in the country where lots of primary care is delivered in groups, and I’ve seen some of your podcasts, James, where some people do functional medicine intact using this model. I think our model for now is going to specifically stay mostly with just taking pretty sick patients and trying to demonstrate cost savings back to the Medicaid going forward.

James Maskell: Yeah. Can you just go a little bit deeper into some of the problems that came up when you tried initially to do it on insurance, and then specifically with the cash? Because I know this is one of the biggest questions that comes up because we’ve had doctors in the past, for instance, that have done it on insurance and billed insurance. But then if people have a high deductible plan, it can come back to bite them with really high fees because they’re paying their whole thing, then on the cash model, I know obviously there’s not that many…any time you charge any cash, you might be stopping some people from coming in, especially if it’s like regular visits. So can you just go a little bit deeper into your learning there?

Mikhail Kogan: Yeah, yeah. Sure. So our initial iteration ran through the university. So we had our own GW University doing the billing through the standard biller, and our biller is within the division of geriatrics, that’s where I’m housed officially. And what we ran into very quickly is not only just the high copays but the fact that we didn’t want to collect the payments every visit. That would’ve complicated things during the running of the group. So suddenly patients were getting eight bills simultaneously from the billing department, and they were all sort of…well, some people were okay with this and they would simply pay, but the billing department also got all confused because suddenly they were seeing repetitive bills of the same magnitude. I was called several times to director of the billing department because they couldn’t figure out what the hell we were doing. I had to explain myself multiple times, and they kept pushing to me to start collecting copays. Where I would say, “Absolutely not. I’m not going to do this. It’s your job.”

So basically after back and forth, we couldn’t even really find an effective solution. And I think after one case where patient did get a massive amount, it was $50 per copay that was just what that person was paying. We did some math and like wait a second, we could bill full amount less than a copay and not being involved with the insurance. And that’s when I started realizing the whole thing with private insurance isn’t trying to screen them in our area to figure out which ones have low copays, which ones not, plus if somebody’s in a high deductible, they’re not going to get paid at all. So all of that’s going to go in their deductible, and suddenly instead of say $30 or $40 a session, they have a bill of $300 times eight or 10. That’s a lot of money. Yeah.

So that kind of, I think, after probably a year of doing this, we said that’s enough. And then we went to cash, and the cash sliding scale. So we take people for 10 sessions or eight to 10 sessions from anywhere from $300 total, up to $500-$600 if they can afford. So it depends on…so we have people who can afford sponsoring people who can’t. That’s the current cash model structure. And I think I misspoke. It’s not $30 a session. It’s $30 an hour because the sessions are about two hours. That’s how we round them. So a session will be around $50-$60 depending on what they end up paying or less.

And interestingly, actually suddenly we start hearing from our patients pretty decent reimbursements because they would submit that who would give them a full bill for each class. They submit that and we had occasional people get paid really well.

Now, we are in a unique environment. So downtown DC, there’s a lot of patients with pretty good insurance, including some international insurances, which pay 90% no matter what is done, including even some individual visits. So that’s probably not the same in lots of parts of the country. So nonetheless, I think asking patients to submit the bill is really valuable because some of them will get paid, and if they don’t, at least it goes into their deductible, and then they can also tax deduct it at the end of the year. So that’s the cash side.

The Medicaid side is very straightforward. So they pay, in our area, they pay $84 per visit for level three. So our model is that if we see at least eight patients, we’re going to make it sustainable. That’s our budget. So we need to generate about $600 per class to go forward, and that’s quite doable. We are struggling with a few parts. So part number one, retaining. So some patients will come up for a few classes, and then suddenly we’re starting with 10, now we have six. That’s probably universal everywhere. I think with time as community gets to know us better that dropout will decrease. We also do some quite interesting things, like we feed patients at every class. We learn how to be very budget-careful and buy food for a very low amount of money. And that seems to help. When we run any kind of studies obviously people not only get food, they also get transportation. So when we were doing our insomnia study, we had a very good retaining rate of over 85%.

James Maskell: Yeah. That’s really great. I think definitely people drop out, and I know there’s like life circumstances and other things that happen, and that is certainly something I’ve heard from other people. And the food is great. Is there something about the two-hour mark or is there something about the number of people that you found to be most effective? Like what does it take to get all that community?

Mikhail Kogan: Yeah. So I think less than two hours…you probably can stretch some classes less than two hours, but to fit in practical aspect, like teaching say specific meditative practice, let’s say relaxation, progressive relaxation, that will probably be half an hour just to do practice together. You need some check-in time, and then every class we have some education component. And that part is really hard to cut short. Sometimes we can, but I say less than 90 minutes is really difficult to run any class, especially given that you try to start on-time but people, there’s always late stragglers. So I think the two hours just over a period of couple of years evolved to be a rough appropriate timing. And I think when we start doing more pain curriculum, I think it may even get bigger, especially since we are planning on adding therapies to it. So like maybe a massage or acupuncture towards the end. So if that happens, then it could even more than that, it could be two-and-half hours. But the issue with that would be of course retaining people for that long, especially in the low-income communities. That’s going to be challenging.

What’s interesting in those communities, we have to do classes in the morning. Usually we run them at our own clinic at night, and that worked really well because (a) the space is not in use anyway, so there’s a lower overhead, and also it’s easier to get practitioners to come and put in time to do that. But it turns out for the low-income, that really doesn’t work. I mean, they’re often…if they’re unemployed, evening is time with the family and kids, and daytime is actually when they can participate. So we’re finding, and also interestingly, most of the clinics where we are…we’re in multiple different locations in the city, and that’s not as much as a problem as we expected. In one of the clinical Bread for the City, for example, we’re exploring multiple different possible locations inside the building where we can run it. I think that’s one absolute advantage of groups is that you really don’t need to have a medical space. You can run them pretty much in your, literally in your living room if you really want to. There’s no requirement, absolute requirements to have some absolute medical space.

James Maskell: Yeah. Let’s get into that a little bit further. So what have you found to be the most conducive spaces to have people get the best kind of results and also want to show up and those kinds of things? What works best, because I go to clinics and see places where, “Oh, this would be a great…” The front room, it’s not really used. The waiting area, the reception could be good. Sometimes people are using like another space inside the medical building that’s more designed for it. What have you found to be useful in terms of the kind of spaces that can house these visits?

Mikhail Kogan: Well, I think we’re limited by what we have, right? So downtown DC currently in our own clinical space, it’s just the front space of the clinic, and that worked just fine. I mean, it’s a good amount of space for about 10 people, and it’s cozy in comfortable chairs. There’s a little bit of space to get up and do a little movement. When we had to do yoga, we actually had to go to a studio. So we would tell the patients instead of coming to a standard place where we run all of them, we would take them elsewhere. Literally, we’ll take them to a classroom, either in a public health school or elsewhere. We haven’t found a problem. People tend to really once they in the class and they really like it, I think it doesn’t really matter. They’ll keep showing up. I think the bigger issue is that initial retention, and most of the dropouts so far, it’s really light. They have some competing events or somebody got sick or they get sick or something. So it’s not like people don’t really want to come to the classes. They really can’t because life’s happening around them.

I think from that side of things the easier the access to the space, the better it is. I think that running that in a medical facility in some ways would actually be worse. Like we tried to look into space at our own GW campus in the medical faculty associates, and they have some really nice space. And I’ve talked to one physician who actually runs dietary classes there, and she was complaining. It’s a maze of a big building, hard to find where you’re going, and if you try to do this after hours where a lot of doors are locked, that’s just the disaster waiting to happen.

So literally I think in the future, we may even consider running it in our own board of directors houses, literally. In my own house because some of the capacity to really have a flexibility of a space, ease of the parking right outside of the building. I mean, believe it or not, those things are actually very important, especially if the people coming frequently, say weekly for 10 weeks, it becomes quite essential that they don’t waste time parking and then walking 10 minutes, and then spending 10 minutes by the elevator. By the time it’s 15-20 minutes each way, that adds to another two hours, and then their entire evening is gone. So you really need to try to tease out how to do it more practically.

James Maskell: Yeah. Absolutely. So you said earlier that you really want to focus in on chronic illness and precision chronic illness.

Mikhail Kogan: Mm-hmm (affirmative).

James Maskell: I’m sure those are issues that cost a lot for the payers that you’re going after. So there’s like—

Mikhail Kogan: Exactly.

James Maskell: —there. What is it about those conditions that make you think that this is the directions to take your group visit work, and what’s your advice for other practitioners thinking about what kind of things to do?

Mikhail Kogan: Yeah. So I think you’re right. You just nailed it. For us, it’s about the payers. If we go into Medicaid, well, actually they’re coming to us in some way because they have no effective solutions. They know that. So they’re looking. They have all kinds of innovative approaches grants, and that’s what we’re trying to secure. I think for people who are really don’t have this direct access to insurers or any kind of payers, I think that’s quite different. I’m not sure that I’d be the best person to advise for that.

But for us, it was no-brainer. We actually when we discussed this with them, we asked them to come up with a list of issues and mental health and chronic pain, that’s the whole conversation was just around those topics. I do include insomnia in there just because we have such a solid randomized data on what we’ve done. So that I feel to demonstrate efficacy, that’s our best bet.

For chronic pain, believe it or not, there’s not that much evidence out there. I think there’s a lot of work and there’s a lot of need to publish more. But it’s not as easy to publish non-randomized trials, as you know, and then when we take those trials to people who make decisions, they don’t really value them the same way. So we were actually told recently, literally by head of the DC Department of Finance that they felt that overall there wasn’t sufficient amount of evidence, even though they’re going to grant us probably. But they didn’t want to start paying us immediately the standard rate.

And, again, our uniqueness is that instead of simply setting up the billing system and start billing for visits, we’re going to them and saying, “Look, we need you to know we’re doing this, and you need to know that we’re do this non-covered service. Yes, we cannot tell you and simply bill them. There’s going to be no issues. You’re going to pay us. But we want you to also not only being aware but also give us additional resources so that we can collect the data appropriately and work with you on demo projects, like basically we’re trying to look at the hospital readmissions rates as one of them.”

James Maskell: Yeah. Sure. Well, chronic pain is interesting because it seems like the most interesting data in integrative medicine is coming out for chronic pain is for like service-based delivery things, like chiropractic and acupuncture, rather than you can see things like type 2 diabetes and heart disease, which are more like diet-related and stress-related, could be better dealt with in a group environment. But I guess there must be a chronic stress component in all of these things.

Mikhail Kogan: Yeah. Absolutely. I mean, all of these conditions can be and probably should be delivered in groups. I think it’s our locale. Surprisingly, Medicaid doesn’t care as much about diabetes. Again, this is in 2019, right? So they’re facing political crisis with the opiate overdose and that’s what they’re driver to actually…there’s a massive waiver that D.C. Department of Behavioral Health just put out. So we try to get into the waiver. We missed the first line. Second wave of that waiver will be in 2021. So we’ll try to get in there. I think things are politically shifting. So chronic pain, especially with all the current publications and white papers of a needle, including non-pharmacological treatments. I think that conversation finally goes noticed by peers, which I think is really good.

James Maskell: Yeah. Beautiful. All right. Great. Well, just with regards to, again, you’ve got the group you, you convinced your group to do it, you’ve got the people in. What are your best tips to actually like then recruiting people into the groups? Because ultimately, when we’ve seen with cash groups, that’s been the hardest thing for a lot of our doctors who are maybe run a cash practice. They’re like, “How do I convince people that this is a good way?” I think people, once they get in there, they love it, and then they see the value of it. But this is quite foreign for people, especially if they have been used to a medical system that’s very focused on privacy. What’s been your tips for recruiting people into these groups?

Mikhail Kogan: Right. Right. That’s actually a lot easier than most people think. Because, especially if you’re in a cash practice, making groups is much easier I feel. In the insurance model, it’s actually harder. In the cash, you simply say, “Hey, I’m going to run this class, and by the way, the whole class is probably going to cost you as one or two visits, one-on-one. Would you like it?” And you’re going to have a lot more teaching and a lot more this and that. And yes, maybe I’m a good salesperson, so is my team—

James Maskell: I believe.

Mikhail Kogan: Yeah. We haven’t had a lot of problem there. It’s more about identifying the right patients to contact. That’s a little tricky because you probably want to have a really good…if your EMR allows you to pull out the data and say, “Look, how many patients with depression do I have? Now let me design the sort of the mass email and contact all of them.” That requires infrastructure in the system and identification process. I don’t have specific kind of “do it this way” advice, except I definitely have EMR ready to pull out the codes so you know how to contact directly.

I think contacting people individually works a lot better than kind of a shooting mass email saying we’re starting the class. That still gets a few people in when we advertise, but most people coming through each class are individual recruitments. Like they would come see me for a standard follow-up, and I say, “Oh, yeah. You have insomnia. Well, we covered this topic and that topic, but those 10 topics, or eight topics, whatever, you and I haven’t covered yet. By the way, we’re starting this class. Would you like to join?” I get to sort of see almost everybody agrees. Again, that’s cash.

Now for the non-cash for insurances, yeah. I mean, we’ve struggled. Even when we were recruiting for the study when everything was covered, there was no insurance billing whatsoever. We were paying people to get there, we were feeding them. That took a while. I think that’s not as easy. The advantage though once you’re in the community and the community gets to know you, and the community itself starts to really helping you. So I think Jeff Geller would be the best person to speak to that aspect because he’s been doing it for so long and he’s so successful. We’re just kind of beginning. So I don’t feel qualified.

James Maskell: Nice. All right. I get it. So you can listen to Dr. Geller’s interview at the beginning of this series, by the way, if you’re just catching this as the first in the series. So then how about the actual delivery of the care? You’ve got the group in, you’ve recruited them. It’s the first meeting. People are a little wary. They don’t know each other at this point. What are some clinical tips you have for gelling the community, creating a great first impression so that people want to come back and participate ongoing?

Mikhail Kogan: Right. So we’ve modeled some of the aspects in Jim Gordon’s work in Mind Body Medicine Center. So we’ve learned how to do certain ice breakers in the way that helps people to connect very quickly. You’re absolutely right the first one or two session are very important to create the cohesiveness. Interestingly, what we’ve been seeing regularly, (a) it’s very unusual to have a very unhealthy dynamic in the group. So I think we’ve only seen it once, and we were able to manage that after a couple of sessions. Somehow people just, they really like this very deep, mindful connection. When you give them the rules, when somebody speaks, you listen, and you listen with this kind of mindful intent. And once we teach them how to do that, there seems to be a not only uniformed acceptance but a very cohesive group formation. I would say by the third or fourth group, they meeting us, if they’ve been like knowing and knowing each other for 10 years. Like there’s suddenly this very close trust that builds. And the things that they share, I, after a first couple sessions, I just couldn’t believe it. I mean, people would share such a close intimate concerns, that frankly there were a few situations where I knew that it was my patient and the patient had not shared that with me. But they were able to share that in the group.

So I think it’s the matter of how you set up the environment. When they’re one-on-one with us with physicians, I think certain things are rerunning in the medical format. We don’t give them space sometimes to open up to sort of a deep layer that feels threatened. So I think a lot of the potential for trauma resolution and for a lot of deep psychological issues to be resolved in the groups is much, much higher because of that. You’re literally allowing people to do that, and you create the appropriate atmosphere and an appropriate facilitation. So I think that’s the art. The art is not the delivering the content. I mean, that’s straightforward. But it’s really delivering the right atmosphere.

But our main provider, Elizabeth Goldbeck, who does this, so she’s been taking a whole facilitators class, and I’ve done a lot of mindfulness training, so I can appreciate some of those components, and I can assist her when needed. A lot of our other practitioners who have participated in the groups, they’ve also done a lot of mindfulness training. So I think that’s one thing that’s required. When we going to start teaching community leaders to do that, I think that’s going to be number one accent is not necessarily the content. Content will be delivered by experts. But it’s really how do you facilitate that depth of the experience and kind of this mindful state for the whole group, not just for one individual.

James Maskell: Beautiful. Yeah, no. I think that’s…do you do like a group meditation as part of it?

Mikhail Kogan: Every class. We do mindfulness at every class, and we would typically start with very simple techniques. So things like Andrew Weil four, seven, eight breath. But then we proceed to more and more complex things, like journaling and Qigong and meditative practices. So we cover…they are actually thought through for a given condition. So if we cover insomnia, like when we do Qigong, we actually give them a little bit of a Qigong for sleep. There’s a specific forms. If we doing yoga, same. Like there’s specific facets that can be more delivered to help the sleep better. So I think even those things get specifically tailored. I know there’s good example would be BU, Boston University. I don’t know if you talked to the leaders there, Paula and Catherine and Rob Saper. So I know they’re designed…their whole yoga modules are designed specifically for pain in groups.

So I think what takes a while is to not only design those pieces but also play around and see whether the community likes them. Give you a simple example. For some reason I thought that HeartMath would be like the best ever, and we’ve pushed it and pushed it and nobody liked it. And we ended up dropping it out because people kept complaining how, “No, we just don’t want this equipment. We just want to talk,” or, “We just want to do some practice together.” But equipment makes it more difficult, not less difficult, which I found shocking. I thought that HeartMath in the group format would be very powerful. I’m surprised. Maybe it’s just our population or we did something wrong.

So I think you do have to know your community really well, and learn from them just as much as they’re learning what you’re offering.

James Maskell: Absolutely. Yeah, no. HeartMath is an interesting one, and I’ve got some…I have some experience of doing HeartMath in a group but not clinical setting, certainly not in a health creation setting as sort of an experimental setting. So I think I love the idea and I think it makes a lot of sense probably to a clinician who wants to see it happen. But I can understand why technology would really get in the way of what’s really human connection, one-on-one. So it’s really exciting.

One of the things the Dr. Geller talked about a lot is just facilitating groups that would be ongoing, right?

Mikhail Kogan: Exactly.

James Maskell: This is not a short-term medical visit but this is like a new part of your community. What have you found on that end as far as keeping people engaged and do you encourage them to engage outside of clinical hours? How do you manage that?

Mikhail Kogan: That’s our biggest weakness right now. We don’t do this well enough. We have almost every participant towards the end say, “Now what? We really want to continue.” So we’ve tried to run some follow-up groups. We haven’t been very successful at that. When we are creating now this whole protocol with the DC Medicaid, we actually specifically told them, “No, no. This is going to be after they’ve done intense groups and then they’re going to run the monthly afterwards.” I think that’s one of the most important components. You really don’t want to come in, start something for a few weeks, and then disappear. That’s something that community doesn’t want at all.

I think that what we really need to do in all of the locations is to have the community own the groups literally. They’re not going to own the expertise, but they can own the facilitation component and they can own the feel of it and how to move it forward on a regular basis. And literally, they probably can also own the topics of importance.

It’s interesting that a couple of years ago when we did a local survey, the Rodham Institute that the directors is one of our advisors did the local survey. We expected things like diabetes, HIV come up top. No, they were not even top 10. And top there were all psychological states. Depression, anxiety and insomnia being first three. And that was a, to me, and PTSD was the fourth, to me, that was like the shocking because it shows us that there are things that community wants that often we don’t even put on our highest radar. So we have to adjust and deliver those services because the community want. I think that’s also the way to establish the long-term relationships.

And the other thing I think clinic groups have a very unique potential at building the community in the way that nothing else do. By groups, I don’t necessarily mean medical shared groups. I mean any kind of groups, any kind of workshops. Because we do a lot of classes and we do a lot of…like we just did a couple of weeks ago, we did a small conference that drew about 80 people, and that was just a couple hours at a very low budget at the medical school. I think we charged people $20-$40 sliding scale and that included lunch, and lunch was donated.

So doing things like this at the very low budget with assistance of a local sponsors, yes it takes time to put it together, but when you think about your potential to create a community around what you do and visibility, at the amount of sometimes people paying different newspapers and radio channels. You can accomplish this with at the fraction of the cost, effectively utilizing things like Eventbrite, which is what we used typically, and platforms, the electronic platforms like Facebook where everybody is on now.

And the other thing I will say, the low income population really don’t have computers and emails is not the best way to reach them. That’s really important point. So Facebook, telephone texts are really the way to go. Everybody has cellphones, and that has to also be put into the context of how do you effectively maintain privacy. That’s actually I think somebody probably that you want to do podcast on that with some experts. How do we maintain and increase our social visibility platforms and encourage patients to come to different larger events and groups and yet maintain the HIPAA compliance and how to stay private. Groups, smaller groups is not a big issue with HIPAA. You tell patients that they can share whatever they want to share and that whatever’s shared stays in the group. And nobody seems to have problems with that, and I have not had any issues where we had something psychologically disturbing come up. We had a lot of trauma coming up, but that’s what we want. I mean, we want to have that trauma surface and try to resolve it. That’s the whole therapeutic intent.

James Maskell: I’m so glad you mentioned about the vulnerability of patients and opening up more in a group than to a health professional because I really feel that is a key component of all of this. There’s something about being able to just share and obviously it can be for different people, sharing to a professional of any sort is not comfortable. Perhaps in times gone by and communities gone by, this was like an elder in a community or a relative rather than a professional. So ultimately we establishing these peer groups is ultimately something that I think is going the be truly transformational for healthcare and for traumatized patients where trauma is really at the core.

Mikhail Kogan: Right. The other thing we do very clear from day one, we say that whoever joins the group is a participant. Everybody. Even the facilitator and the content expert, even if the content expert say comes in to teach acupressure, for example, which we do at several, once or twice at every group. They just participants, and the group knows about that. So they’re going to share about themselves as well. So when we go in circle and we’re saying how are day was, it’s expected that everybody participating is going to speak. So I think that also creates this unified feel of there’s no separation with me and the doctor. It’s like everybody on the same plane rather than…and yes, somebody maybe teaching me something, but they’re still just part of the group. And I don’t necessarily feel like I’m here to talk to a doctor. I’m really here as part of the group.
I was worried about this in the beginning, but after a few classes, I realized it’s just so easy to establish. But then it actually makes it kind of tricky to have visitors. So we have a policy of not having visitors. So if somebody would like to shadow, they have to shadow the entire time, or they may shadow say majority of classes. Maybe it’s six or something like that out of eight. So we don’t have a lot of trainees because of that, especially when we run evening classes and they know they have to commit for six weeks, once a week. That’s a big ask.

James Maskell: Absolutely. Well, look, I think there’s so much to be gained from everything that you’re sharing, and I hope that everyone who’s listening as you start to put this together are encouraged that yes, medical facilities and hospitals are excited about doing this kind of stuff. The payers are ready to pay for this stuff. It just takes a little bit of like action and selling and moving to be able to create something that’s really functional.

So I’m very, very excited to have captured this. I hope that it’s as inspiring to you as you’re listening as it has been to us. And thank you, Mikhail Kogan, for all of your amazing work to bring this to the forefront, and I hope that through this podcast and through some of the other efforts that I can make that we can have more and more doctors, practitioners, and all sorts of groups from private practice to the biggest institutions will be take on groups as a way of delivering medicine in an era where medicine is going to really care about value. And ultimately that’s where I feel like where this conversation has to go is that what could be more valuable than peer-to-peer medicine. Because the generation of the value is created in a non-paid peer-to-peer fashion, which I think is an exciting starting point of the future.

So thank you for all your great work and for being a pioneer. And we look forward to what’s to come in the future.

Mikhail Kogan: Thank you, James. Happy to be here and good luck with all the great work you’re doing. Thank you.

James Maskell: Thank you so much. Appreciate it.

Mikhail Kogan: Take care. Bye, bye.

James Maskell: If you want to find out more about doing group visits in your practice, you can go to the Lifestyle Matrix Resource Center. It’s goevomed.com/LMRC. They have Group Visit Toolkits that make it really easy for you to run a group visit in your practice or in your organization. Go to goevomed.com/LMRC.

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