News From ACFAS

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A limited number of spots are still available for Foot and Ankle Arthroscopy, December 16–17, 2018 at the Orthopaedic Learning Center in Rosemont, Illinois. Register now at acfas.org/skills so you don’t miss out on:

• More than nine hours of hands-on laboratory time
• The chance to use state-of-the-art equipment and advanced techniques on fresh cadaver specimens
• Presentations by expert faculty, including videos of actual arthroscopic cases
• A fireside chat, during which you can share radiographs of your most challenging cases

Foot and Ankle Arthroscopy is worth 16 continuing education contact hours. Visit acfas.org/skills to sign up now and be part of what is considered the gold standard in arthroscopic training. Download the summer issue of FootNotes from the ACFAS Marketing Toolbox and turn up the heat on your practice’s marketing efforts.

Articles in this latest issue include:

• Don’t Forsake Foot Health for Fashion with Flip Flops
• Tips for a Safer Barefoot Summer
• Living with Diabetes? Protect Your Feet from Summer Heat

To get the most mileage from FootNotes, customize page 2 with your practice’s contact information then print and distribute copies to your patients, post FootNotes on your practice’s website and social media pages and distribute copies during any local speaking engagements you have lined up for this summer.

FootNotes is just one of many free resources available in the Marketing Toolbox. New products, including PowerPoint presentations, infographics and healthcare provider referral tools, are added to the Toolbox regularly. Visit often for easy and creative ways to spotlight your practice any time of year. Tune into this month’s podcast, “Reducing the Incidence of Postoperative Infections,” for real-world advice on steps you can take before, during and after surgery to reduce postop infections in your patients.

• Hear a panel of your peers discuss:
• Which patient populations are at a higher risk of infection
• Use of prophylactic antibiotics
• Alternative approaches to take based on patients’ prescribed medications
• Prepping for surgery

ACFAS’ complete podcast library is available 24/7 at acfas.org/e-learning. New podcasts are added to the library each month to help you stay up to date on hot topics in the profession.

Foot and Ankle Surgery

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Researchers sought to evaluate the outcomes of Gustilo type III open distal tibial and tibial shaft fractures with severe anterior and medial soft-tissue injuries, treated with posterolateral minimally invasive plate osteosynthesis (MIPO) technique.

From May 2015 to May 2016, 10 patients with Gustilo type III open distal tibial and tibial shaft fractures with severe anterior and medial soft-tissue injuries were treated with staged protocol using posterolateral MIPO technique.

The initial wound lavage, debridement and application of a spanning external fixator were performed within 24 hours, and the mean interval from injury to definitive surgical treatment was 12.8 days. An additional bone graft was performed in two patients when definitive internal fixation was performed. All patients were followed to union. Postoperative radiographs, postoperative complications, bone union, ankle joint motion and limb functional outcome information of AOFAS ankle–hindfoot score were recorded. The mean follow-up period was 17.8 months. The mean interval to bony union was 25.8 weeks. Bone union was achieved in all cases and there were no complications. The average AOFAS score was 90. Of ten patients, two had a superficial wound infection and another showed a 6° varus deformity.

Researchers concluded that staged treatment using MIPO technique through a posterolateral approach is a safe treatment option for open distal tibial and tibial shaft fractures, especially Gustilo type III with severe anterior and medial soft-tissue injuries.


Preoperative ankle coronal malalignment has been considered as a risk factor for poor outcomes and failure after total ankle arthroplasty. The study sought to evaluate whether intermediate to long-term outcomes of total ankle arthroplasty in ankles with preoperative varus and valgus malalignment (5° to 20°) are comparable with those with neutral alignment (<5°).

The researchers enrolled 144 consecutive ankles that underwent primary total ankle arthroplasty (140 patients) using a mobile-bearing HINTEGRA prosthesis and had a minimum follow-up of four years. Patients were placed into three groups according to the preoperative coronal plane tibiotalar angle: the varus group (59 ankles, 5° to 20° of varus), the valgus group (34 ankles, 5° to 20° of valgus) and the neutral group (51 ankles, <5°).

The final tibiotalar angle showed that the degree of coronal alignment of the varus group was significantly less corrected as compared with the neutral group. The varus group had significantly more concomitant procedures compared with the neutral group. The overall probability of implant survivorship was 91.1 percent. In the intermediate to long-term follow-up, mobile-bearing total ankle arthroplasty showed similarly good outcomes in patients with varus and valgus malalignment up to 20° compared with the neutral alignment group when neutrally aligned ankles were achieved postoperatively.


Researchers sought to evaluate the optimal timing of the sinus tarsi approach for calcaneus fractures, to avoid iatrogenic injury of the sural nerve and to assess for wound complications. They retrospectively analyzed a case series of 53 patients with calcaneus fractures treated by a single surgeon with the sinus tarsi approach. On the basis of the delay time from injury to surgery, patients were classified into four groups: immediate (zero to three days), early (four to six days), intermediate (seven to 14 days) and late (14 to 18 days). Incisions were classified into group A, patients with incisions extending posterior to the lateral malleolus, and group B, patients with incisions confined anterior to the lateral malleolus. Forty-three patients with 52 Sanders type II fractures were included.

The overall postoperative rate of wound complications was 5.8 percent (three of 52). In the immediate group, deep infections and wound necrosis were found in two of eight fractures (25 percent). In the early group, one of 15 fractures developed superficial infection (6.7 percent). Group A had 33 percent (4 of 12) nerve injuries and group B had 2.5 percent (one of 40). In 70 percent of cases, a main branch of the sural nerve was directly under the incision.

Practice Management

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Practices should have a strategy to collect copayments and coinsurance amounts before services are rendered, especially given the rise in high-deductible health plans (HDHPs), said Lovell D. Davis, MHA, CPC, director of revenue cycle management at Virginia Eye Institute in Richmond, Virginia. He offers five tips to help practices manage patient payments more effectively.

First, create a financial policy that is simple and includes clear expectations, including acceptable forms of payment. Second, notify patients of your financial policy, such as over the phone when they make an appointment, or posted prominently on your practice's website.

Third, provide financial training to front desk staff. Consider creating scenario-specific scripts, such as what to say to patients when collecting copayments, cost-share amounts or past-due balances, said Lovell. Staff should also receive training on carrier-specific allowables and have access to an updated fee schedule for the practice, he said.

Fourth, hire front desk staff who have a billing background to help ensure they can explain the practice's financial policy to patients, while also performing duties like financial counseling and helping patients apply for Medicaid or other patient assistance programs, said Lovell. And finally, send timely statements, ideally the day after claims are adjudicated, so patients know immediately when a balance is owed. This greatly enhances cashflow, Lovell said.


Before signing a recruitment agreement with hospitals and medical practices in rural and healthcare shortage areas, physicians need to be aware that these arrangements are set up to comply with federal law and generally treat amounts paid to physicians as "loans." Taxes on the extra funds can be substantial and hard to afford.

The recruiting practice should also take an active responsibility in any arrangement. This includes meeting an affirmative commitment in the written recruitment documents to properly bill and collect for the recruited physician's services and to provide monthly documentation of income and expenses.

Understanding termination stipulations is also essential, in particular when there are still loan amounts to be forgiven. Ideally, the practice should bear some or all of the responsibility for the loan should the practice terminate a physician without cause. There should also be no noncompete, or a very limited one, that reasonably allows the physician to continue to meet his or her obligations to earn loan forgiveness in the community.

Before entering into a recruitment arrangement, key questions to ask include: Have other physicians been recruited to the particular hospital before? What happened in those situations? Will the practice owner(s) be threatened by a new doctor coming into the community?


Evidence shows that the administrative burden of medicine, and with it the proportion of burned-out doctors, is on the rise. A study published last year in Health Affairs reported that from 2011 to 2014, physicians spent progressively more time on “desktop medicine” and less on face-to-face patient care. Another study estimates that more than 50 percent of physicians feel burned out, which in turn makes them more likely to leave the profession.

What makes the burnout crisis especially serious is that it coincides with a growing doctor shortage. One solution is to improve the workflow of medicine so that physicians are empowered to do their job well and derive satisfaction from it.

Doctors are most valuable when doing what they were trained to do: treating patients. Likewise, nonphysicians are better suited to accomplish many of the tasks that currently fall upon physicians. The use of medical scribes during clinic visits, for instance, not only frees doctors to talk with their patients but also potentially yields better documentation.

Meanwhile, evidence shows that patients are more satisfied with their care when nurse practitioners or physician assistants provide some of it. This may be because these nonphysicians spend more time than doctors on counseling patients and answering questions.

A healthcare organization's success will depend on its delegating of responsibilities among physicians and nonphysicians, training the nonphysicians to do their work independently and empowering everyone—not just doctors—to shape a patient's care and to be accountable for the results.

Health Policy and Reimbursement

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U.S. Centers for Medicare and Medicaid Services (CMS) Administrator Seema Verma said the Trump administration is firmly opposed to lifetime limits on Medicaid benefits. When CMS recently rejected Kansas's request for a three-year lifetime cap for its Medicaid recipients, "We indicated we would not approve lifetime limits and have made that pretty clear to states," she said.

However, the agency is encouraging states that want to include some form of work requirement—known at CMS as "community engagement"—for able-bodied adults in the Medicaid program. Community engagement programs usually require recipients to either be working, going to school or volunteering in the community. Older adults, recipients with disabilities and children are exempted. Verma noted that other federal-state programs, such as the Supplemental Nutrition Assistance Program (SNAP) and Temporary Assistance for Needy Families (TANF), also include work requirements.

Verma distinguished the two types of populations in the Medicaid program, now that some states have expanded it. For the Medicaid expansion population, which mostly includes able-bodied individuals, "the goal should be not only to provide healthcare coverage, but also to provide a pathway out of poverty." She was more cautious about Wisconsin's request to test its Medicaid recipients for drugs. States may want to consider "ideas around risk assessment and not only identifying substance abuse but also [performing] a comprehensive health assessment to look at all the health issues a person may be facing," she said.


California Attorney General Xavier Becerra and 16 other state attorneys general in Democratic states were granted the right to intervene in a lawsuit filed in Texas that seeks to dismantle the Affordable Care Act (ACA). The lawsuit was filed in February by 20 state attorneys general from Republican states, led by Texas.

Becerra and the other Democratic attorneys general sought to intervene in the case because the lawsuit was technically filed against the Trump administration, which likely would not put up a strong defense of the ACA. GOP attorneys general argue in their lawsuit that the ACA is no longer constitutional because congressional Republicans eliminated the fine for not having insurance, but not the requirement itself. They argue that the U.S. Supreme Court upheld the fine in 2012, not the mandate itself, so the law is now illegal.


U.S. Department of Health and Human Services (HHS) Secretary Alex Azar announced the Trump administration is considering expanding Medicare's authority to negotiate drug costs by giving private payers a role in setting the price of medications administered in hospitals and doctors' offices. Azar noted that the president views tougher negotiation as key to the plan, and his agency will consider an alternative system for purchasing Medicare Part B drugs, which are administered by a healthcare provider and covered directly by the government. The administration would seek to permit private payers to negotiate the price of those medicines, as health insurers and pharmacy benefit managers (PBMs) currently do in Medicare Part D, which covers drugs that beneficiaries get at the pharmacy.

HHS officials said at a press briefing that they could trial the transfer of certain drugs from Medicare Part B to Part D in a pilot program, but did not state when that might begin. However, the American Enterprise Institute's Joe Antos noted most expensive drugs will remain in Part B, constraining the proposal's ability to significantly lower prices. Leerink analyst Ana Gupte said firms best positioned to participate in the new proposal would be insurers that have their own PBMs, Part D plans and Medicare Advantage business, such as UnitedHealth Group, Humana, Anthem and Cigna.

Medicine, Drugs and Devices

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The U.S. Centers for Medicare and Medicaid Services (CMS) has issued an interim final rule raising Medicare payments for durable medical equipment (DME) to ensure beneficiaries have access to critical medical devices. These payments will be increased from June 1, 2018, to December 31, 2018, within rural areas not subject to the DME Prosthetics, Orthotics, and Supplies (DMEPOS) Competitive Bidding Program (CBP).

The agency calculates that Medicare will pay an additional $290 million in benefit payments and $70 million in beneficiary cost sharing for DME services during the six-month interval. CMS says many small DME providers and businesses undergo financial challenges under current DME payments rates, and raising them would ensure that these businesses can maintain financial stability and provide beneficiaries with devices.

Last year and the year before, the DMEPOS CBP adjusted payment rates for devices, such as oxygen tanks and enteral nutrition systems, in rural regions catalogued as "nonbid" areas. These areas experienced adjusted payment rates that were 50 percent lower than unadjusted rates in parts of the country participating in the DMEPOS CBP. DME providers in rural areas will now receive "blended rates" that are calculated by combining half of DMEPOS CBP rates and half of the traditional fee-for-service payment rates. "Going forward, CMS will continue to review data and information about rates for DMEPOS items and services," the agency says. "CMS intends to undertake subsequent notice-and-comment rulemaking to address the rates for durable medical equipment and enteral nutrition furnished in 2019 and beyond."


The U.S. Food and Drug Administration (FDA) has published new data alleging 39 drug companies are all potentially blocking generic drug makers from accessing samples of their products. The new list, which includes Celgene, Gilead Life Sciences and Johnson & Johnson's Actelion Pharmaceuticals, is part of the White House's efforts to lower prescription drug prices.

While broader regulatory and legislative changes must go through an extensive process, top health officials have used their position to call out a number of firms for what they consider bad behavior.

The FDA announcement focuses on branded companies that may be trying to delay competition from a generic competitor by blocking access to product samples the other company needs to test its own version of the drug. FDA Commissioner Scott Gottlieb called this "gaming tactics." The agency's new data outlines which drug makers and which drugs were the subject of the more than 150 inquiries it has received from generic companies that want assistance gaining access to a branded drug maker's samples.


Drug adherence is critical both for patients and also the financial well-being of the healthcare system, as nonadherence can cost the industry as much as $300 billion annually, according to some estimates. A new report from medical communications agency Couch found almost one-half of those with health conditions said they skip their medication sometimes, despite knowing its benefits, while more than one-quarter are unsure what to do if they experience adverse effects.

In the report, Couch set out to find if patients are getting value from their healthcare practitioner, such as providing patients with relevant information, ensuring they understand their illness and treatment, and how to manage it. The likelihood of a person following medication guidelines correctly depended on the condition they were managing. For example, while at least one-half of those with mental health, respiratory and musculoskeletal conditions reported skipping medication, no one with cancer reported doing so, indicating a potential link between the life-shortening potential of a disease and a patient's management of his or her treatment.