KeyMed Report – November 2016

House Calls


What once had been common practice has all but disappeared from the medical landscape. By 1980, house calls accounted for 0.6% of all doctor-patient encounters. The reasons: increased specialization and new technology that require patients to go to hospitals and doctors’ offices for their care. In the view of many medical professionals, an inconvenient and inefficient use of their time.

But house calls may be making a comeback as a way to cut costs and provide better quality care for the elderly and chronically ill. Our changing demographic picture may hasten the revival, given that by 2040 the number of people over 65 will double to nearly 72 million, or one in five Americans.

House calls could save Medicare billions of dollars by reducing expenses for the highest-cost beneficiaries—the 5% that account for more than 50% of Medicare’s expenditures. It could also help reduce costs by caring for people at the end of their lives at home instead of in the hospital. Twenty-five percent of Medicare dollars is spent on people in their last year of life, mainly because of the high cost of hospitalization.

Helping spark prospects for a house call revival is a demonstration project by the federal Center for Medicare and Medicaid Services (CMS) that has won plaudits for delivering high-quality medical care and social services to chronically ill people in their homes while significantly reducing total Medicare costs.

Telemedicine Program


An effective telemedicine program is the result of an effective strategy, business model, operations and technology. Reasons for clinicians to create a telemedicine program include increasing access to care, reducing cost, attracting consumers and expanding reach. The impact of these strategies can be measured through both return on investment (ROI) and value metrics. When looking at ROI metrics, these may include any combination of direct revenue from payers or contracts, indirect revenue from new patients or cost avoidance through avoided visits or hospitalizations. Value metrics may vary greatly depending upon the telemedicine intervention and clinical specialty, but could include improvements in access for new patients or clinical quality metrics like medication adherence.

Telemedicine provides an avenue to participate in the shift to value-based care by offering patients new ways to access healthcare, improving the quality of care for patients through sustained connections between clinician and patient and improving patient outcomes and experience. Flipping the traditional paradigm of having a patient come to the clinician’s office, telemedicine allows for clinicians to meet patients in their location—whether in the patient’s home, office, an outpatient clinic closer to the patient’s home, or even inpatient or post-acute settings.

In many ways, telemedicine has allowed the return of the “virtual" house call.

ICD-10 Specificity “Grace Period” Has Ended


October 1st marked one year since ICD-10 replaced ICD-9 as the diagnostic code set for all HIPAA standard health insurance claims. The new coding system significantly increased the amount of data that is captured by diagnostic codes including greater specificity regarding disease severity and greater data on the specific anatomy the disease or condition is affecting.

Rather than diagnosing a broken hand, ICD-10 allows providers to document precise details such as which specific bone was broken on which hand as well as the severity of the fracture. This ability for more granular documentation therefore required an increase from about 14,000 ICD-9 codes to about 70,000 codes under ICD-10.

Claims adjudication rules have always required that a claim be coded to the greatest degree of specificity available. Because the information embedded in an ICD-9 code was less specific than what is in the ICD-10 code, the prospect of a claim being rejected due to lack of specificity was limited under ICD-9. With ICD-10, however, the possibility that claims could be rejected due to lack of specificity multiplied by several times. It wasn’t enough to select a code indicating that the patient had a broken bone, under ICD-10, the provider could specific laterality and cause as well.

MACRA Final Rule

The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) repeals the Medicare sustainable growth rate (SGR) methodology for updates to the physician fee schedule (PFS) and replaces it with a new approach to payment called the Quality Payment Program that rewards the delivery of high-quality patient care through two avenues: Advanced Alternative Payment Models (Advanced APMs) and the Merit-based Incentive Payment System (MIPS) for eligible clinicians or groups under the PFS. This final rule with comment period establishes incentives for participation in certain alternative payment models (APMs) and includes the criteria for use by the Physician-Focused Payment Model Technical Advisory Committee (PTAC) in making comments and recommendations on physician-focused payment models (PFPMs). Alternative Payment Models are payment approaches, developed in partnership with the clinician community, that provide added incentives to deliver high-quality and cost-efficient care. APMs can apply to a specific clinical condition, a care episode, or a population. This final rule with comment period also establishes the MIPS, a new program for certain Medicare-enrolled practitioners. MIPS will consolidate components of three existing programs, the Physician Quality Reporting System (PQRS), the Physician Value-based Payment Modifier (VM), and the Medicare Electronic Health Record (EHR) Incentive Program for Eligible Professionals (EPs), and will continue the focus on quality, cost, and use of certified EHR technology (CEHRT) in a cohesive program that avoids redundancies. In this final rule with comment period we have rebranded key terminology based on feedback from stakeholders, with the goal of selecting terms that will be more easily identified and understood by our stakeholders.

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