News From ACFAS

---

Take a New Look’s next stops will be the American Association of Diabetes Educators’ and the American Academy of Family Physicians’ conferences. For more on ACFAS’ referral campaign, visit TakeANewLook.org. ACFAS has been educating healthcare professionals and the public about who you are and what you do. Help us strengthen our campaign by being a part of it.

Incorporate the messaging from the College’s national patient education PR initiative and the Take a New Look at Foot & Ankle Surgeons PR campaign into your practice’s marketing plan with the new free PowerPoint presentation, When to See a Foot and Ankle Surgeon, available for download in the ACFAS Marketing Toolbox.

Use the PowerPoint and prewritten script when speaking at community health events this summer to help educate patients on foot and ankle surgeons’ education, training and responsibilities and to raise awareness of the expert care you and your colleagues provide. Also add your practice contact information to the customizable slide in the PowerPoint presentation so patients can reach you.

Be sure to take advantage of the many other free resources available at acfas.org/marketing, including the seasonal FootNotes patient newsletter, infographics, fill-in-the-blank press release templates and tools for increasing referrals to your practice. New graduates, take the next step in your career development and join ACFAS for free! Our local Regions are proud to support first-year podiatric surgical residents with a complimentary first-year membership to the College. Receive all member benefits, including special pricing on conferences, products and services, free for one year (a $120 value).

Enjoy access to acfas.org, the College’s premier website, and a subscription to the online version of The Journal of Foot & Ankle Surgery (JFAS), your source for the latest surgical techniques and research.

Join now to receive an additional three months of membership, through September 2017, and access JFAS that much sooner! Results of last month's poll in This Week @ ACFAS show that the majority of readers are interested in more original research articles in The Journal of Foot & Ankle Surgery (JFAS).

Seventy-three percent would like to see more original research articles in JFAS, while 13 percent would prefer to see more case studies. The remaining 13 percent said JFAS includes the right balance of original research and case studies.

Thank you to all who voted in this latest poll, and watch the July 5 issue of This Week @ ACFAS for a new poll on telemedicine.

Foot and Ankle Surgery

---

In this study, researchers investigated the clinical and functional outcomes of chronic Achilles tendon rupture reconstruction via the Lindholm method and by Vulpius’ lengthening of the gastrocnemius. They evaluated 15 patients with chronic Achilles tendon rupture (Lindholm technique in eight patients and primary repair with the Vulpius technique in seven patients). In the final follow-up, the Hooker scale was used to measure the ankle functional capacity in all patients. The patients were evaluated on the basis of their capability to stand on tiptoe on the affected limb and the time required to return to preinjury daily activities. The mean follow-up time was 19.6 months (range, 12 months to 38 months). The mean time to return to work and daily activity was 3.2 months. The mean calf atrophy at the end of follow-up was 1.2 cm. At the last follow-up visit, no patient had any limitation in the activities of daily living and the active and passive ankle range of motion was good. All patients were able to perform single-leg heel rises at the end of follow-up, and the Hooker scores were excellent for 11 patients and satisfactory for four patients. The researchers concluded that reconstruction of chronic Achilles tendon ruptures via the Lindholm technique or via the Vulpius technique is associated with good clinical and functional outcomes.


A study was conducted to assess the value of computed tomography (CT) postprocessing images in postoperative assessment of Lisfranc injuries in comparison with plain radiographs. The researchers analyzed 79 cases with closed Lisfranc injuries treated via conventional open reduction and internal fixation from January 2010 to June 2016. Postoperative evaluation was conducted by two independent orthopaedic surgeons with both plain radiographs and CT postprocessing images. Analysis of inter- and intraobserver agreement by kappa statistics was performed while the differences between the two postoperative imaging assessments were evaluated via McNemar's test. Inter- and intraobserver agreement of CT postprocessing images was determined to be significantly higher compared to plain radiographs. Nonanatomic reduction was more easily spotted in patients with injuries of Myerson classifications A, B1, B2 and C1 using CT postprocessing images with overall groups, as was poor internal fixation in patients with injuries of Myerson classifications A, B1, B2 and C2 using CT postprocessing images with overall groups. From these observations, the researchers concluded that CT postprocessing images offer greater reliability than plain radiographs in the postoperative evaluation of reduction and implant placement for Lisfranc injuries.


A study was conducted to validate three Patient-Reported Outcomes Measurement Information System computer adaptive tests (CATs) most relevant to the foot and ankle discipline against the Foot and Ankle Outcome Score (FAOS) and the Short Form 12 general health status survey in patients with six common foot and ankle pathologies. A total of 240 patients presenting for operative treatment for one of six common foot and ankle pathologies completed the CATs, FAOS and Short Form 12 at their preoperative surgical visits, seven days prior to surgery and at six months following the procedure. The psychometric properties of the instruments were evaluated and compared. CAT scores were more normally distributed and had fewer floor and ceiling effects versus the FAOS, of which there were as many as 24 percent. The CATs offered more precision than the FAOS and had similar responsiveness and test-retest reliability. The physical function and mobility CATs exhibited strong correlation with the activities subscale of the FAOS, and the pain interference CAT correlated strongly with the pain subscale of the FAOS. The CATs and FAOS responded to changes with operative treatment for six common foot and ankle pathologies. The CATS were found to perform as effectively as or superior to the FAOS in all aspects of psychometric validity.

Practice Management

---

Physicians can avoid getting sued for medical malpractice by following a number of strategies, including supporting a line of communication between them and their patients, according to Marks Healthcare Consulting founder Michael R. Marks. "When something bad happens, physicians need to get closer to their patient, stay on top of the issue and let the patient know they care," Marks notes. He also says physicians should avoid setting up unrealistic expectations for patients. Meanwhile, attorney Michael Sacopulos says, "an explanation of how something went wrong and why it won't happen again does more to deter a lawsuit than anything else." A second strategy to avoid lawsuits is to deter misuse of patients' electronic healthcare records, with healthcare lawyer Ericka Adler recommending physicians double-check their work and review their patients' complete medical records prior to administering tests. "Being sure you have the patient's full medical record and keeping an open line of communication in the event of a question either party may have is a recipe for a successful physician-patient relationship," Adler says. Mental preparation for a possible lawsuit is another strategy for physicians of all ages, and experts say clear communication and follow-up with patients is the best approach to avoiding them.


Under U.S. Department of Health and Human Services (HHS) rules, hospitals are only required to report cyberattacks that result in the exposure of private medical or financial information, such as malware that steals data. HHS publicly reports breaches that expose confidential data for at least 500 people. The threshold for when ransomware's data encryption meets HSS criteria is a gray area. Advocates of more mandatory reporting say this regulatory gap limits the healthcare system's ability to fight cybercriminals. Hospitals that are not informed about attacks affecting their peers are less likely to be ready to defend themselves, they say. U.S. Reps. Ted Lieu (D-Calif.) and Will Hurd (R-Texas) are pushing HHS to require hospitals to report ransomware attacks. "I view it as a loophole that ransomware need not be reported," Lieu said. However, opponents say HHS reporting comes with potential penalties and liability risks. When MedStar Health was hit with a cyberattack in 2016, the hospital system "shared insights privately" with other hospitals, a spokeswoman said.


A study published in JAMA Internal Medicine indicates that informing physicians of drug, scan or test costs would not make a significant difference in the costs of such items to patients. Included in the study were about 100,000 patients, more than 140,000 hospital admissions, and a random sample of laboratory tests. During the electronic ordering process, 50 percent of the tests were shown to physicians alongside fees. Although the cost to the patient may vary, these Medicare-permissible fees were what was reimbursed to the hospital for the test or tests being considered. The remaining 50 percent were presented without such data. Contrary to researchers' expectations, there was no meaningful or consistent decrease in the number of tests ordered each day per patient for the group seeing the prices. An earlier study published in Pediatrics detailed a similar trial on physicians caring for children. The randomization of physicians into one of three groups did not affect test orders for those exposed to price displays, while adult-focused physicians in fact ordered more tests when they saw the prices. No impact in telling physicians prices was observed in another study of more than 1,200 physicians in an accountable care organization.


A clear case exists for conducting customer service training on a yearly basis, and it should only be about an hour-long event. The practice should take pains to remind the front office staff of company policies, any changes made at the start of the year and if there are any exceptions they should be cognizant of. A call center training program is essential for this group, as they take all customer calls. Customer service is also handled by back office personnel, which often include the billing department, scheduling department and insurance verification center. Proper training can ensure a reduction in statement errors, to name one example. This is particularly important as customer statements go digital. Also worth training every year are medical providers and practitioners, partly to remove some of the burden from staff, who often feel overworked and undervalued. In addition, seeing more patients to provide for staff is becoming increasingly necessary because of insurance companies cutting visit reimbursements. This adds to the staff's patient load, which can cause irritability and bad patient interactions. To avoid this, practitioners should check in with this group at least once a month to assess their workload and defray any frustrations before they lead to staff and customer attrition.

Health Policy and Reimbursement

---

Senate Republicans unveiled a healthcare bill that makes deep cuts in Medicaid and ends the Affordable Care Act (ACA) mandate that most Americans have health insurance. The bill would create a new system of federal tax credits to help people buy health insurance, while offering states the ability to drop many of the benefits required by the ACA. The draft bill would cap federal payments to the states for most beneficiaries at the medical component of the Consumer Price Index (CPI) starting in 2020. Growth of those payments would be limited to the much lower CPI rate starting in 2025, a much tighter cap than proposed in the House bill. Under the draft Senate bill, tax credits to help people buy insurance in the individual market would be limited to those with incomes up to 350 percent of the federal poverty level, below the ACA's current limit of 400 percent of poverty. Qualified health plans would only need to cover an average of 58 percent of medical costs, which is lower than the minimum required actuarial value under the ACA. That likely would lead to increased out-of-pocket costs for consumers. The bill would repeal the ACA's tax penalty for not buying insurance as of December 31, 2015. Healthcare industry groups and patient advocates have criticized the House bill for increasing the number of uninsured, and they likely will criticize the Senate bill if the Congressional Budget Office scores it as having a similar effect.


The U.S. Centers for Medicare and Medicaid Services (CMS) has unveiled a proposed rule to simplify the Quality Payment Program as required by the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). The proposal in particular targets small, independent and rural practices to ensure fiscal sustainability and high-quality care within Medicare. The proposed rule would amend certain existing requirements and contains new policies for doctors and clinicians to encourage participation in either Advanced Alternative Payment Models or the Merit-Based Incentive Payment System. If finalized, the proposed rule would further advance the agency's goals of regulatory relief, program simplification and state and local flexibility in the creation of innovative approaches to healthcare delivery. CMS is also making it easier for rural and small providers to participate in the Quality Payment Program. CMS Administrator Seema Verma said, "By proposing this rule, we aim to improve Medicare by helping doctors and clinicians concentrate on caring for their patients rather than filling out paperwork."


The U.S. Centers for Medicare and Medicaid Services (CMS) will soon be required to remove Social Security numbers from Medicare ID cards because of identity theft and fraud risks, but CMS has not given providers clear guidance on their responsibilities to ensure their Medicare billing privileges are not affected by the ID changes. Many medical practices are uncertain how to prepare, and some are calling on CMS to do more to educate providers about the change, which could put physicians at risk of losing their ability to bill Medicare. Claims with the old numbers will not be accepted beginning in 2020, and practices also need to update their EHR systems to accept the new ID numbers. Making this change without transparency or stakeholder input could create scenarios where providers will not be paid in a timely fashion, potentially affecting access to care, the American Medical Association, Medical Group Management Association and others have said in letters to the CMS. CMS attempted to address some providers' concerns by announcing last month it would create a secure database where both providers and beneficiaries can look up their new ID numbers.


The U.S. Centers for Medicare and Medicaid Services (CMS) wants to exempt more small providers from having to comply with the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). Physician practices with less than $90,000 in Medicare revenue or fewer than 200 unique Medicare patients per year would be exempt under the new draft rule released on June 20. The move will eventually exclude a total of approximately 834,000 more clinicians from complying with the quality reporting program under MACRA. The original threshold was $30,000 or fewer than 100 Medicare patients. "We've heard the concerns that too many quality programs, technology requirements and measures get between the doctor and the patient," CMS Administrator Seema Verma said in a statement about the rule. "That's why we're taking a hard look at reducing burdens." CMS estimates only 37 percent of 1.5 million Medicare clinicians now billing under Medicare will be complying with quality reporting system under MACRA. To avoid penalties under the law that replaced the sustainable growth rate that was long considered flawed, physicians must follow one of two payment tracks: the Merit-Based Incentive Payment System (MIPS) or advanced alternative payment models like accountable care organizations. Small practices also can create "virtual groups" that would be evaluated under MIPS as one large entity.


The Quality Payment Program (QPP) established by the Medicare Access and CHIP Reauthorization Act of 2015 links physician reimbursement more closely to performance and encourages providers to participate in risk-based alternative payment models (APMs). Healthcare organizations are following different strategies to educate and ready physicians and other providers for the performance reimbursement system's deployment. The Palmetto Health Quality Collaborative rolled out an education initiative that includes face-to-face meetings, webinars and a newsletter. "The dialogue has been really important," notes Palmetto Health Quality Collaborative CEO Bill Gerard. "With a many-sided topic like this, you can't just send doctors some typed-up information. This is a case where they want to talk through the implications." Meanwhile, the multistate Catholic Health Initiatives (CHI) health system is training physicians about QPP on a regional basis. CHI has physicians in the MIPS, Advanced APM and MIPS APM tracks, and since each QPP track has distinct compliance mandates, national office staff have devised three separate education programs for the tracks. Northwestern Medicine has assigned six work groups to get ready for different facets of QPP, specifically communications, operations, performance, finance, independent physician alignment and information technology. Northwestern's data analytics group is developing an internal scorecard to provide timely insight into physician performance on MIPS metrics and to encourage improvement efforts.

Credentialing/Privileging

---

Grassroots doctor organizations across the country have banded together to demand relief from mandatory maintenance of certification (MOC), particularly for hospital credentialing and insurance network membership. "We have amassed almost 50,000 physicians who are communicating about this on Facebook," says Dr. Westby Fisher, cofounder of Practicing Physicians of America (PPA), a coalition of grassroots physician groups. Together, this movement has been influential in pressing medical societies to propose legislation to ban mandatory MOC requirements by hospitals and insurers in at least 17 states this year. Doctors in the anti-MOC movement argue that whereas initial board certification is a legitimate requirement, MOC has become an onerous money-making scheme that forces them to pay unnecessary and expensive recertification testing fees. A powerful MOC advocate is the American Board of Medical Specialties (ABMS), which helps set the standards for physician certification, and argues that ongoing assessment is vital to ensure doctors' knowledge and clinical judgment are up to date in their specialty. ABMS Member Boards have adopted some changes to lower the costs and increase flexibility for meeting the standards, but none of these attempts short of making MOC nonmandatory is stopping doctors in the anti-MOC movement from seeking legislative relief.