News From ACFAS

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If you attended the ACFAS 2014 Annual Scientific Conference in Orlando, you're eligible to download the session handouts, which are now available online.

To download, visit acfas.org. Log in is required. ACFAS is Coming to You to bring the latest cutting-edge education to practicing and in-training surgeons across the nation with the hands-on lab, Simple to Complex Forefoot Revisional Surgery Workshop and Seminar. Next stops: Tysons Corner, VA on April 25-26 and Manhattan Beach, CA on May 2-3.

Register today for this program, which begins on a Friday evening at 4pm with a presentation on Common Forefoot Surgical Complications and a case study discussion and presentations by the audience. It wraps on Saturday afternoon after a full-day lecture and lab, and you’ll walk away with advanced surgical knowledge of a wide-variety of fixation options for the treatment of forefoot deformities. Participants will also earn 12 continuing education contact hours upon completion.

To register, visit acfas.org.

Foot and Ankle Surgery

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A new study has found that the rate of complications is high in seniors who undergo surgery for ankle fractures. The study examined 186 patients at an average age of 70.67 years who underwent surgery for ankle fractures, 132 of whom were females and 54 of whom were males. The overall complication rate was 21.5 percent, though 10.8 percent were major complications that required surgery for wound washout, removal of implants, and revision of fixation. The study found that there was a significant association between smoking, age, diabetes, local factors such as osteopenia and peripheral neuropathy, and a higher modified Charlson score and post-surgical complications. The study concluded that doctors should look for the presence of these factors when deciding whether or not to operate. If any of these factors are present, surgeons should inform their patients about the higher risk of complications following surgery, the study noted.


Diabetics who fail to get prompt medical attention for foot problems run the risk of having to undergo an amputation, research presented at Diabetes UK's Annual Professional Conference has found. The study by researchers at Leicester University examined 20 cases of foot problems in which care had been delayed for an average of 18 weeks. The study found that amputations were needed in 30 percent of cases in which care had been put off in order to prevent the onset of more serious complications. Bridget Turner, the director of policy and care improvement at Diabetes UK, said the results indicate that more needs to be done to increase awareness among diabetics about the risk of lower limb amputation and to ensure that people who are at high risk of amputation are given information about how to respond to problems in their feet. Diabetics are being urged to reduce their chances of lower limb amputation by properly controlling their disease and by visually inspecting their feet for problems such as in-grown toenails, bunions, and dry skin.

Practice Management

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Theft by employees at all levels has been on the rise at medical practices and other businesses over the last several years. However, doctors' practices can adopt a number of best practices to help prevent embezzlement and other forms of employee theft. For example, doctors' practices should be on the lookout for employees who display an interest in practice finances that does not seem to be related to their jobs. The presence of inappropriate relationships between practice employees and customers or suppliers may also be an indication of employee theft. Beyond employee behavior and relationships, practices should also keep a close eye on accounting and record keeping issues, including any unusual inventory changes, sudden declines in profits, or travel expenses that seem unreasonable. Finally, discrepancies between daily receipts and daily bank deposits may be a clue that an employee is committing theft.

Health Policy and Reimbursement

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A study published in the online edition of the journal Health Services Research has found that about 60 percent of group physician practices have not joined accountable care organizations and do not plan to do so in the immediate future. Of the roughly 1,180 medical groups that were surveyed, 25 percent said they were currently part of ACOs and an additional 15 percent said they planned to join an ACO soon. The study also found that a practice's decision not to join an ACO can impact the care it provides. According to the study, practices that had no plans to join an ACO had the lowest scores on an index of 25 measures of care management, patient engagement and quality, while practices that had already joined ACOs had the highest scores. Study author Stephen Shortell of the University of California at Berkeley says that these differences suggest that the ACO payment model will not be widely or quickly adopted. This may be because many medical groups do not have the ability to manage the financial risk associated with ACOs. However, Shortell and his co-authors said the success practices have enjoyed after joining ACOs could encourage practices that are not in ACOs to join.


The Obama administration has released a number of proposed rules and guidelines for insurance companies that want to participate in the Affordable Care Act's insurance exchanges next year. One such proposal calls for the Centers for Medicare and Medicaid Services (CMS) to take responsibility for ensuring that provider networks include an adequate number of medical providers--a task that is currently the purview of the states. Plans would generally be required to work with at least 30 percent of the essential community providers in the areas where they do business. Federal officials say this rule, as well as several other proposals, are designed to encourage insurance companies to adopt better protections for their customers. Another proposal calls for changes to the risk corridors, reinsurance, and risk adjustment that are designed to provide insurance companies with financial protections as they begin to offer plans through the health insurance exchanges. However, the proposals are being met with skepticism from the insurance industry. Anne Hance, the co-chairwoman of the insurance/payers affinity group at McDermott Will & Emery, said the proposals just add to the uncertainty that the insurance industry is already facing in 2015 as a result of the incomplete information it is being given about the health status and costs for those who enrolled in insurance coverage this year.


With the end of the Affordable Care Act's open-enrollment period on March 31 rapidly approaching, insurers are trying to increase the number of young people enrolled in plans offered through the nation's health insurance exchanges. For example, Independence Blue Cross in Pennsylvania and Arches Health Plan in Utah have both launched efforts to encourage young people to purchase health insurance plans. Their efforts come amid concern that not enough young people have signed up for coverage since the health insurance exchanges went online last fall. Since then, only about 25 percent of those who have purchased coverage were between the ages of 18 and 34. Most experts believe that between 33 percent and 40 percent of enrollees need to be in that age group in order to offset the cost of insuring older people with more health problems and thus keep premiums down next year. Peter Cunningham, a professor of healthcare policy and research at Virginia Commonwealth University, says the challenge in getting young people to sign up is to convince them that health insurance is worth the premiums they will have to pay for coverage.


The Congressional Budget Office (CBO) has released an analysis of the expected effects of Rep. Dave Camp's (R-Mich.) plan to pay for the repeal of the Medicare Sustainable Growth Rate (SGR) formula by delaying penalties for those who do not comply with Affordable Care Act's individual mandate. The plan is included in an amendment to the bipartisan SGR repeal bill. Delaying the penalties until 2019 would save roughly $169.5 billion over 10 years, CBO said--which is more than enough to pay for the $138.4 billion 10-year cost of repealing SGR. But CBO also said that the delay would increase the number of people without health insurance by 13 million by 2018. That would include 5 million fewer people with coverage from Medicaid or the Children's Health Insurance Program, CBO said. The discussion of the effects of Camp's amendment may be moot, because it is unlikely to be adopted by the Senate. Without another way to pay for the repeal of SGR, Congress could be forced to pass another temporary fix before the current patch expires at the end of the month.


Health and Human Services Secretary (HHS) Kathleen Sebelius appeared before the House Ways and Means Committee on March 12 and said that there would be no delay in the implementation of the Affordable Care Act's individual mandate, nor would there be an extension of the open enrollment period that is currently scheduled to end March 31. The response was criticized by some Republican members of the panel, who said that the administration should give consumers more time to comply with the Affordable Care Act, just as it has given businesses and other groups additional time. Sebelius responded by saying that only a small number of businesses are affected by the Affordable Care Act's employer mandate, which was one of the provisions of the law that was delayed. Sebelius also squabbled with GOP committee members over how many people have signed up for health insurance coverage through the new exchanges and have paid their premiums. Sebelius said that 4.2 million people have signed up for coverage, but she did not know how many had paid--a remark that was met with incredulity from Rep. Tom Price (R-Ga.). HHS should have a better idea about how many people have paid their premiums once the open enrollment period ends, Sebelius said.


The Centers for Medicare and Medicaid Services (CMS) is advising hospitals that have not successfully participated in the Medicare Electronic Health Record (EHR) Incentive Program of the steps they can take to avoid the payment changes that are scheduled to take effect Oct. 1. For example, hospitals that have never participated in the incentive program have two options for avoiding the payment adjustments: they can either submit a hardship exception application to CMS by 11:59 p.m. April 1 that details the significant obstacles that prevented them from achieving meaningful use, or they can achieve 90 days of meaningful use beginning April 1 and ending July 1. CMS says that hospitals that participated in the incentive program in 2011 or 2012 but did not successfully participate last year due to various problems can also submit a hardship exception by April 1. Hardship exemptions that are approved by CMS will be valid for one year. Finally, CMS says that hospitals that are eligible for both the Medicaid and Medicare EHR incentive programs can avoid the Medicare payment adjustment by achieving meaningful use under the Medicaid incentive program.


The Government Accountability Office (GAO) has issued a report criticizing the Department of Health and Human Services (HHS) for failing to develop a comprehensive strategy for its meaningful use electronic health record (EHR) program. The report noted that this lack of a comprehensive strategy is problematic partly because some healthcare providers may report clinical quality measures (CQM) from their EHRs based on and tested to different requirements, depending on whether their EHRs include technical updates or not. In the absence of a comprehensive strategy for meaningful use, the report said, HHS could find it difficult to use these CQMs to deal with reliability issues and improve quality and efficiency. The report concluded by calling on HHS to develop a strategy that would help ensure CQM data collected via EHRs is reliable and to develop and implement outcome-oriented performance measures to keep tabs on the progress that is being made towards meeting the meaningful use program's goals. HHS, for its part, said it agreed that data reliability and performance monitoring are important, though it took a neutral position on GAO's specific recommendations.


President Obama's fiscal 2015 budget asks Congress to provide $1.8 billion to support health information technology incentives--an amount that would represent an increase from the $1.07 billion that was spent on such incentives in 2013. Elsewhere, President Obama proposes cutting discretionary funding for the Department of Health and Human Services by $800 million from fiscal 2014 levels to $77.1 billion. That money will be used to fund a variety of activities, including enhancing the Affordable Care Act's health insurance coverage improvements, starting a new program designed to improve access to high-quality healthcare providers and services, and adopting Medicare and Medicaid payment innovations and other reforms. The goal of these payment innovations, the president's budget states, is to ensure Medicare and Medicaid beneficiaries receive high-quality healthcare in an efficient manner and to improve the integrity of the programs. President Obama believes these payment innovations will also save the federal government $402 billion over the next 10 years.

Medicine, Drugs and Devices

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A systematic literature review and meta-analysis of 34 randomized controlled trials has found that there is no difference between duloxetine and other post-first line oral osteoarthritis (OA) treatments in terms of changes in total Western Ontario and McMaster Universities Index (WOMAC) score after about 12 weeks of treatment. There was some evidence that duloxetine was better than etoricoxib and worse than tramadol and oxycodone, though no consistent differences between these drugs were seen. However, the analysis did find that all of the post-first line oral OA treatments that were examined except oxycodone and hydromorphone were more effective than placebo. Researchers warned that their analysis had several limits, including the low number of studies that were included and the fact that only English-language publications served as sources for the studies that were analyzed.


A recent study examined the effect that syndesmosis screw removal has on the reduction of the distal tibiofibular joint. The study involved 25 patients who displayed intraoperative evidence of syndesmotic disruption. Computed tomography (CT) scans were performed on bilateral ankles within two weeks after patients underwent operative fixation. Surgeons removed syndesmotic screws after three months and then performed an additional CT scan 30 days after the screws were removed. Axial CT images were used to evaluate syndesmotic reduction in comparison to the contralateral healthy ankle. The study found that 36 percent of patients displayed evidence of syndesmosis malreduction when their initial axial CT scans were performed after surgery. When CT scans were performed after the removal of the postsyndesmosis screws, adequate reduction of the tibiofibular syndesmosis was seen in 89 percent of the malreductions. Surgeons also observed that there was a statistically significant reduction in syndesmotic malreductions between the initial rate of malreduction after screw placement and the rate of malreduction following screw removal. These findings led surgeons to conclude that syndesmotic screw removal can help achieve final anatomic reduction of the distal tibiofibular joint, and that screw removal should be used for the malreduced syndesmosis.