Nintendo CEO outlines plan to move into health-related entertainment

Boxed in by rivals in video games, Nintendo outlined its plan to redefine itself as a health-oriented entertainment company in the coming decade. In a letter to shareholders, Nintendo chief executive Satoru Iwata said the company plans to expand beyond games to make entertainment that improves “quality of life” for people.

It is a risky strategy to expand beyond video games at a time when its core business is losing money and rivals like Sony, Microsoft, and mobile companies are gaining ground on it. But it’s also the kind of “blue ocean” strategy that Iwata has tried before — something that worked with the Wii console, which recorded more than 100 million in worldwide sales during its life.

Iwata talked about Nintendo’s history since its founding as a seller of Hanafuda, or traditional Japanese playing cards, 125 years ago. It innovated and shifted to becoming a toy company, then an electronic toy company, and then a video game company. Nintendo launched its first game console, the Nintendo Entertainment System, in 1983. Its Wii console in 2006 was a big success, but the Wii U has been a disaster, and the 3DS handheld isn’t selling as many as its predecessor, the DS.

So to adapt to the shifting market, Nintendo is expanding into health.

Above: The Nintendo Vitality Sensor.

Image Credit: Nintendo

“As the business environment around us has shifted with the times, we have decided to redefine entertainment as something that improves people’s quality of life (“QOL”) in enjoyable ways and expand our business areas. What Nintendo will try to achieve in the next 10 years is a platform business that improves people’s QOL in enjoyable ways,” Iwata said.

Back in 2009, Nintendo hinted at a health entertainment strategy when it announced a “vitality sensor” that could measure your heartbeat and input that data into a Nintendo Wii game. But Nintendo never shipped that sensor.

Health tech is a rising, competitive field in the U.S. But to compete in it, Nintendo not only has to deal with competitors with more knowledge and more experience in the sector, but it may also need to learn how to work with the U.S. Food and Drug Administration. (Ask 23andMe how that went.)

He said that Nintendo will still remain focused on dedicated video game hardware and software platforms.

But he added, “We will attempt to establish a new business area apart from our dedicated video game business. We have set ‘health’ as the theme for our first step and we will try to use our strength as an entertainment company to create unique approaches that expand this business.”

While Nintendo continues to lose money, investors and analysts have clamored for the publisher to get into the mobile gaming business. But this is something the Japanese company has denied it’s doing. Others have talked about it acquiring or merging with other game companies.

Nintendo wants to expand its base of users, much like it did with the Wii, whose motion-sensing controller was so easy to use that it appealed to people who weren’t traditional video game fans. With its new health products and services, Iwata said that Nintendo wants to “create an environment in which more people are conscious about their health and in turn expand Nintendo’s overall user base.”

“What has remained the same from the past is that we have always tried to create something new from materials and technologies available at that time, to position entertainment as our core business and to improve people’s QOL in enjoyable ways,” Iwata said. “We will continue to value self-innovation in line with the times and aim for growth.”

http://venturebeat.com/2014/03/03/nintendo-ceo-outlines-plan-to-move-into-healt-related-entertainment/

The Glucose Grizzly Challenge - We Need Your Help!!!

Unpredictable blood sugar swings, including a record amount of carbs, has made for difficult going this season. Practices have taken place in the gym, the parking lot, the cafeteria and rented facilities.

Mr. Apple White, the lead attacker for the defending champions the “Great Glucose Grizzlies” has a tremendous season, but it is that incredible teamwork that has gotten them this far.

With only 2 games left to go in the 2014 season the Grizzlies are up by one, but in jeopardy of forfeiting tonight’s game. They only need one more player! Are you up for the challenge? Click the bear above to play!

Isn't it time to become the STAR of your own HEALTH?

Do Consumers Understand Their Health Terms? New Health Literacy Innovations' Survey Suggests

When it comes to understanding basic health information, many Americans do not understand simple terms, even some of America's biggest chronic conditions, so says a new survey from Health Literacy Innovations (HLI), a company that creates tools to eliminate confusion from low health literacy.

Using Amazon Mechanical Turk (MTurk), a crowdsourcing Internet site, HLI asked 1,000 respondents to define 21 health terms. Some of the respondents offered correct definitions for some of the terms, yet many did not know what these terms meant or gave incorrect answers.

When asked to define "hypertension," 53.7% of those surveyed defined it as "high blood pressure." Yet, 12% "did not know" and another 9.8% defined hypertension as high blood sugar, a potentially dangerous wrong description, especially in a medical emergency. 

Other findings include:

Melanoma 

• 59.2% defined melanoma as "skin cancer;" 15% defined it as "cancer" 
• 11.3% "did not know"

Myocardial Infarction 

• 64.5% defined "acute myocardial infarction" as "heart attack" 
• 8.3% "did not know" 
• 2.4% defined it as a "body part"

Hyperglycemia 

• 59.4% defined "hyperglycemia" as "high blood sugar" 
• 13% "did not know" 
• 7% defined it as "diabetes"

Edema 

• 44.7% defined edema as "swelling of a body part due to fluid retention" 
• 29.7% "did not know" 
• 24% defined it as a "body part"

Benign 

• 64.9% defined benign as "not very harmful" 
• 16.4% "did not know" 
• 13.5% defined it as "very severe"

Other consumer responses included:

• Bilateral: 16.9% "did not know"; 2.3% defined it as an "Illness" 

• Analgesic: 24.5% "did not know" 

• Angina: 28.9% "did not know"; 3% defined it as a "body part" 

• Transdermal: 12.2% "did not know"; 8% said it was "skin issue"

"Given the complexity of the health care environment, it’s no surprise that many consumers are confused about simple health terms," says HLI's Chief Content Director Aracely Rosales. "Having good health literacy -- understanding basic health information, and how to read, act on, and follow information -- is crucial for America’s consumers, especially those new to health care via the Affordable Care Act. HLI’s Health Literacy Advisor, a comprehensive health literacy software tool, can help health care providers to explain simple health terms while creating industry standardization.

Read more: http://www.digitaljournal.com/pr/1789381#ixzz2waporwsv

Humana deal to help Medicare members

If you’re one of Humana’s 41,000 Medicare Advantage members in Franklin, Fairfield, Licking and Delaware counties, you can expect your family doctor to know far more about which specialists you're seeing and how often you see them.

Humana officials expect that increased awareness to translate into better coordination of care, meant to improve members’ health at a lower cost.

The health insurer reached the new “pay-for-value” agreement with Health4, a health-care delivery model co-owned by the OhioHealth hospital system and the Medical Group of Ohio. The three-year deal, which took effect on Jan. 1, was disclosed this week.

Medicare Advantage patients “are going to see the same outcomes that we’ve demonstrated ... in the commercial population,” said Dr. John Schmeling, the Medical Group of Ohio’s CEO.

Since its creation in 2010, MGO officials said the organization has improved rates for breast, cervical and colorectal cancer screening, as well as for preventive visits and diabetes management.

As part of the deal with Humana, emphasis also will be placed on prescribing generic medications and avoiding X-rays on a patient’s initial visit for back pain, Schmeling said.

Humana has established similar partnerships in Cincinnati and northeastern Ohio, said Larry Costello, the insurer’s president for senior markets in Ohio.

Doctors have incentives to meet certain quality measures. A spokesman declined to specify how large the incentives would be, saying only that the payments would be a “needle-mover in terms of enabling proactive, integrated care delivery.”

Officials also declined to say how much improvement must be seen for specific health conditions in order for physicians to be rewarded monetarily.

Costello said the partnership is one of the first and largest such partnerships involving Medicare patients in central Ohio.

Such “accountable-care” deals are becoming common across the state. In October, for example, UnitedHealthcare and Mount Carmel Health Partners embarked on a similar three-year deal meant to improve the health of 20,000 patients.

http://www.dispatch.com/content/stories/local/2014/03/20/humana-deal-to-help-medicare-members.html

Welltok acquires Seattle mobile health company Mindbloom

Welltok Inc., a Denver health-optimization company, continued its growth Thursday by acquiring Mindbloom, a Seattle mobile health company that it believes will help it to deliver more interactive mobile experiences.

Officials from Welltok did not disclose what they paid for Mindbloom, a builder of apps such as Bloom for inspiration and Life Game for life improvement. 

But they said they will use the company’s expertise and resources to expand Welltok’s CafeWell Health Optimization Platform that it offers to engage people more in their own health, working with insurers and health systems to promote its products.

“To profoundly change consumers’ health-related awareness, actions and behaviors for the better, we need an effective and practical platform to become ingrained in their daily lives,” said Jeff Margolis, Welltok chairman and CEO. “We were impressed by the Mindbloom team’s ability to integrate behavioral science and user-centered design principles with health-related content to deliver a superior consumer experience.”

The acquisition comes slightly more than one month after Welltok received $22.1 million in new funding, including the first investment from IBM’s newly created Watson Group.

http://www.bizjournals.com/denver/news/2014/03/20/welltok-acquires-seattle-mobile-health-company.html

Practice Anatomy and Physiology for ICD-10 with the NEW GAME "Wellness World Series"

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Health providers may experience information and financial loss during transition to ICD-10

Health providers may experience information and financial loss during the mandated conversion from the current International Classification of Diseases to its new and improved version, report researchers at the University of Illinois at Chicago.

The study, appearing in the March issue of the Journal of Oncology Practice, looked at coding ambiguity for hematology-oncology diagnoses to anticipate challenges all providers may face during the transition from ICD-9-CM to ICD-10-CM.

The researchers chose to look at hematology-oncology because prior research suggested that, compared to other sub-specialties, it would have a simpler transition, due to fewer ICD-10 codes and less convoluted mappings.

The nation's health care system is scheduled to fully implement ICD-10 on Oct. 1, and many doctors and hospitals are still preparing for the transition. The system is used to classify and code all diagnoses, symptoms and procedures for reference in managing all aspects of health care - from insurance reimbursement to staffing decisions to supply procurement.

The ICD-10-CM includes more than 68,000 diagnostic codes, compared to 14,000 in ICD-9-CM. The Centers for Medicare and Medicaid Services provides a general equivalent mapping (GEM) code translation system, but it's complex and often difficult even for billers and coders to interpret, according to the researchers.

Codes often do not map one-to-one or one-to-many, says Andrew Boyd, UIC assistant professor in biomedical and health information sciences and one of the study's co-authors. A cluster of codes might map to several ICD-10 codes, which might then map back to different ICD-9 codes, he said.

In the study, the researchers used 2010 Illinois Medicaid data to identify ICD-9-CM outpatient codes and the associated reimbursements used by hematology-oncology physicians. The researchers identified 120 codes with the highest reimbursement for analysis.

They also looked at ICD-9-CM outpatient diagnosis codes and associated billing charges used by University of Illinois Cancer Center physicians from 2010 to 2012 and selected the 100 most-used codes.

Using a web-based tool developed at UIC, the researchers input the ICD-9 codes and translated them into ICD-10 codes. They looked at whether the translation made sense; whether a loss of clinical information occurred; and whether a loss of information had financial implications.

"What we found was the transition from ICD-9 to ICD-10 led to significant information loss, affecting about 8 percent of the Medicaid codes and 1 percent of the codes in our cancer clinic," said Dr. Neeta Venepalli, UIC assistant professor of hematology/oncology and first author of the study.

In looking at the financial implications, the researchers found that 39 ICD-9-CM codes with information loss accounted for 2.9 percent of total Medicaid reimbursements and 5.3 percent of UI Cancer Center billing charges.

The report highlights the 39 codes "to help identify that there might be trouble with reimbursement for these codes," said Boyd.

http://www.medicalnewstoday.com/releases/273992.php

Are your patients fluent in the language of their disease?

What are you doing to empower your patients into healthier behaviors? What tools have you giving them to support the journey to wellness?

Traditionally, physicians have used their power of their influence or the strength of their relationship to encourage healthier habits in patients.

Today’s delivery system is changing and evolving rapidly. New models of care that focus on the whole patient while integrating the entire system have greatly improved both the experience and outcome for stakeholders. This progress is incredible, but what more can we do?

CVS released recently a study that found 70% of patients don’t understand written medical instructions. How are you educating your patients on the disease and treatment? How much information is made available? How do you know if your patient read the material, and if they did – how much did they understand?

What if we could engage our patients with more than just data? Consider the value of teaching patients how to manage their chronic condition through fun and interactive games? Could games that teach and monitor their transition prevent re-admissions in high risk patients?

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• If you work in healthcare and want to learn more about ICD-10 or Medicare Risk Adjustment, please create your free account at: www.healthstargames.com today!!!

PCMH Model is Alive and Well Despite One Negative Study

March 12, 2014 03:12 pm "Voices" Staff – The Patient-Centered Primary Care Collaborative (PCPCC) released a report in January that reviewed 20 patient-centered medical home (PCMH) studies released in the previous 17 months.

The majority of those studies found overall cost reductions and decreases in ER visits, and 40 percent reported fewer hospital admissions. Smaller percentages of the studies reported improvements in other vital areas, including improved population health or increased use of preventive services (30 percent), improvements in access to care (25 percent), patient satisfaction (20 percent), and hospital readmissions (15 percent).

Although that report reinforced the concept of the PCMH as the future model of primary care and provided a five-year summary of evidence supporting the model(www.pcpcc.org), it didn't generate much media attention. Good news rarely does.

Fast forward one month. The Journal of the American Medical Association (JAMA) released one PCMH study(jama.jamanetwork.com) in late February that found "limited improvements in quality" and no association with reductions in use of hospital, ER or ambulatory care services or total costs. Based on that one study, reports in some daily newspapers and on medical news websites declared the PCMH a failure. If the PCMH could be likened to a horse, it would be fair to say that some particularly critical bloggers were ready to take it out back and shoot it.

Well, put your shovels away. There will be no burial today.

The PCMH is a work in progress. The AAFP has been developing the model for 10 years, a result of the original Future of Family Medicine project. Despite the findings of this one study, we still think the PCMH is a vital part of our specialty's future. The Academy and others will continue to study and refine it.

Mark Friedberg, M.D., the corresponding author of the JAMA article, said in an interview with AAFP News that physicians should not "attach too much importance to any study" and that more research on the PCMH is needed.

It's worth noting that the Pennsylvania Chronic Care Initiative, the program studied in the JAMA article, launched in 2008 under PCMH standards that were updated by the National Committee for Quality Assurance (NCQA) three years later. NCQA plans to update its standards again(www.ncqa.org) this month. Again, it's a work in progress. We know more now than we did in 2008 about what works, what's required and how to implement it.

The JAMA study has other limitations, too.

The Pennsylvania practices involved in the study were given incentives to earn PCMH recognition but no incentives to reduce costs. The project also failed to target chronically ill patients. With no incentive to control costs and no priority to help improve the health of the system's biggest users of care, should it be a surprise that costs did not decline?

Becoming recognized as a PCMH does not magically improve care and reduce costs. There is more to it than marking off the boxes on a checklist. For example, improving access to care is an element of the PCMH, but practices in the study didn't offer evening hours or weekend care because that step isn't required to earn PCMH recognition. But that kind of patient-centered effort can lead to reduced health care costs and less use of ERs and hospitalization.

Furthermore, only half the NCQA-recognized practices in the study achieved Level 3. According to NCQA, 75 percent of recognized practices in pilot projects typically achieve Level 3. "A higher (and more typical) concentration of high-capability medical homes would probably have produced better outcomes," NCQA said in its response to the study(www.ncqa.org).

The PCPCC also responded(www.pcpcc.org), saying the study failed to measure other key elements of the PCMH, including patient engagement and satisfaction, team-based care, and behavioral health integration.

The Commonwealth Fund, which helped fund the Pennsylvania study, also defended the PCMH(www.commonwealthfund.org), making some of the same points we have here: that we better understand how to implement the model than we did in 2008, and patients with complex conditions should be targeted to improve outcomes and reduce utilization and costs. It also points out that the three-year study may not have been long enough to see the long-term benefits of the model.

Since the JAMA study was initiated in 2008, six other regions of Pennsylvania have started their own pilots. Based on lessons learned from the first study, these subsequent projects have been updated accordingly. It will be interesting to see the findings when these more recent projects are completed.

The bottom line is that one study that questions the value of the PCMH is no more valuable than one study that supports it. No one study should drastically alter the way we practice medicine. It is the totality of evidence that matters, and right now, we have a mountain of evidence that shows that in the majority of studies, the PCMH has been shown to decrease costs and improve outcomes.

One study can get our attention, which this one surely did, and make us scrutinize what we are doing. The JAMA article could help us learn how to better implement and study this evolving model, but it should not lead us to abandon it.

http://www.aafp.org/news/opinion/20140312pcmhjamaedl.html

Jury Convicts All Seven Defendants in $97 Million Medicare Fraud Scheme

Washington, DC—(ENEWSPF)—March 12, 2014. A federal jury in Houston today convicted two owners of a former Houston mental health care company, Spectrum Care P.A. (Spectrum), several of its employees and the owners of certain Houston group care homes for their participation in a $97 million Medicare fraud scheme.

Acting Assistant Attorney General Mythili Raman of the Justice Department’s Criminal Division, U.S. Attorney Kenneth Magidson of the Southern District of Texas, Special Agent in Charge Stephen L. Morris of the FBI’s Houston Field Office and Special Agent in Charge Mike Fields of the Dallas Regional Office of HHS’s Office of Inspector General (HHS-OIG), the Texas Attorney General’s Medicaid Fraud Control Unit (MFCU), Special Agent in Charge Joseph J. Del Favero of the Chicago Field Office of the Railroad Retirement Board, Office of Inspector General (RRB-OIG) and Special Agent in Charge Scott Rezendes of Field Operations of the Office of Personnel Management’s Office of Inspector General (OPM-OIG) made the announcement following a jury trial before U.S. District Judge Vanessa Gilmore in the Southern District of Texas.

Physicians Mansour Sanjar, 81, and Cyrus Sajadi, 66, the owners of Spectrum, were each convicted of conspiracy to commit health care fraud and conspiracy to pay kickbacks as well as related counts of health care fraud and paying illegal kickbacks. Adam Main, 33, a physician’s assistant, was convicted of conspiracy to commit health care fraud and related counts of health care fraud.   Shokoufeh Hakimi, 66, administrator of Spectrum, was convicted of conspiracy to commit health care fraud, conspiracy to pay kickbacks and a related count of paying an illegal kickback.   Chandra Nunn, 35, a group home owner, was also convicted of conspiracy to commit health care fraud, conspiracy to pay and receive kickbacks and related counts of receiving illegal kickbacks.   Sharonda Holmes, 40, a patient recruiter, was convicted of conspiracy to pay and receive kickbacks and a related count of receiving an illegal kickback.   Shawn Manney, 51, a group home owner, was convicted of conspiracy to pay and receive illegal kickbacks.

According to evidence presented at trial, Sanjar and Sajadi orchestrated and executed a scheme to defraud Medicare beginning in 2006 and continuing until their arrest in December 2011.  Sanjar and Sajadi owned Spectrum, which purportedly provided partial hospitalization program (PHP) services.  A PHP is a form of intensive outpatient treatment for severe mental illness.   The Medicare beneficiaries for whom Spectrum billed Medicare for PHP services did not qualify for or need PHP services.  Sanjar, Sajadi, Main and Moore signed admission documents and progress notes certifying that patients qualified for PHP services, when in fact, the patients did not qualify for or need PHP services.  Sanjar and Sajadi also billed Medicare for PHP services when the beneficiaries were actually watching movies, coloring and playing games–activities that are not covered by Medicare.

Evidence presented at trial showed that Sanjar, Sajadi and Hakimi paid kickbacks to Nunn, Holmes, Manney and other group care home operators and patient recruiters in exchange for delivering ineligible Medicare beneficiaries to Spectrum.  In some cases, the patients received a portion of those kickbacks. According to evidence presented at trial, Spectrum billed Medicare for approximately $97 million in services that were not medically necessary and, in some cases, werenot provided.

Sanjar, Sajadi and Nunn are scheduled to be sentenced on Sept. 8, 2014.   Main, Hakimi, Holmes and Manney are scheduled to be sentenced on Sept. 15, 2014.

http://enewspf.com/latest-news/law-and-order/federal-and-international/50944-jury-convicts-all-seven-defendants-in-97-million-medicare-fraud-scheme.html

Nintendo ‘Quality of Life’ to replace Wii U?

It is no secret that Nintendo’s Wii U is struggling, but would to it be too much to suggest they are already planning to replace it? ‘Quality of Life’ is a mysterious new platform which Nintendo is working on, with a possibility that it could take over from the Wii U early on.

Very little is know about the QOL platform, however Nintendo CEO Satoru Iwata has hinted that this initiative is separate from their current Wii ventures. Whether or not Quality of Life is created as a games console or all round multimedia device is unclear, although Iwata has said that the keyword with QOL is “Health”.

Fitness and health is a big theme being brought to the table right now, mobile devices and smartwatches are doing it, so Nintendo could be looking to get in on this popular trend. Wii Fit and a variety of other health related games and accessories have all been featured on the Wii and Wii U in the past; Nintendo will need to be trying something bold here.

In a detailed report on Gamestop, it has been suggested that Nintendo would continue 2014 with their Wii U games strategy and look to have QOL ready for next year. Once Quality of Life is completes it will become the forefront of Nintendo’s business and quietly edge the Wii U out of the picture.

This would see QOL and the Nintendo 3DS as the 2 main options for consumers, a risky but potentially rewarding move. It is hard to predict the success of Nintendo replacing the Wii U with Quality of Life because we know so little about it. On the other hand though, things can’t get much worse for the Wii U so any kind of change should help the company’s cause.

Is a new platform with a health focus from Nintendo what they need to replace the Wii U?

http://www.product-reviews.net/2014/03/12/nintendo-quality-of-life-to-replace-wii-u/

Calls for national telehealth strategy within the Australian Health System

A collaboration of health industry stakeholders released a White Paper in Canberra last week to promote the adoption of telehealth nationally.

The group (One in Four Lives) concluded that telehealth could save $4 billion a year in avoidable hospital presentations related to chronic conditions. The group’s name reflects the fact that almost six million, which equates to one in four, Australians are affected by chronic health conditions – and this accounted for 60% of all hospital bed days and an estimated $17 billion annually in public health costs.

The White Paper outlines that the Australian health system is not sustainable in its current form, citing Treasury modeling that predicted healthcare costs would ‘eat up’ more than 100% of the entire revenue collected by the Nation’s states by 2046.

Chair of the body, BT’s Director of Health Lisa Altman said the aim was to encourage industry participation in the large-scale adoption of telehealth – providing faster, more efficient healthcare solutions without imposing an additional burden on the health budget. Ms Altman also said the evidence-base for telehealth already existed, proven by large-scale operations such as the Department of Veterans Affairs in the USA and the Whole System Demonstrator Program in the UK.

Ms Altman reported that the UK program found telehealth could deliver a 15% reduction in emergency visits, a 20% reduction in emergency admissions, a 14% reduction in hospital admissions and bed days as well as a 45% reduction in mortality rates.

One In Four Lives group speaker Dr George Margelis said there were already notable telehealth trials and projects up and running across Australia that demonstrate telehealth works well.

“But the industry believes that there is a need for more flexible funding models for the widespread adoption of telehealth, to help us prevent the thousands of avoidable admissions we have every year because of chronic disease,” he said.

Dr Margellis said telehealth had the potential to revolutionize the way chronic disease was managed, by enhancing communication with patients and improving monitoring of their conditions. The White Paper is an attempt to “kick start the discussion between industry and government,” he added.

http://www.healthcareitnews.com/news/calls-national-telehealth-strategy

How Will New Physician Value-Based Payment Modifier Affect Medicare Reimbursements?

Program will have hospitalists identify appropriate metrics, patient attribution

by Danielle Scheurer, MD, MSCR, SFHM

We talk a lot about value in healthcare—about how to enhance quality and reduce cost—because we all know both need an incredible amount of work. One tactic Medicare is using to improve the value equation on a large scale is aggregating and displaying physician-specific “value” metrics. These metrics, which will be used to deduct or enhance reimbursement for physicians, are known as the Physician Value-Based Payment Modifier (PVBM).

This program has been enacted fairly rapidly since the passage of the Affordable Care Act; it is being rolled out first to large physician practices, then to all groups by 2017. Those with superior performance in both quality and cost will experience as much as a 2% higher reimbursement, while groups with average performance will remain financially neutral and those who show lower performance or choose not to report will be penalized up to 1% of Medicare reimbursement. This first round, for larger groups of 100-plus physicians, will affect about 30% of all U.S. physicians. The second round, for groups of 10 or more physicians, will affect about another third of physicians. The last round, for groups with fewer than 10 physicians, will be applicable to the remaining physicians practicing in the U.S.

On the face of it, the program does seem to be a potentially effective tactic for improving value on a large scale, holding individual physicians accountable for their own individual patient-care performance. A few fatal flaws in the program as it currently stands make it extraordinarily unlikely to be universally adopted by all physicians, however. Here are a few of those flaws:^1,2

1 Uncertain yield: Because it is essentially a “zero-sum game” for Medicare, the incentive or penalty for a physician (or the physician’s group) depends on the performance of all the other physicians’ or groups’ performance. As a result, there is incredible uncertainty as to how strong a physician’s performance actually needs to be, year to year, to result in a bonus payment. Given that many of the metrics will require some type of investment to perform well, such as information technology infrastructure or a quality coordinator, there is an equal amount of uncertainty about how much investment will be needed to get a certain budgetary yield. For smaller physician practices, taking a 1% to 2% reduction in Medicare reimbursements may be easier to weather financially than investing in the infrastructure needed to reliably hit the quality metrics for every relevant patient.

2 Uncertain benchmarks: Unlike many hospital quality metrics, which have been publicly displayed for years, physician-level value metrics are just now being reported publicly. This leaves uncertainty about how strong a physician’s performance needs to be in order to be better than average. In the hospital value-based purchasing program, “average” performance is extremely good, in the 98% to 99% compliance range for most metrics. It is less clear what compliance range will be “average” in the physician-based program.

3 Physician variability: More than a half million physicians in the U.S. bill Medicare, and their practice types range from primary care solo practice to multi-group specialty practice. Motivating all brands to understand, measure, report, and improve quality metrics is a yeoman’s task, unlikely to be successful in the short term. Most physicians have not received any formal education or training in quality improvement, so they may not even have the skill set required to improve their metrics into a highly reliable range, worthy of bonus designation.

4 Metric identity and attribution: Because the repertoire of physician types is broad, the ability of each physician type to have a set of metrics that they understand and can identify with is extremely unlikely. In addition, attribution of patients and their associated metrics to any single physician is complicated, especially for patients who are cared for by many different physicians across a number of settings. For hospitalists, the attribution issue is a fatal flaw, as many groups routinely “hand off” patients among other hospitalists in their group, at least once if not several times during a typical hospital stay. The same is true of many other hospital-based specialty physicians.

Motivating all brands to understand, measure, report, and improve quality metrics is a yeoman’s task, unlikely to be successful in the short term. Most physicians have not received any formal education or training in quality improvement, so they may not even have the skill set required to improve their metrics into a highly reliable range, worthy of bonus designation.

5 Playing to the test: As with other pay-for-performance programs, there is a legitimate concern that physicians will be overwhelmingly motivated to play to the test, so that their efforts to perform exceedingly well at a few metrics will crowd out and hinder their performance on unmeasured metrics. This tendency can result in lower-value care in the sum total, even if the metrics show stellar performance.

6 Reducing the risk: As seen in other pay-for-performance programs, there is a legitimate concern that physicians will be overwhelmingly motivated to avoid caring for patients who are likely to be unpredictable, including those with multiple co-morbid conditions or with complex social situations; these patients are likely to perform less well on any metric, despite risk adjusting (which is inherently imperfect). This is a well-known and documented risk of publicly reported programs, and there is no reason to believe the PVBM program will be immune to this risk.

In Sum

Because these flaws seem so daunting at first glance, many physicians and physician groups will be tempted to reject the program outright and take the financial hit induced by nonparticipation. An alternative approach is to embrace all of the value programs outright, investing time and energy in improving the metrics that are truly valuable to both patients and providers.

Regardless of which regulatory agency is demanding performance, we need to be active participants in foraging out what metrics and attribution logic are most appropriate. For hospitalists, these could include risk-adjusted device days, appropriate prescribing and unprescribing of antibiotics, judicious utilization of diagnostic testing, and measurements of patient functional status and/or mobility.

Value metrics are here to stay, including those attributable to individual physicians; our job now is to advocate for meaningful metrics and meaningful attribution, which can and should motivate hospitalists to enhance their patients’ quality of life at a lower cost.

http://www.the-hospitalist.org/details/article/5870191/How_Will_New_Physician_Value-Based_Payment_Modifier_Affect_Medicare_Reimbursemen.html

J.D. Power ranks AvMed, Humana tops for member satisfaction

A J.D. Power study placed AvMed Health Plans and Humana in a tie for highest member satisfaction among Florida health plans.

The Westlake Village, Calif.-based company measures member satisfaction for the largest health plans in 18 regions using a 1,000-point scale.

The average customer satisfaction score across all regions was 669, but the Florida average came in a little below that, at 664. Both AvMed and Humana scored 690, which is considered five out of five stars. It’s the third consecutive year AvMed’s been at the top.

“At AvMed, we’re committed to building a unique member experience that we feel only we can deliver,” said James M. Repp, senior VP of the Miami-based health plan. “Working with our providers, we’re putting the members at the center of the health care experience, exactly where the member belongs.”

The J.D. Power study ranked AvMed high for provider choice, claims processing, cost and coverage. Humana received high rankings for communication, customer service and coverage.

The other Florida plans rated by J.D. Power were Cigna (680), Florida Blue (677), Aetna (649), UnitedHealthcare (646) and Aetna subsidiary Coventry Health Care (602).

Cigna received high ratings for provider choice and coverage. Florida Blue was above average in most areas. UnitedHealthcare scored below average for customer service. Aetna scored below average for both cost and coverage. Coventry scored below average in all areas.

http://m.bizjournals.com/southflorida/news/2014/03/11/j-d-power-ranks-avmed-humana-tops-for-member.html?r=full

Halifax Health to pay $85m to resolve part of whistle-blower suit

Halifax Health has agreed to pay $85 million to resolve allegations that it violated a federal law designed to prevent Medicare abuse, according to an agreement filed Monday.
News-Journal file

DAYTONA BEACH — Halifax Health must pay the U.S. Department of Justice $85 million within 10 days and operate under a corporate-integrity agreement for five years to resolve allegations that it broke a federal law meant to stop Medicare abuse, according to a settlement agreement filed Monday in federal court in Orlando.

Halifax Health says the settlement is not an admission that it committed fraud by submitting false Medicare claims to the government. The agreement states the hospital admits no liability in the settlement, except that it violated the Stark Law, which bars paying doctors based on referrals and volume.

Another part of the case involving allegations of unneeded admissions to the hospital is set for trial in July.

“We believe we have a fiduciary responsibility to avoid the risks associated with trial and the potential of a lengthy appeals process,” John Guthrie, a Halifax Health spokesman, said in a prepared statement. “We will continue our mission of providing exceptional patient care and providing health and wellness services to our community as the only safety-net hospital in the area.”

Elin Baklid-Kunz, the hospital's director of physician services, filed the whistle-blower lawsuit in 2009 accusing the hospital of maintaining illegal contracts with doctors and billing the federal government for unnecessary medical procedures. Baklid-Kunz and her attorneys will receive 24.5 percent of the settlement amount — about $20.8 million. Baklid-Kunz, who still works for the hospital, earns an annual salary of $92,081, according to hospital records.

The Justice Department accused Halifax Health of overpaying six cancer doctors and three neurosurgeons and submitting false Medicare claims. When the Justice Department joined the case, it said in a statement it was doing so because employment agreements such as the ones structured by Halifax Health can lead to unnecessary medical procedures and health care expenses.

In the settlement, the federal government maintains the merits of its accusations. Assistant U.S. Attorney Ralph Hopkins declined comment about the case Monday afternoon. A Justice Department spokesman said a statement would be forthcoming.

Halifax Health's employment contracts and business practices will be under greater scrutiny as a result of the corporate-integrity agreement in the 17-page settlement. The agreement includes federal oversight of all physician contracts, Guthrie said.

Last week, Halifax Health officials said the settlement would not include an admission of wrongdoing, and the public hospital with taxing authority would pay the settlement amount over a period of several years through “belt-tightening and the potential delay of capital expenses,” instead of raising taxes. The hospital system has poured more than $21 million into its legal defense so far.

In the agreement filed Monday, though, Halifax Health admits it violated the Stark Law, and the hospital is required to pay the money in the next 10 days — instead of over a period of several years. Halifax Health has about $420 million in cash reserves, while carrying about $348.2 million in long-term debt, according to a recent review by Standard & Poor's rating agency.

Halifax Health officials deny the hospital's doctors performed unneeded procedures and say they tailored the agreements with the intention of keeping critical doctors in the community.

The settlement does not include another part of the suit involving allegations that the hospital admitted patients for unnecessary inpatient stays of two days or less, instead of treating them on an outpatient basis. That matter is set for trial in July and carries potential damages and penalties of more than $240 million. The government did not intervene on those claims. The whistle-blower's attorneys are also entitled to ask for fees and costs related to the case.

“Halifax has not put this case behind them,” said Marlan Wilbanks, an attorney for Baklid-Kunz. “We think the biggest part of the case is left in front of them.”

Halifax Health has consistently denied the whistle-blower's allegations.

http://www.news-journalonline.com/article/20140310/NEWS/140319952?Title=Halifax-Health-to-pay-85m-to-resolve-part-of-Medicare-fraud-suit