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The media is full of bad news about many of the nation’s financial institutions, but there’s good news to report from America’s non-profit credit unions. And the ACFAS credit union, Healthcare Associates Credit Union (HACU), just released its 2008 audit that the auditor described as a “phenomenal year.” ACFAS members now have over $4 million in business and personal loans via HACU.

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Foot and Ankle Surgery

Increased Foot-related MRSA Infections Seen by Physicians

An increasing number of infections involving MRSA (methicillin-resistant Staphylococcus aureus) are stemming from common foot problems like cracked and cut skin, ingrown toenails, and athlete's foot, according to information presented at the 67th Annual Scientific Conference of the American College of Foot and Ankle Surgeons. "If you have a cut or a scrape that gets infected and it's not healing in a timely fashion, don't hesitate to get it checked out," says Karl Collins, DPM, FACFAS, a foot and ankle surgeon in St. Louis. Brandi Johnson, DPM, AACFAS, a Brandon, Fla., foot and ankle surgeon, estimates treating 20 patients in 2008 for community-associated MRSA, of which half had infected ingrown toenails. The remaining infections were linked to puncture wounds, pedicures, and cuts from seashells or glass, according to Johnson. One of her patients, a teenage boy, waited months before seeing his primary care doctor, who referred him to Johnson. Test results showed a community-associated MRSA infection, which had spread to the bone of the big toe. Foot and ankle surgeons recommend that people promptly wash and bandage cuts, see a physician within 24 hours for any puncture wounds, keep their feet dry and clean to prevent fungal infections such as athlete's foot, and abstain from cutting or digging ingrown toenails. Healthcare-associated MRSA has existed for decades in settings such as hospitals and nursing homes. But within the past decade, community-associated MRSA has emerged as a threat, as outbreaks occur in schools, sports teams, prisons and other places in the community with populations that are generally healthy.



Surgical Treatment of Distal Tibia Fractures: A Comparison of Medial and Lateral Plating

A study was conducted to determine if there was an advantage to using medial or lateral plating for distal tibia fractures. Anterior plating is a good procedure because it allows the physician to examine the tibia closely, but there is a high risk of wound complications and nonunions. Additionally, if the fibula needs to be fixed, another cut has to be made on the lateral side of the shin. Lateral plating has shown good results in patients, but the studies that have been done have been small series. Eighty-eight patients with distal tibia fractures were used in the study. The anterior group contained 49 individuals, and the lateral group contained 39 people. The two groups had similar characteristics with regard to injury mechanism, union rate, malunion rate, time spent on operation, functional score, and the range that the ankles could move. Both groups had patients with good functional outcomes and low malunion rate, but the lateral group did not have as many complications or hardware issues.

Practice Management

How to Make Electronic Medical Records a Reality

The U.S. effort to adopt electronic medical records stands as an excellent example of the challenges, both in terms of economics and in terms of engineering, of adopting new technology. Large medical groups' use of data analysis from digital records has demonstrated the technology's ability to improve how chronic-disease patients' care is managed, among other things. However, three out of four doctors in the United States are in small offices with no more than 10 doctors, which means most of them see digital records as an expense they will not be reimbursed for. "This is really not a technology problem," said Erik Brynjolfsson, an economist at the Sloan School of Management at the Massachusetts Institute of Technology. "It's a matter of incentives and market failure." As a result, the Obama administration is attempting to influence the market with incentive payments of over $40,000, spread over several years, for physicians who implement electronic health records. To help ensure that the technology is used to its best advantage, meanwhile, the legislation includes language that says it will pay physicians only for the "meaningful use" of digital records, though the government has not put forth a precise definition of this so far. Experts say one important element of success with digital records will be local organizations' efforts to help small practices adopt and use electronic records, and to this end, the legislation calls for creating "regional health IT extension centers," such as New York City's Primary Care Information Project.



Studies Examine the Impact of Scan Quality on Imaging Costs

Medical imaging is now a $100-billion-a-year industry in the United States, with Medicare paying for $14 billion of that. However, recent studies claim that as many as 20 percent to 50 percent of the procedures should never have been done because their results did not help diagnose ailments or treat patients. Some medical observers say that bad scans are part of a growing problem with medical imaging, due in part to the fact that insurers do not distinguish between scans that are done poorly or done well or read by less- or more-qualified doctors. Dr. Gary Glazer, the chairman of radiology at Stanford, says technology has advanced so much that [an] older scanner "is not the same machine." Imaging centers can gain accreditation from the American College of Radiology, but some centers are not accredited, although the percentage is not known because there is no national registry of imaging centers. However, new Medicare rules that go into effect in 2012 will result in Medicare only paying for scans done at accredited centers. “The studies I see coming from the outside vary from marginal quality to very good quality,” says Dr. Chris Beaulieu, a Stanford radiology professor, who notes that interpretation can be crucial. “A good radiologist can sometimes accurately read scans off of a lower-quality scanner,” he says. “I see that all the time."



States Called Lax in Reviewing Inactive Doctors

A report in the February issue of Pediatrics discovered that 66 percent of state medical boards do not inquire about whether a doctor is actively practicing upon licensure and renewal. Another survey in the same issue found that one in eight pediatricians has not practiced for a year or longer. "If [physicians] are not participating in maintenance of certification or other activities to continuously demonstrate their knowledge and other acts of practice, then what really are we licensing them for?" says Dr. Gary L. Freed, MD, MPH, lead author of both studies. The Federation of State Medical Boards has examined a potential policy that would make up for the lack of information upon reviewing doctors. The policy suggests that state licensing boards require doctors applying for license renewal to do a self-evaluation, a judgment of their practice, show knowledge in areas such as patient care and medicine, and be tested on their specialties. If the policy is used, each state board and state lawmakers would determine if they would like to use it.



Docs Seek Gag Orders to Stop Patients' Reviews

Some physicians are asking patients not to post negative comments online, with North Carolina neurosurgeon Dr. Jeffrey Segal complaining that Internet reviews do little but spread bad word-of-mouth instead of providing helpful information to patients and consumers. He attests that such posts fail to assess a doctor's medical skills, and physicians have little recourse open to them because of privacy laws and medical ethics. Segal runs Medical Justice, a firm that offers doctors a standardized waiver agreement in which a patient consents not to post online comments about the doctor, "his expertise and/or treatment." "Published comments on Web pages, blogs and/or mass correspondence, however well intended, could severely damage a physician's practice," says suggested wording provided by Medical Justice. The company recommends that doctors have all patients sign the agreements, and suggest that new patients find another physician if they refuse. Segal says he is unaware of any instances in which longtime patients have been denied treatment for not signing the waivers. Doctors are alerted when a negative rating appears on a Web site, and they can use the signed agreements to force the site to take down the comments if the author's name is known. Almost 2,000 physicians have signed up for Medical Justice's service since its rollout two years ago.

Health Policy and Reimbursement

United Sets New Basis for Fee Schedule

United Healthcare says that it will amend contracts that permitted downgrades in physician pay without notice starting in April, and this move will impact 70,000 doctors across the United States. Rather than changing pay rates when Medicare adjusts its relative-value units (RVUs) every three months, United will continue to pay those physicians fees founded on the 2008 Medicare pay scale. United's Cheryl Randolph said the goal of this revision was to "increase the reliability and predictability of physician payments." The California Medical Association's (CMA) Aileen Wetzel reported that some 25,000 California physicians were paid under the variable fee schedules, and her organization said that the progressive RVU fee schedule updates were dropping payment by up to 9.5 percent, including pay for some common CPT codes, such as those used for preventive visits. Wetzel noted that an attachment to doctors' contracts indicated that United reserved the right to make changes to reimbursement as part of "routine maintenance," adding that CMA requested last year that United send notices of their rate changes for physicians who were contracted under the variable scale. The [revised] fee schedule is not necessarily more favorable, but the good side of that is it is fixed," she said. The American Medical Association is against the use of RBRVS as a platform for non-Medicare reimbursement unless the scale is "annually updated and rigorously validated." California and other state insurers are mandated to provide written advance notice of material changes to contracts, and health plans agreed over the last five years to give reasonable notice of fee schedule and contract changes as part of federal class-action settlements with doctors.



Therapy Cap Bill Introduced on Hill

Separate measures in the U.S. House and Senate would permanently remove caps limiting Medicare beneficiaries' access to outpatient physical therapy and occupational therapy as well as speech-language pathology services, guaranteeing permanent access to these services. The Balanced Budget Act of 1997 imposed caps on access, though Congress has routinely passed moratoriums on these caps. Lacking any congressional action, the cap on therapy services would go into effect on Jan. 1, 2010, impacting some 650,000 patients. "For more than a decade, Congress has taken stop-gap measures to ensure that Medicare beneficiaries receive the therapy and services they need and their doctors prescribe," said Rep. Roy Blunt (R-Mo.). "It’s time that we put aside the temporary patches we have passed for the last decade and work on a permanent fix that eliminates arbitrary caps limiting the quality of care patients receive." American Health Care Association President and CEO Bruce Yarwood said, "The long term care profession is deeply committed to enhancing the quality of care and services provided to patients in our facilities, and access to therapy services plays an integral role. ... The high-acuity patients we serve are those Medicare beneficiaries most in need of therapy services, such as those patients recovering from strokes and joint replacements."



Stimulus Will Help Laid-off Workers With COBRA Costs

Effective at the beginning of this month, the federal stimulus package is subsidizing 65 percent of COBRA premiums for employees laid off since Sept. 1 and until the end of this year. Employers have until April 17 to notify eligible former employees, and employees who did not immediately sign up for COBRA coverage now have 60 days to re-enroll after receiving such a notice. Employees who left voluntarily or retired are not eligible, nor are people who have access to other group insurance, such as a spouse's insurance or Medicare. People who are eligible for the study may also be allowed by their employers to switch to less expensive insurance, unlike the usual COBRA requirement that people stay with the plan they were on while they were working.

Technology and Device Trends

Researchers Find Safer Way to Make Stem Cells

Scientists from Britain and Canada have announced they have found a way to transform skin cells into stem cells, potentially enabling researchers to bypass the use of embryonic cells in their research. The researchers were able to convert skin cells into induced pluripotent stem cells, or iPS cells, without the use of viruses. The iPS cells were created by using a "piggyBac" transposon which was rigged to carry four genes and alter the genetic code. This new technique is important because it eliminated the need to use viruses. Methods without viruses are safer since viruses can insert their genes into the iPS cells, potentially causing abnormalities. Additionally, the genes can be removed after the procedure. "It is a step toward the practical use of reprogrammed cells in medicine, perhaps even eliminating the need for human embryos as a source of stem cells," says Keisuke Kaji from the Medical Research Council Center for Regenerative Medicine in Edinburgh. The research appears in the online edition of the journal Nature.



Pain May Occur After Magnetic Resonance Arthrography

Research appearing in the March issue of Radiology says that patients undergoing magnetic resonance (MR) arthrography may notice pain, particularly several hours after the procedure. The research, by Nadja Saupe, MD, of the Orthopedic University Hospital Balgrist in Zurich, Switzerland, and colleagues, analyzed data from 1,085 adults who underwent MR arthrography of various joints, including the ankle. Those patients under the age of 30 reported the most pronounced pain, though within a week all pain was resolved. "MR arthrography is more accurate than standard MR imaging in the detection of many internal derangements. However, MR arthrography has an invasive component and may cause pain and anxiety. In rare instances, severe complications, such as infection, may occur," the authors write. "In conclusion, MR arthrography temporarily increases joint-related contrast medium pain. Such pain depends on patient age but does not depend on joint type, injected contrast medium volume, sex, or radiologist experience."



Abstract News © Copyright 2009 INFORMATION, INC.

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