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News From ACFAS
Foot and Ankle Surgery
Practice Management
Health Policy and Reimbursement
Technology and Device Trends

News From ACFAS

Congress, AHA Share Concerns on Doc Pay Fix

Members of Congress are concerned about finding a better fix to the Medicare physician reimbursement formula, and a clearer definition of “meaningful use” and a reasonable timetable for adoption of electronic health records (EHR), said representatives speaking at this week’s American Hospital Association (AHA) annual membership meeting in Washington, D.C. AHA has announced it will advocate for positive changes in these areas.

Rep. Chris Van Hollen, D-Md., who is chair of the Democratic Congressional Campaign Committee, said that if a permanent fix to the reimbursement formula cannot be passed, “at the very least we hope to enact a five-year fix, which would certainly be better than the month-to-month and year-to-year approach.”

Both Van Hollen and Rep. Michael Burgess, MD, R-Texas, expressed concerns that Centers for Medicare and Medicaid Services (CMS) rules on EHR adoption are trying to push hospitals too far, too fast, and that few hospitals will be able to meet CMS’ current definition of “meaningful use.”
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Foot and Ankle Surgery

Early Active Motion Versus Immobilization After Tendon Transfer for Foot Drop Deformity: A Randomized Clinical Trial

Researchers sought to determine whether, when compared with immobilization, early active mobilization after a tendon transfer for foot-drop correction would have a similar low rate of tendon insertion pullout, reduce rehabilitation time, and result in similar functional outcomes. They randomized 24 patients with surgically corrected foot-drop deformities to postoperative treatment with early mobilization with active motion at 5 days (n = 13) or 4 weeks of immobilization with active motion at 29 days (n = 11). In both groups, the tibialis posterior tendon was transferred to the extensor hallucis longus and extensors digitorum communis for foot-drop correction. The researchers observed no case of tendon pullout in either group during follow-up visits. Rehabilitation time in the mobilized group was reduced by an average of 15 days. The various functional outcomes were similar in the two groups.

From the article of the same title
Clinical Orthopaedics and Related Research (04/17/10) Rath, S.; Schreuders, T. A.; Stam, H. J.

Influences of Anti-tumour Necrosis Factor Agents on Postoperative Recovery in Patients with Rheumatoid Arthritis

Researchers investigated the influences of the anti-tumour necrosis factor (TNF) agents infliximab and etanercept on the postoperative recovery of patients with rheumatoid arthritis (RA) as well as the impact of biologics on wound healing. Patients with RA were split into a TNF group that underwent 39 operations and were treated with anti-TNF agents and a non-TNF group that underwent 74 operations and were treated only with conventional disease-modifying antirheumatic drugs. Operations included ankle arthrodesis and total arthroplasty of the hip, knee, elbow, shoulder and ankle. Adverse events (AEs) of surgical wounds occurred in two operations (5.1 percent) in the TNF group and in five operations (6.8 percent) in the non-TNF group, but this difference was not statistically significant. There were also no significant differences in the time for complete wound healing and in the length of the febrile period between the two groups. Percentage recovery of haemoglobin was significantly better in the TNF group than in the non-TNF group (96.3 vs. 90.1 percent, respectively). These results suggest that the use of anti-TNF agents does not cause specific AEs on surgical wounds after elective orthopaedic operations in RA patients and might improve the percentage recovery of Hb due to its prompt anti-TNF effects.

From the article of the same title
Clinical Rheumatology (05/01/10) Hirano, Yuji; Kojima, Toshihisa; Kanayama, Yasuhide

Percutaneous Interventions Below the Knee in Patients With Critical Limb Ischemia Using Drug Eluting Stents

Researchers conducted a midterm technical and clinical evaluation of stent angioplasty with drug-eluting stents in infrapopliteal lesions in patients with critical limb ischemia (CLI). Percutaneous stent angioplasty was performed in 128 limbs in 114 patients presenting with 320 vascular lesions. Lesions with up to 6 cm in length and at least one patent vessel below the obstruction were treated. Success was achieved in 99.06 percent of cases. Minor complications (hematoma, distal emboli, and vessel dissection) were documented in 8.77 percent of the patients. The 6, 12, and 18 months primary patency rate as controlled by Duplex sonography was 89.8, 84.2 and 83.3 percent, respectively; 77.6 percent of the lesions healed postinterventionally. The cumulative limb salvage rate was 95.6 percent. The researchers concluded that drug-eluting stent (DES) angioplasty in infrapopliteal arteries is a safe and effective technique for the treatment of patients with CLI.

From the article of the same title
Journal of Cardiovascular Surgery (04/01/10) Vol. 51, No. 2, P. 183; Balzer, J. O.; Zeller, T.; Rastan, A.; et al.

Practice Management

More Doctors Are Prescribing Medicines Online

The number of e-prescriptions nearly tripled in 2009 to 191 million from the previous year's 68 million, representing about 12 percent of the 1.63 billion original prescriptions, excluding refills, according to the online network that handles the bulk of the electronic communications. Approximately 25 percent of all office-based doctors currently have the technology to e-prescribe, more than twice as many as at the end of 2008. The increase in e-prescribing is expected to continue, due in part to a regulatory ruling last month that will soon allow doctors to start prescribing controlled medications such as narcotics and anti-depressants electronically.

From the article of the same title
Wall Street Journal (04/21/10) Martin, Timothy W.

Rightsizing Your Physician Practice's Staff

Finding the right level of staffing is important to creating an efficient and healthy practice. Under-staffing can negatively affect employee recruiting and retention, disrupt physician productivity, hinder patient service, and place patients and business operations in jeopardy. Meanwhile, over-staffing can cause poor staff interactions with physicians, a decrease in productivity, and an overall decrease in the bottom line. Achieving appropriate staffing levels is one of the more complex issues in healthcare, and a problem that every practice manager will face. "It is a balancing act. The more physicians you have, the more patients you see, the more staff you should anticipate to take care of them," says South Coast Orthopaedic Associates practice administrator Christopher Clark. "But you can't get to a level where it's just going to be breaking even. You have enough staff to take care of everybody, but you aren't making money. That is where you have to push the efficiencies." Clark says staff members receive a lot of cross training, so each person can perform a variety of tasks as needed. Some practices base their staff on the number of physicians, while others use a formula based on encounters, which involves counting both visits and procedures, like tests. If the economic recession has a positive, it is that staff members are largely staying in the positions they have, and when a job opportunity is posted there is a plethora of qualified applicants.

From the article of the same title
HealthLeaders Media (04/19/10) Commins, John

TN System Gives Patients Access to Health Records

Vanderbilt's MyHealth system, launched some six years ago, is an example of what might be created on a larger scale as health providers try to give patients more online access to health records. The health portal, accessed with a user name and password, began as an avenue for patients to send messages to doctors with whom they had appointments but has expanded since to include lab results, online bill payment, health tips, and more.

From the article of the same title
Tennessean (TN) (04/19/10) Sanchez, Christina E.

Health Policy and Reimbursement

Health IT Policy Group Calls For Patient Safety Oversight Program

The federal Health Information Technology Policy Committee is pushing for the development of a national program to monitor patient safety problems in healthcare IT (HIT) systems. One of the group's first suggestions was creating a national transparent oversight process and information system, similar to a patient-safety organization, capable of receiving reports from numerous sources on patient safety issues related to the use of healthcare IT systems. The FDA, which currently has regulatory authority over medical IT, says it will work with the recommendations from the group, and that it is willing to be flexible as part of a larger approach to health IT safety.

From the article of the same title
Medical News Today (04/26/10)

Report Says Healthcare Will Cover More, Cost More

Economic experts at Medicare's Office of the Actuary concluded in a report issued Thursday that the recently-enacted healthcare reform measure will provide coverage to an additional 34 million individuals but will raise projected spending by approximately 1 percent over 10 years. That increase could get larger, since Medicare cuts in the law may be unrealistic and unsustainable, according to the report, which projected that Medicare cuts could drive about 15 percent of hospitals and other institutional providers into the red, "possibly jeopardizing access" to care for the elderly. The report, however, did acknowledge that some of the cost-control measures in the bill—Medicare cuts, a tax on high-cost insurance, and a commission to seek ongoing Medicare savings—could blunt the rate of cost increases after 2020.

From the article of the same title
Associated Press (04/23/10) Alonso-Zaldivar, Ricardo

Legislation Expands Scope of EHR Meaningful Use Eligibility

President Obama signed The Continuing Extension Act of 2010 into law April 15, changing the definition of "hospital-based physician" as it was originally stated in the 2009 American Recovery and Reinvestment Act's (ARRA's) HITECH legislation and thereby expanding EHR meaningful use incentive eligibility to outpatient-based hospital physicians. The Continuing Extension Act changes the word "outpatient" in the description of a hospital-based setting "whether inpatient or outpatient" to read "inpatient or emergency room setting." The change was necessary, says Margret Amatayakul, president of Margret\A Consulting, LLC, in Schaumburg, Ill., because "it became obvious that [ARRA] was not going to cover providers that had to buy their own system, but did much of their work in hospital."

From the article of the same title
HealthLeaders Media (04/21/10)

Rescission Practices in the Limelight

Tens of thousands of Americans have lost their health insurance shortly after being diagnosed with life-threatening, expensive medical conditions. Insurance companies have used the practice, known as "rescission," for years. A congressional committee last year said WellPoint was one of the worst offenders, specifically targeting women with breast cancer for aggressive investigation with the intent to cancel their healthcare policies. A recent investigation by Reuters showed that another health insurance company, Assurant Health, targeted HIV-positive policyholders for rescission. That company was ordered by courts to pay millions of dollars in settlements.

In his push for healthcare reform, President Barack Obama said the legislation would end such industry practices. But critics worry the new law will not lead to an end of these practices, saying the healthcare legislation lacks teeth, at least in terms of enforcement or regulatory powers to prevent the practice.

From "WellPoint Routinely Targets Breast Cancer Patients"
Reuters (04/22/10) Waas, Murray

Doctors Slam Blue Shield's Physician Rating System

The California Medical Association (CMA) has withdrawn from a new physician-rating system co-created by Blue Shield of California and the Pacific Business Group on Heath set to go public June 1, citing "serious and disturbing flaws" with data collection that lead to "gross inaccuracies." The Blue Ribbon Recognition Program will highlight physicians who achieve high scores according to evidence-based quality standards. Those whose scores are "above average" based on data collected for up to eight measures by the California Physician Performance Initiative will have a blue ribbon icon placed next to their online Blue Shield profiles. CMA says the ratings are "defective" for several reasons, including "lack of relevant data collection" and "no consideration for the patient's role."

From the article of the same title
Fierce Healthcare (04/20/2010) Bowman, Dan

Technology and Device Trends

Discovery Could Help Diabetics and Others With Slow-to-Heal Wounds

A discovery by Loyola University Health System researchers that certain immune system cells retard the wound-healing process could provide clues into inactivating these cells to improve healing, according to research detailed in the Journal of Surgical Research. The cells in question, known as natural killer T (NKT) cells, destroy tumor cells and virus-infected cells, but also flock to wound sites and hinder healing. "We demonstrated that early wound closure was accelerated in the absence of NKT cells," wrote the researchers. "Importantly, we also made the novel observation that NKT cells themselves are a constituent of the early wound inflammatory infiltrate." The research determined that NKT cells may play a role in the prevention of wounds healing in persons with diabetes or certain infections, and that it may be possible to inactivate the cells with an antibody; this hypothesis is being tested in a follow-up study.

From the article of the same title
Newswise (04/16/10)

Stem Cell Therapy Feels Food and Drug Administration's Pinch

Stem cell therapy is a regenerative procedure in which adult stem cells are harvested from the patient's bone marrow, cultivated, and injected into damaged tissues, but the U.S. Food and Drug Administration (FDA) says stem cells are a type of drug that requires rigorous study and licensing. A lack of licensing threatens the provision of stem-cell therapy, with the FDA contending that the performance of such procedures appears to be in violation of the Public Health Service Act. Chris Centeno, who developed a stem-cell treatment called Regenexx, argues that the FDA overstepped its authority when, in an attempt to prevent the proliferation of disease, it decided that a patient's own stem cells should be regulated as if they were being used on another human being. If the FDA digs in its heels, Centeno may be forced to go outside the United States with his Regenexx therapy, which he licenses to other doctors; he is currently helping to open a Regenexx clinic in a Chinese orthopedic hospital. Centeno reports that stem-cell procedures have been quite positive in terms of safety, noting that "when compared to other things like knee replacement or a big orthopedic surgery or microfracture or a laminectomy, the risk profile of this is far less than all of them."

From the article of the same title
Denver Post (CO) (04/13/10) Blevins, Jason

The Diabetogenic Mouse MHC Class II Molecule I-Ag7 is Endowed With a Switch that Modulates TCR Affinity

A group of researchers from the Scripps Research Institute have reached a new understanding of how certain genetic mutations can lead to Type 1 diabetes, and this could lead to new treatments for Type 1 diabetes and other autoimmune diseases. "We were interested in trying to understand why certain MHC molecules [which are molecules in mice analogous to HLA molecules in humans] are linked to autoimmune disease, particularly type 1 diabetes," says researcher Adam Corper. "In particular, we wanted to know why a single residue at position 57 on the ß chain of HLA molecules seems to be linked to the disease." The structure of a "diabetogenic" MHC molecule had been previously determined, and it was discovered that only subtle changes stemmed from mutations to position 57; a later study found that diabetes-triggering mutations changed the charge at one end of the MHC peptide-binding groove, causing the molecules to select a novel subset of T cells that bound to it strongly, with "higher affinity." The cells may overreact and potentially perceive "self" peptides as dangerous rather than innocuous.

From the article of the same title
Journal of Clinical Investigation (04/19/2010) Yoshida, Kenji; Corper, Adam L.; Herro, Rana; et al.

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April 28, 2010