News From ACFAS

---

As we all are adjusting to a new normal after COVID, ACFAS is reaching out to consumers through a new national “Welcome Back” public relations campaign aimed to let the public know foot and ankle surgeons are open for business (both in-person and virtually) and are committed to keeping them safe on return to the doctor’s office.

How can you help? We want to showcase how foot and ankle surgeons are helping to ease the stress and fear patients may be feeling upon heading out in public and to doctors’ offices again. If you have photos or video of your staff taking additional steps to keep your office safe or welcoming patients back, send them to publicrelations@acfas.org. We are also looking to highlight some unique patient stories—if you have a patient who put off care during the COVID crisis and you’ve been able to help them recover now, reach out to us as well.

Watch ACFAS’ social media channels for items you can share on your own channels to help get the word out, foot and ankle surgeons are here and open for business! It is projected that the landscape of clinical medicine will change dramatically post-COVID-19 and that telemedicine will have an impact on all disciplines, including ours. In order to better understand how practitioners have been utilizing telemedicine, a short survey follows from Robert Fridman, DPM, FACFAS, President of the ACFAS Northeast Region. For the purposes of this survey, telemedicine is defined as the remote diagnosis and treatment of patients by means of telecommunications technology. This study is for podiatrists who are utilizing telemedicine of any manner in patient care.

If you are performing telemedicine, please take a few minutes to complete the survey.

Please post your answers before Monday, June 8.

Foot and Ankle Surgery

---

The study investigated whether recombinant human amelogenin (rHAM+) can regenerate torn ankle calcaneo-fibular ligament (CFL). Right CFLs of Sabra rats were transected and treated with 0, 0.5 or 1µg/µl rHAM+ dissolved in propylene glycol alginate (PGA). Healing was evaluated 12 weeks post-treatment by mechanical testing and histology including immunohistochemical staining of collagen I and S100. The mechanical properties, structure, and composition of transected ligaments treated with 0.5µg/µl rHAM+ were similar to un-transected ligaments. PGA (control) treated ligaments were much weaker, lax and unorganized compared to un-transected ligaments. Treatment with 1µg/µl rHAM+ was not as efficient as 0.5µg/µl rHAM+. Normal arrangement of collagen I fibers and of proprioceptive nerve endings was detected in ligaments treated with 0.5µg/µl rHAM+, and scattered arrangement was detected in control ligaments.


The study looked at 25 patients with 26 calcaneal fractures treated with percutaneous and arthroscopically assisted calcaneal osteosynthesis (PACO). Researchers evaluated the reduction of the fractures as well as osteoarthritis of the subtalar joint. The median Manchester-Oxford Foot Questionnaire score was 26.6, the Calcaneus Fracture Scoring System (CFSS) score was 85, and the American Orthopaedic Foot & Ankle Society Ankle-Hindfoot score was 85. The visual analog scale score was 0 at rest and 4.1 during activity, and the Böhler angle improved from a mean of 3.5 degrees preoperatively to 27.7 degrees postoperatively. The follow-up radiographs showed subsidence of the fractures and a Böhler angle of 20.3 degrees. There were no wound-healing complications, and two patients had additional surgery with screw removal due to prominent hardware. The findings suggest that PACO gives good clinical outcomes and a low risk of complications in selected calcaneal fractures.


The study evaluated the effects of timing between endovascular intervention and minor lower-extremity amputations and its impact on wound healing and limb loss within one year, as well as the impact of restoring in-line flow on healing rates. The study included a total of 310 patients who underwent endovascular intervention and a minor lower-extremity amputation within 90 days. Healing rates were defined as optimal, delayed or failure. There was a significant difference between patients with optimal or delayed healing and amputation 30 days after endovascular intervention. There was no difference in healing rates regarding amputation timing for patients who ultimately healed versus patients who failed to heal. Absence of in-line flow, male sex, diabetes mellitus, presence of infection and wound dehiscence were significant factors for failing to heal. End-stage renal disease trended toward significance for failing to heal, and amputation-free survival at one year after endovascular intervention and pedal amputation was 76.8 percent.

Practice Management

---

Physician burnout is an epidemic, and the COVID-19 crisis will only make it worse. Hospitals and practices can work to curtail the wave of physician burnout and suicide by reducing administrative burden and giving physicians input on their schedules. Appropriate and timely mental health treatment is also critical and may include counseling and medications. Reducing gender discrimination also plays a role. The National Academy of Medicine reports that burnout may be up to 60 percent higher in female physicians, and over 70 percent of women doctors have experienced gender discrimination. Female physicians are often paid less than their male counterparts, and they also spend 8.5 additional hours per week on domestic duties compared to 40 minutes for men.


A study of nearly 35,000 online healthcare reviews revealed that 96 percent of unhappy patients are content with the quality of medical care they receive, but many are not seeing their expectations met with regards to customer service, such as phone hold times and wait times. These points are important to a healthy patient-doctor relationship. Phone hold times and wait times can be improved and refined and should be seen as an ongoing challenge to address. Practices should make small, continual improvements to overcome issues with customer service.


Many small physicians' practices are struggling to survive the COVID-19 pandemic, unable to secure loans under the Paycheck Protection Act (PPA) even as they continue tending to patients amid a health crisis. A recent survey by the Larry A. Green Center found that half the doctors who sought PPA loans were unsuccessful. Nineteen percent of the 2,774 doctors who responded to the survey said they had to temporarily close because of financial problems, and 42 percent had to lay off or furlough staff. Independent doctors are forced to compete for grants against bigger practices and hospitals or against other small businesses for loans they admit they may not be able to repay. Small practices have struggled for years with stagnant insurance reimbursement rates and high overhead.

Physicians that have started doing virtual visits are frustrated by insurance payments they say are stingy and slow to arrive. Eighteen percent of the doctors responding to the survey also said they had been denied payment for virtual visits. Independent doctors want the federal government to renew the advance Medicare payments that ended last month and offer them more direct grants. They would also like to see an expansion of a Medicare pilot program that rewards doctors for keeping patients out of the hospital. The Green Center survey found 236 doctors had been supported by patient donation.

Health Policy and Reimbursement

---

According to Andrew Musbach of Maryland-based MD Wealth Management, LLC, the Coronavirus Aid, Relief and Economic Security (CARES) Act, signed into law in late March, included important changes that affect many physicians with student loans. The CARES Act suspends all federal direct loan payments and sets the interest rate at zero percent through September 30. Those six months still count as qualifying payments for the Public Service Loan Forgiveness program. The payments were stopped automatically, so payers do not have to do anything to take advantage of these changes. The CARES Act does not apply to private loans, and although some lenders are offering forbearance, the interest will still accrue, so this is not an ideal strategy. For physicians who want to refinance their loans, Musbach recommends choosing a fixed loan right now because interest rates are very low.


According to health experts surveyed by STAT News, the COVID-19 crisis has the potential to transform healthcare entirely. Already, COVID-19 has accelerated telemedicine dramatically and highlighted the contributions of non-physicians. Going forward, it could help end the tradition of tying health insurance to employment status. Transmission concerns could mean an end to nursing homes and assisted living facilities in favor of home health aides. The crisis could also draw attention to the fact that marginalized populations suffer disproportionately from almost every health issue, not just COVID-19. Some also see the pandemic as a chance for the pharmaceutical industry to rehabilitate its reputation, showcasing its research and development capabilities, though high unemployment means that high drug prices could become more dire. There are calls to revitalize drug manufacturing in the United States, increase the healthcare workforce in times of emergency and re-evaluate the fee-for-service model.


States across the country are considering Medicaid cuts to shore up budget shortfalls caused by the COVID-19 pandemics, and federal restrictions could mean the brunt of cuts could fall on provider payments. Congress increased federal matching funds in its second COVID-19 relief package, but included restrictions that leave states few options to cut Medicaid other than slashing provider payments. States are also facing increased Medicaid enrollment alongside decreasing revenue, and many expect Medicaid budget shortfalls next fiscal year. The cuts could be another blow to providers that have already been disadvantaged by formulas used to distribute federal relief funds. House Democrats' proposal for the next COVID-19 relief bill would funnel $500 billion to state governments and bump federal matching funds to a total of 14 percentage points through June 2021. The funds would help states avoid or mitigate provider pay cuts, but Senate leaders have made clear they have no intention of taking up the legislation as-is.

Medicine, Drugs and Devices

---

The Washington University of St. Louis School of Medicine announced that more than 50,000 healthcare workers will be enrolled in a clinical trial to assess chloroquine's potential in protecting against COVID-19. The US arm of the study, which is funded through the COVID-19 Therapeutics Accelerator, will begin enrolling participants later this month, with results expected in early 2021. Participants enrolled in the study will receive either 300 milligrams (mg) of chloroquine weekly, 300 mg of the drug twice weekly, 150 mg daily after being administered an "induction dose" of 1200 mg of chloroquine or a placebo in four divided daily doses. New dosage arms may be added or removed as the trial progresses. The study will aim to determine which, if any, of the chloroquine regimens is most effective at decreasing incidence of severe COVID-19 without unacceptable side effects or safety events.


Microsoft plans to launch a version of its cloud-based software for healthcare organizations. The company said all of its technologies, including its general productivity software, chat app and more specialized business software, into "Microsoft Cloud for Healthcare." The package will enable hospitals to maintain data throughout its interaction with a patient. The process could involve a patient having initial questions answered by a chatbot via a patient portal website before communicating with a service agent and scheduling a virtual visit with a nurse or doctor, which could be handled via Microsoft Teams video chat. Microsoft's Deb Cupp said the data from each interaction will be carried throughout the patient's health experience. The company plans to make the system work with Allscripts Healthcare Solutions Inc. and other electronic health record software providers.


The Trump administration is laying out new plans to expand the Strategic National Stockpile after it ran out of critical medical supplies in the early weeks of the coronavirus pandemic. Plans include ensuring there is a 90-day supply of testing supplies and essential drugs, to serve as a backup while the United States boosts manufacturing capacity. When the new coronavirus first began to spread in the United States, the Strategic National Stockpile contained one to three weeks of most equipment and did not carry several supplies that have proved critical in combating the virus, including critical-care drugs and testing equipment, administration officials said. Of all the supplies that a patient ill with COVID-19 consumes in a hospital, the stockpile only carried 28 percent of those units. President Trump signed an executive order granting the chief executive of the US International Development Finance, Adam Boehler, new authorities to issue targeted loans to support production of supplies to assist with the coronavirus response and recovery.