News From ACFAS

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Poster abstracts for the annual poster competition at ACFAS 75 in Las Vegas are due September 1. Don’t miss this chance to display your latest research in one of the busiest spots at the conference.

Electronic versions of all posters presented will also be available on acfas.org after ACFAS 75 concludes to bring your research to an even wider audience. Visit acfas.org/asc for poster guidelines and to submit your abstract today. Bring the coding and billing process to life in Coding and Practice Management Workshop, October 21–22 in Chicago.

Code real-time patient scenarios with expert faculty in this case-based, interactive workshop and learn practical tips for coding:

• multiple-procedure cases when performing forefoot, rearfoot or ankle reconstructive surgery
• open reduction and internal fixation of multiple fractures
• complex arthroscopy cases
• diabetic foot surgery

Register today at acfas.org/practicemanagement or call Sheila Alegria, ACFAS senior education coordinator, at (800) 421-2237, ext. 1323, and take the first steps toward simplifying your coding and reimbursement practices. Make an impact on the College’s educational programs and the profession—apply to join the educational faculty at ACFAS! As a member of the faculty, you will help lead and expand the College’s educational programs by sharing your expertise and fresh ideas. Plus, it's one of the best ways to give back to the profession!

If you're an active Fellow member of the College and have attended our educational programs within the past three years, complete a Faculty Application today and fax it to the ACFAS Education Department at (800) 382-8270 or email it to Mary Meyers, ACFAS director of Education Curriculum and Alliances.

Visit acfas.org for more information.

Foot and Ankle Surgery

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A patient’s perception of outcomes is not always defined by resolution, or the absence of symptoms, but can be characterized by behavioral adaptation and coping. A study compares patient-reported outcomes of patients with and without residual symptoms and limitations to expand the definition of a satisfactory outcome following ankle reconstruction. Based on a self-reported questionnaire regarding recovery and coping, ankle arthroplasty and arthrodesis patients were categorized as “Recovered-Resolved” (better with no residual effects) “Recovered, not Resolved” (better with residual effects), or “Not Recovered” (not better). Only 15 percent of patients were Recovered-Resolved, while 69 percent were Recovered, not Resolved. Fourteen percent of patients were categorized as Not Resolved. Recovered-Resolved patients experienced lower rates of pain, stiffness and difficulty performing activities of daily living. Outcome measures were high for Recovered-Resolved patients, midrange for Recovered, not Resolved patients and low for Not Recovered patients.


Researchers conducted a prospective pedobarographic study of a patient after undergoing microsurgical reconstruction of the foot with a latissimus dorsi flap and cutaneous paddle in order to demonstrate the role of pedobarography in the treatment of foot reconstruction. Pedobarographic measurements were recorded after the initial coverage surgery and two subsequent foot remodeling procedures, comparing the noninvolved foot and the injured foot. Values and progressions of foot shape, peak foot pressure, average foot pressure, contact surface, loading time and step time were measured. Initially, the pressure distribution of the reconstructed foot showed higher peak values at nonanatomic locations. Over time, the values improved in the involved foot. Patient-specific insoles were designed to correct imbalances between the two feet.


A longitudinal prospective study evaluated the outcomes and patient satisfaction of 28 patients who have undergone minimally invasive surgery for tibiotalocalcaneal arthrodesis with an intramedullary nail. Patients were evaluated clinically and radiographically at one, two, three and six months after surgery and at a last follow-up examination. At a mean follow-up of 25.07 months, the mean score recorded with the American Orthopaedic Foot and Ankle Society scale was 68.28 ± 5.02 points, and the mean visual analog score was 70.76 ± 7.72 points. Clinical improvements in both evaluations were statistically significant. Mean fusion time was 14.85 ± 4.12 weeks. Ankle and foot alignment was optimal in 27 patients, and patient satisfaction averaged 6.71 ± 1.37 points.

Practice Management

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Wireless networking offers both benefits and challenges in a healthcare environment. Not having to install network wiring throughout an office is a clear benefit, as is freedom of movement. However, security and reliability are obvious concerns, as a slow or unprotected network can waste time and resources and can make a practice vulnerable to security incidents. Fortunately, Wi-Fi technology has evolved to address security concerns, and reliability has improved, although this depends in part on the network, the connected devices and the surrounding environment. New Wi-Fi protocols increase the theoretical maximum speed of performance, but only if devices support the protocol. The basic technical standard for Wi-Fi is 802.11, and the newest and highest-performing standard is 802.11ac. If possible, invest in newer devices that support the highest-performing Wi-Fi possible. Using 802.11ac will allow offices to operate on a much less crowded bandwidth, but wireless should still be limited to essential activities to avoid using large amounts of bandwidth and slowing connection speeds for other users. Offices should also be aware of architectural features like elevator shafts that can block Wi-Fi signals and should add access points to achieve total wireless coverage.


As medical practices transition toward value-based payments under the Medicare Access and CHIP Reauthorization Act (MACRA) and the Merit-Based Incentive Payment System (MIPS), experts say they will need to leverage data. Doctors should review their Medicare Quality and Resource Use Reports. Some solo and small practices could also join forces with others through an entity, such as an accountable care organization or clinically integrated network, to help offset some of the costs of data reporting. Experts also recommend customizing the electronic health record software to make data collection as easy as possible and integrated into the practice's workflow. Dr. Dominic Gaziano, a solo internist practicing in Chicago, says practices will need to be able to have data that demonstrates they are taking actions that define quality, such as controlling patients' hypertension, getting them vaccinated and keeping them out of the emergency department. A document from the Centers for Medicare and Medicaid Services (CMS) notes that there are some exemptions from MIPS for small practices, including those with less than $10,000 in Medicare charges or fewer than 100 Medicare patients. The MACRA legislation also includes language allowing solo and small practices to join together in what it terms "virtual groups" for purposes of MIPS reporting. Doing so will enable them to spread the costs over a larger patient base and to compensate for some of the methodology bias favoring groups with large patient bases on which to report, says Shawn Martin, senior vice president of advocacy, practice advancement and policy for the American Academy of Family Physicians. CMS has said it will not issue rules regarding virtual groups until 2018.


Experts say new federal overtime rules taking effect December 1 may boost overhead for medical practices that underpay their office managers. The Fair Labor Standards Act (FLSA) requires employers to pay workers 1.5 times their hourly wage, or time and a half, when they put in more than 40 hours per week. Hourly workers are guaranteed overtime, and salaried employees should receive it unless they qualify as exempt. Starting on December 1, the threshold in the overtime rules will increase from $455 per week, or $23,660 per year, to $913 a week, or $47,476 per year. Office managers earning less than $47,476 a year should be paid overtime beyond 40 hours worked per week. This salary floor will be automatically updated every three years. Medical practices with salaried employees below the new overtime exemption threshold should not immediately consider a pay raise. Instead, they should ensure their employees are properly classified as exempt or nonexempt from overtime pay under FLSA, says Karen Felix at human resources consulting firm Marketstaff. Examples of staffers who warrant overtime are medical assistants and billing clerks. For a medical practice employee to be correctly classified as an exempt executive, he or she must be engaged primarily in managing the practice under FLSA. This includes those who regularly supervise at least two employees and also play a role in hiring and dismissing employees. Department heads in larger groups may also qualify for the executive exemption, such as billing department managers and medical-assistant managers.

Health Policy and Reimbursement

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Physician groups are pressuring regulators to solidify proposed changes to the federal electronic health record (EHR) program so physicians have more time to prepare for upcoming Medicare reimbursement revisions. Some major U.S. groups want the Centers for Medicare and Medicaid (CMS) to quickly issue a final rule that would expedite the reporting periods and make other changes to the meaningful use program that encourages doctors to adopt EHRs. The groups also are pushing CMS to postpone the start of the proposed Merit-Based Incentive Payment System. The Medical Group Management Association (MGMA) and other physicians' groups hope the agency will release final rules sooner this year, says MGMA's Rob Tennant. "Doctors are trying to meet their obligations for meaningful use and get ready for MIPS, and some certainty would go a long way." he notes. Physicians have long argued a full-year reporting period gives them no time to get ready for the next year of the program, which usually requires them to upgrade their EHR systems and collect new data about their patients to report to the CMS. In July, CMS issued the proposed Medicare outpatient hospital payment rule permitting hospitals and physicians that have previously participated in the meaningful use program to report during any continuous 90-day period within the calendar year on their compliance with meaningful use program mandates. The proposed rule also would remove the clinical decisions support and the computerized provider order entry goals for hospitals participating in the second and third phases of the program.


Claims cost growth was virtually flat from 2014 to 2015, indicating a healthy risk pool as enrollment continues to grow. According to the Centers for Medicare and Medicaid Services (CMS), per-member-per-month paid claims in the Affordable Care Act individual market fell by one tenth of one percent between 2014 and 2015. In comparison, per-enrollee cost in the employer market grew by 3 percent and private insurance premiums grew overall by 4 percent. Additionally, cost growth was lower in states that saw greater individual market enrollment. Marketplace member months increased 66 percent in 2015. Premiums increased by 2 percent in 2015, but 2016 marketplace premiums are estimated to be between 12 percent to 20 percent lower than the rates initially predicted by the Congressional Budget Office.


Aetna said it will stop selling individual Affordable Care Act (ACA) plans in 2017 in 11 of the 15 states where it had been participating in the program. The third largest health insurer in the United States said it had incurred $430 million in losses selling insurance to individuals since January 2014. According to CEO Mark Bertolini, there are not enough healthy people to financially offset those with significant health issues who incur major medical costs. "As a strong supporter of public exchanges as a means to meet the needs of the uninsured, we regret having to make this decision," he said. "The vast majority of payers have experienced continued financial stress within their individual public exchange business due to these forces." Several other large insurers have said they are losing money selling their plans in the marketplaces, and some are significantly reducing their participation. But Katherine Hempstead of the Robert Wood Johnson Foundation notes that these national carriers were not traditionally the largest part of the exchanges. Choices and competition may be affected in some areas; however, she does not consider this a death knell. "I think the market could survive without these guys," Hempstead said. "Obviously, it would be better to see lots of people seeing a lot of opportunity in this space. But I don't think it's a chapter in a Greek tragedy."


Expanded coverage in Medicaid expansion states has led to a dramatic improvement in patient access to medical care. Low-income patients in states that expanded Medicaid in 2014 are less likely to delay care because of cost concerns and have more regular checkups than residents of states without the expansion, according to a study published in JAMA Internal Medicine. In 2015, nearly 55 percent of low-income Arkansas residents had a checkup in the last year, up from 45 percent in 2013. Low-income patients reporting regular checkups in Kentucky jumped from 46 percent to nearly 60 percent. In comparison, fewer low-income patients in Texas, which is not an expansion state, reported getting a checkup in 2015 than in 2013. Medicaid has driven a historic drop in the uninsured rate; at least 20 million previously uninsured Americans have gained coverage since 2014. However, continued Republican opposition has left nearly 3 million Americans in 19 states without health insurance. "The sad thing is that in states that have not expanded, you see that same hunger for coverage," says Judy Solomon, a healthcare expert at the Center on Budget and Policy Priorities. "People just aren't getting it."

Medicine, Drugs and Devices

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The Internet of Healthcare Things (IoHT) consists of an increasingly vast array of Web-enabled devices, including wearables, implants, ingestible sensors, smartphone apps and home monitoring systems. As the technology matures, IoHT devices will facilitate a transformation in care by enabling constant monitoring of a patient, automating communications with clinicians and averting health episodes. According to a Goldman Sachs report, IoHT could save the industry more than $300 billion by improving chronic disease management. However, several challenges need to be addressed by the industry before IoHT can meet its full potential. The sheer amount of patient-generated health data could be overwhelming for providers if steps are not taken to evaluate what kind of data is included in patient records and how providers should use the data. Network infrastructure will also need to be improved and expanded to accommodate demand. With an abundance of devices on the market, these technologies should be able to communicate with each other safely and effectively. New standards will need to be established to ensure interoperability. The growth of the IoHT also opens doors for malicious activity, so these devices will require strong authentication features and secure communication channels. Finally, to make use of the influx of data, providers should develop competencies in big data analytics and invest in an information technology infrastructure.


Medtronic, one of the world’s largest manufacturers of medical devices, faces a whistleblower lawsuit claiming the company misled the U.S. Food and Drug Administration (FDA) and promoted its devices for unapproved uses. The Medtronic VERTE-STACK implant was cleared by FDA for use in the thoracic and lumbar spine but was marketed for use in the cervical spine. As of June, at least 6,000 people have sued the company for injuries related to its INFUSE bone graft system. The whistleblower suit was filed under the False Claims Act by one or more unnamed Medtronic employees and contends Medicare, Medicaid and other agencies reimbursed providers using the misbranded Medtronic device with hundreds of millions of dollars. Medtronic and FDA have not responded to the suit, but a ruling in the whistleblower’s favor could result in astronomical damages and penalties. Patient advocates say the case highlights the shortcomings of the medical device regulatory system, which does not subject devices to clinical trials.


Wearable technologies could soon become ubiquitous in the exam room, giving doctors another tool to deliver care and strengthen personal connections with patients. Smart glasses and head-mounted devices are already available and used on a small scale in clinical settings. These tools can give clinicians access to medical records, patient vitals or medical instructions without the need to look away from the patient to search for information. Some smart glasses enable two-way audio and visual communication, allowing a provider in one location to consult with a clinician in another office or a paramedic in the field. Identification badges equipped with radio-frequency technologies can be scanned to automatically record a clinician’s routine tasks. Many wearable devices are still in the testing phase while developers and providers work to integrate these technologies with other systems and ensure HIPAA compliance. Additionally, wearables require secure WiFi and sufficient network bandwidth and must be durable enough to withstand the medical environment. Once wearables enter the workplace, providers will need to adjust their workflow process to accommodate the technology.