News From ACFAS

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The deadline for responding to the College’s triennial Member or Practice Surveys has been extended to June 24. Make sure your voice is heard.

Search your inbox for an email from ACFASpresident@perceptionsolutions.com and respond ASAP to have a shot at winning an Apple iPhone 10 or Bose noise-canceling headphones.

All responses are anonymous and are only reported in the aggregate by a third-party survey consultant. Survey results will be available on acfas.org in late summer. Share your exciting patient success stories with us so we can spread the word to the national media about the meaningful and lifesaving work you do as a foot and ankle surgeon!

The College would like to specifically focus on how you:

• Improved a patient’s quality of life through the use of an innovative or “first of its kind” surgical procedure
• Helped a patient adjust after an amputation
• Detected a life-threatening illness in a patient before it was too late
• Gave a patient hope when s/he felt no other options were available
• Got an athlete back in the game
• Made a positive impact on the lives of those in your community

Contact Melissa Matusek, CAE, ACFAS director of Marketing and Communications, at melissa.matusek@acfas.org or (773) 444-1306 with your story, and watch This Week @ ACFAS for updates on the College’s national public relations campaign. Through corporate grants and sponsorships, ACFAS is able to provide you with the high-quality educational opportunities you count on to enhance your career. Visit the Corporate Sponsorship Mall at acfas.org to learn how our sponsors' products and services can help you in your practice.

Foot and Ankle Surgery

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The purpose of the study was to clarify the effect of the containment of osteochondral lesions of the talus (OLTs) on clinical and radiological outcomes in patients who underwent autologous osteochondral transplantationn (AOTs) for OLTs.

The researchers conducted a retrospective cohort study comparing 94 patients who underwent AOT for the treatment of contained-type or uncontained-type OLTs between 2006 and 2014. Clinical outcomes were evaluated using the Foot and Ankle Outcome Score (FAOS) and the 12-Item Short Form Health Survey (SF-12) preoperatively and at final follow-up. Magnetic resonance imaging (MRI) at two years' follow-up was evaluated with the modified magnetic resonance observation of cartilage repair tissue (MOCART) score. Multivariate regression models were used to evaluate factors affecting postoperative FAOS, SF-12 and MOCART scores.

The median FAOS and SF-12 scores improved significantly after surgery in both contained-type and uncontained-type lesions. The median postoperative FAOS score of patients with contained-type OLTs was higher than that of patients with uncontained-type OLTs (91.7 versus 85.0, respectively), but no significant differences were found between the contained-type and uncontained-type groups for postoperative SF-12 and MOCART scores. The multivariate regression models showed that patients with contained-type OLTs had an approximately 10-point better score on the FAOS compared to patients with uncontained-type OLTs.

The researchers concluded that patients with contained-type OLTs had better clinical outcomes than those with uncontained-type OLTs after AOT for the treatment of OLTs. However, the AOT procedure still provided good clinical and MRI outcomes in both contained-type and uncontained-type OLTs at midterm follow-up.


The aim of this study was to compare a minimally invasive chevron osteotomy technique (MIS group) and the well-established open chevron technique (OC group) for correction of hallux valgus deformity. Patients who were scheduled to undergo a hallux valgus surgery by means of a distal chevron osteotomy were randomly assigned to one of the two groups. Preoperatively, six weeks, 12 weeks and nine months postoperatively the following outcome parameters were determined: Visual Analog Scores (VAS) of pain, the American Orthopaedic Foot and Ankle Society forefoot score, radiographic outcome measures, range of motion (ROM) and patient satisfaction.

The researchers analyzed 47 cases (25 MIS group; 22 OC group). Both operative techniques achieved significant correction of the hallux deformity. The intermetatarsal angle (IMA) improved from 15.1° to 5.8° in the OC and from 14° to 6.8°in the MIS group, while the hallux valgus angle (HVA) improved from 28.3° to 8.5° in the OC versus 26.4° to 6.9° in the MIS group. No significant differences were observed between the groups by any of the determined outcome parameters. Regarding patient satisfaction, statistically significant differences were found between MIS and open surgery 12 weeks postoperatively in favor of the MIS group.


The objective of this retrospective study was to evaluate the early and intermediate outcome of intravenous Iloprost therapy on bone marrow edema (BME) of the foot and ankle. The following patient-rated outcome measures (PROMs) were assessed prospectively (t2): 12-Item Short Form Health Survey (SF-12), Visual Analog Scale Foot and Ankle (VAS FA) and the Foot Function Index (FFI) (also at t0).

Out of 70 eligible patients, 42 patients with a mean follow-up of 28 ± 19 months were included. Twelve patients reported minor complications during Iloprost therapy. At t1, pain decreased significantly in 56 percent of patients, and the amount of BME decreased in 83 percent of patients.

Both parameters correlated moderately. The PROMs at t2 revealed moderate results. The overall FFI improved from 59 ± 21 to 30 ± 22 (P < .001), the overall VAS FA was 68 ± 20, the SF-12 Physical Component Summary was 42 ± 12 and the Mental Component Summary was 50 ± 9. Subgroup analysis revealed no significant influence of the etiology or Association Research Circulation Osseous (ARCO) stage on any outcome measure. Iloprost therapy for BME of the foot and ankle resulted in a 60 percent pain and 80 percent edema decrease after three months. After two years, patient-rated outcome measures showed residual impairment. Neither the etiology nor ARCO stage significantly influenced the outcome.

Practice Management

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An estimated 42 percent of physicians will go through a malpractice lawsuit at some point in their career, and its impact can linger for years. Research indicates that a distinct correlation exists between patient satisfaction and the risk of being sued for malpractice. As a result, knowing how patients rate a physician is a proven way to predict the risk of being sued and gives physicians an opportunity to curb that risk. Patients should be sent surveys regularly, ideally within 24 hours to 48 hours of a visit as well as between visits.

In addition, a separate one-question survey after each visit can help track the physician's "net promoter" score, which examines the likelihood of a patient recommending the physician to friends and family. This scale-based response helps provide a quick picture of patients' satisfaction and loyalty. It can also be beneficial to offer an incentive and invite small groups of individuals to the office for more in-depth conversations. These visits can shed light on issues the physician had not considered. If patient satisfaction levels are lower than they should be, practices can take steps, such as reducing long wait times, ensuring the office lets in natural light and facilitating patient-clinician communication.


Effective patient identification is vital to ensuring quality care and avoiding financial losses at health systems, hospitals and physician practices. "The misidentification of patients in clinical settings has untold financial impacts for an organization in uncompensated care as well as serious patient safety consequences, such as wrong-side surgeries and even death," according to an article in the Journal of AHIMA's June edition. The piece, "Tips for Trusting Identity in the Era of Cybercrime and Fraud," offers six best practices for patient identification.

First, two-factor authentication is the industry standard for verifying patient identity, but using three or four factors, such as adding the patient's home address, is more effective. Second, asking patients to verbally state their authentication factors is better than having registrars ask "yes" or "no" questions to verify information. Third, adult patients should be required to present a photo ID as part of the identification process. Fourth, patients should check their wristbands to confirm the accuracy of their registration, if possible. Fifth, healthcare organizations should consider taking photos of patients and including those images in medical records, which could help deter medical ID fraud, among other benefits. Finally, patient registration kiosks offer several uses, such as taking a patient's photo, matching images of a patient to pictures in a database and requiring patients to verify their demographic information.


The costs of changing from one electronic health record (EHR) to another are usually much higher than most practices predict, experts say. Even before the EHR system is implemented, there are research and negotiation costs. Then when it comes to the EHR software contract, there are maintenance fees, software subscription fees and support fees to be aware of, experts warn. Furthermore, new software often requires additional hardware and other technology costs. For example, some practices that implement new EHRs might realize they do not have the Internet bandwidth to support the new software. Practices should also anticipate the costs of integrating their new EHR with other systems, such as coding and insurance verification applications.

Another expense is consultants and the other outside expertise needed to guide practices through the EHR switch. For larger physician practices, especially those with more complicated IT systems, it might be necessary to use consultants throughout the entire process, while smaller practices might hire consultants on a short-term basis. Another cost of changing EHRs that is often underestimated is the transfer of data, a process that might involve fees to both the previous EHR vendor as well as the new one. In addition, productivity could be affected for months after switching EHRs, experts say, and then there are the underestimated and unanticipated expenses that come with any project.

Health Policy and Reimbursement

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U.S. Department of Health and Human Services (HHS) Secretary Alex Azar recommended that lawmakers draft a bill to update and correct the Medicare wage index. The index establishes payments to hospitals as adjusted for market conditions, including cost of living, but more and more rural hospitals in areas where the cost of living tends to be lower say the index plays a large role in shutdowns. "We believe the wage index needs to be addressed and fixed," Azar told the House's Education and the Workforce Committee. "It's been stuck in time."

Twelve hospitals have closed in Alabama alone since 2011, while 12 more could be threatened with closure in the next two years, said Rep. Bradley Byrne (R-Ala.). Hospitals and doctors with higher average wages are typically in higher-cost areas and receive larger reimbursements, while regions with lower wages are compensated at lower rates, causing a shortfall of some provider types in rural areas, noted Sen. Jerry Moran (R-Kan.).

Azar said HHS is open to collaborating with lawmakers on a legislative fix, but he warned it would be difficult to modify the index without taking funds from some hospitals to boost reimbursement at others. "It will be winners and losers unfortunately among Congress and states, and that will be difficult," he acknowledged. "But we will gladly work with you."


The U.S. Department of Justice (DOJ) is asking a federal court to strike down key elements of the Affordable Care Act (ACA) and said it will not defend major provisions in the law, according to a brief it filed in a lawsuit brought by 20 state attorneys general. The provisions DOJ is targeting include the bans on insurers denying coverage and charging higher rates to individuals with preexisting health conditions. The department is also aiming to roll back limits on how much insurers can charge people based on gender and age.

The move will likely rattle insurers, which are now setting rates for 2019 based on the belief that they must adhere to the ACA consumer protection requirements. Some legal and health experts said the decision could destabilize markets. In its brief, DOJ said certain ACA provisions, such as banning insurers from denying coverage to people with preexisting conditions, are invalid as of January 1 with the mandate penalty repeal. The United States agreed with the plaintiffs that sections "must now be struck down as unconstitutional," the brief stated. DOJ did not say other aspects of the ACA, such as its expansion of Medicaid and its exchanges, should be halted.


The Medicare board of trustees' annual report to Congress warned that Medicare's hospital insurance trust fund could be depleted by 2026, three years earlier than forecast last year. One government official cited several factors that are shrinking funding and causing spending to spike, including reduced wages for several years, which adds up to lower payroll taxes. Meanwhile, the recently passed tax cut means fewer Social Security taxes will be paid into the hospital trust fund, as some higher-income seniors pay taxes on their Social Security benefits.

In addition, the senior population's growth is straining Medicare funds, while maneuvers by the Trump administration and Congress to rescind two provisions of the Affordable Care Act (ACA) are also threatening the program's future. Those moves include repealing the penalties for people who lack insurance and the elimination of an independent board charged with regulating spending if certain financial thresholds are reached.

Marc Goldwein with the Committee for a Responsible Federal Budget said the change to the ACA's individual mandate penalties, which takes effect in 2019, will likely leave millions more uninsured, burdening hospitals with higher rates of uncompensated care. The Kaiser Family Foundation's Juliette Cubanksi noted the board's report signals that Medicare Part A will only be able to pay 91 percent of covered benefits starting in 2026.

Medicine, Drugs and Devices

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The U.S. Food and Drug Administration (FDA) estimates that generic drugs approved in 2017 led to $8.8 billion in cost savings during the calendar year and $11.8 billion in savings through February 2018. The estimate is based on pharmacy acquisition costs and does not reflect rebates, discounts or off-invoice adjustments. FDA's Office of Generic Drugs approved a record 1,027 abbreviated new drug applications in 2017, 843 of which were fully approved. FDA estimates that the total full year savings from generics approved in 2017 will be $16 billion, using extrapolated data to fill in for products that were not approved for a full year by the end of February 2018.


Advances in imaging, technology and surgical approaches are playing a greater role in helping patients with a diabetic or Charcot foot joint recover, according to a presentation by Önder I. Kilicoglu, MD, at the EFORT Annual Congress. Among other things, Kilicoglu discussed clinical recovery in the Charcot foot joint, which results from the neuropathy and ischemia of the diabetic foot. He said he tries not to operate on the midfoot to forefoot in these patients and discussed the results of a study of 214 patients published in Foot & Ankle International in which midfoot surgery was indicated in 223 feet and was performed in a minimally invasive fashion.

"Clinical recovery comes before radiological recovery," Kilicoglu said. As a result, new magnetic resonance imaging and sensitive nuclear medicine modalities are being used to provide more specific information about the status of healing of Charcot foot. Another imaging modality used in these patients is a PET/CT scan, which is used to label leukocytes in the foot, he said. Kilicoglu also discussed some new techniques for superficial debridement, such as hydrosurgery and the effect of high-speed vacuum flow and ultrasound assistance.


Medicare recipients filled fewer prescriptions for expensive brand-name drugs but spent more on such products anyway, according to a U.S. Department of Health and Human Services inspector general's report. The report found a 17 percent decline in the overall number of prescriptions for brand-name medicines under Medicare's Part D program over a recent five-year period. But beneficiaries' share of costs for branded medicines from 2011 to 2015 rose by 40 percent, from $161 in 2011 to $225 on average. Data for 2011–2015 was the most recent available for the analysis.

"Increases in unit prices for brand-name drugs resulted in Medicare and its beneficiaries paying more for these drugs," said the report. Rising Medicare payments for brand-name products "will continue to affect Part D and its beneficiaries for years to come." The report emphasized that the most persistent problem for Medicare beneficiaries is the high cost of maintenance medications for common chronic conditions, such as diabetes. Total out-of-pocket costs for patients were highest for brand-name insulin, cholesterol products and asthma inhalers.