News From ACFAS

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It’s true you learn from your mistakes. Join your colleagues as they reveal real complications that taught them life lessons in the Forefoot Complications Webinar Series.

Wednesday, July 29
2nd Ray and Revisional Digital Surgery: When “It’s Not JUST Toe Surgery” Anymore
8pm CT
CME Hour: 1 Credit
Register

Wednesday, August 26
Metatarsal Fracture Conundrums: A Minor Trauma Played in F Sharp
8pm CT
CME Hour: 1 Credit
Register

Each panel is led by expert moderators, Thanh Dinh, DPM, FACFAS and Alan Ng, DPM, FACFAS. Visit acfas.org/OnDemand for more information and to register for an upcoming webinar. While everyone adapts to navigating a new normal, ACFAS is taking great lengths to make sure our educational programming is as safe as possible for attendees. We are following CDC guidance and are committed to the safety of our attendees at all meetings. Here are some of the safety precautions you can expect at our upcoming meetings:

• Masks are required throughout courses
• Hotel’s new standard of cleaning and disinfection protocols: Marriott Commitment to Cleanliness & Hilton CleanStay
• Any waivers will be signed electronically in advance
• Registration packets will be distributed in clear bags
• Lunch and breakfast selections will be individually packaged
• Seating will be allocated to allow for a six-feet distance
• Small groups will be assigned in labs to accommodate spacing of attendees
• Lockers are staggered to allow for changing into scrubs
• Any cadavers will have been tested for COVID through Science Care

The College is working diligently to make attendees feel safe and comfortable at all upcoming programming. We will continue sharing how we’re making meetings safe for you. Visit acfas.org/SafetyPrecautions for more information.

Foot and Ankle Surgery

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The study looks at the frequency of incidental or early subclicinal tendinopathic ultrasound (US) characteristics in asymptomatic posterior tibial tendons. Overall, 266 tendons belonging to 150 patients were assessed by US, and 128 were determined to have at least one tendinopathic trait. Specifically, 51 had circumferential fluid, 69 had noncircumferential fluid, 22 had thickening, 31 had heterogenicity, 19 had hyperemia and two had calcification. Additionally, Caucasian participants were nearly three times more likely to have tendinopathic findings when compared with African American participants.


The study hypothesized that the changes in the internal structure of the Achilles and patellar tendons after a ski mountaineering race competition could be detected with ultrasound. Twenty athletes were recruited during a three-day ski mountaineering competition. Ultrasound measurements of the Achilles and patellar tendons were carried out before the first race and immediately after each competition day. Tendon thickness, cross-sectional area (CSA) and ultrasound gray scale analysis were calculated. Significant differences were observed between the pre- and post-race measurements for the Achilles tendon thickness and CSA, while no significant differences were noted for the patellar tendon thickness and CSA. However, gray scale analysis of both the Achilles and patellar tendons showed significantly higher post-race values.


The authors outline some of the measures undertaken at their unit in response to COVID-19. The authors' unit was the first trauma and orthopaedic center in the Republic of Ireland to introduce a virtual fracture clinic (VFC) service and serves about 400,000 people. Authors say that expanding their VFC referral pathway has allowed for a significant reduction in physical clinic attendances, allowing them to adhere to the national lockdown policy without comprising patient treatment and outcomes. In addition, the use of Siilo (the instant messaging medical application) and Zoom (the video conferencing application) has assisted the unit in the areas of governance, rapid senior decision making and timely subspecialty input. With regard to post-operative follow-up, recent evidence has lowered the number of x-rays being carried out routinely at the unit. Patients are now directed to a dedicated unit-designed website, which contains validated post-operative rehabilitation instructions, and the unit is also looking into the concept of remote wound evaluation.

Practice Management

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There are certain steps that practices can take to improve hiring during a pandemic, which may change recruitment metrics significantly. This includes setting goals that are specific, measurable, achievable, reasonable and bound to fixed timelines. It also involves crafting strong job descriptions that adequately communicate one's expectations in a straightforward manner. Due to the impact of pandemics, employers may need to adjust their recruitment metrics. Practices should also prepare for remote screening and onboarding through tools such as video conferencing software, screen sharing and screen recording.


It is critical that physicians and other providers make their practices inclusive and welcoming. A focused effort to do so could yield a designation with the Healthcare Equality Index, which is awarded by the Human Rights Campaign to policies and practices that meet the highest standard of LGBTQ+ inclusion and equality. Steps to take include changing physical signage to be more inclusive, training staff to use inclusive language and updating forms and marketing collateral to account for a range of identities and experiences. Physicians should also educate themselves about the LGBTQ+ community and adopt an open mindset when treating patients.


Virtual care played a minor role in healthcare for years, but the COVID-19 pandemic has forced this to change. Proponents of telehealth have long argued that 50 to 70 percent of visits to the doctor's office could be replaced by remote monitoring and checkups. However, many rural clinics and community hospitals in small American towns fear that their medical staffing and on-site revenues will be further hollowed out by remote medicine. The patients who need care the most often do not have smartphones or broadband connectivity or cannot afford extra minutes on their wireless plans. Telehealth totaled just 0.1 percent of all medical claims filed in 2018, and surveys indicate that many patients feel a telehealth visit will be inferior to an in-person appointment. Specialists and primary care physicians are also hesitant about the limitations of virtual care; until recently, there were also a number of regulatory barriers. Telemedicine can reduce the expense of intensive care, but the cost of equipping and running telemedicine technology can be prohibitive for many smaller hospitals.

Health Policy and Reimbursement

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The US Centers for Medicare and Medicaid Services (CMS) is calling for a renewed national commitment to value-based care based on Medicare claims data that show some of the impact of the COVID-19 pandemic on the Medicare population. The data show that more than 325,000 Medicare beneficiaries were diagnosed with COVID-19 between January 1 and May 16, which translates to 518 COVID-19 cases per 100,000 beneficiaries. The data also indicate that nearly 110,000 Medicare beneficiaries were hospitalized for COVID-19-related treatment, equalling 175 COVID-19 hospitalizations per 100,000 beneficiaries. Black people were hospitalized with COVID-19 at a rate nearly four times higher than whites. Beneficiaries enrolled in both Medicare and Medicaid saw 473 hospitalizations per 100,000 beneficiaries, and they also had higher infection rates than those enrolled only in Medicare. Beneficiaries living in rural areas have fewer cases and were hospitalized at a lower rate than those living in urban and suburban areas.


The US Centers for Medicare and Medicaid Services (CMS) announced the creation of a new office that aims to cut red tape for providers. The new Office of Burden Reduction and Health Informatics stems from CMS' Patients over Paperwork (PoP) initiative. According to CMS, its burden reduction work started three years ago with the launch of PoP, which has focused on reducing unnecessary regulatory burden, so providers can concentrate on their primary goal of patient care. The results, says CMS, are expected to save providers and clinicians $6.6 billion and 42 million unnecessary burden hours through 2021.


Since the Trump administration relaxed restrictions on short-term health insurance plans, enrollment has increased, but so too have consumers' medical bills, according to a report released by House Democrats on the Energy and Commerce Committee. Short-term health insurance plans do not have to comply with the Affordable Care Act (ACA), and they often exclude coverage for preexisting conditions and charge women more for the same coverage as men, according to an investigation. The plans often have lower premiums than ACA-compliant plans. An investigation of 14 companies that sell or help people buy short-term health plans found an increase of 27 percent, or more than 600,000 individuals, enrolled in short-term plans during the 2019 plan year compared with the prior plan year, for a total of about 3 million consumers enrolled.


Judge Carl Nichols with the US District Court for the District of Columbia sided with the Trump administration Tuesday, saying the US Department of Health and Human Services (HHS) can force hospitals to reveal the prices they negotiate with insurers. Nichols wrote that HHS had the right to issue the rule because it considered the concerns of providers and payers, acknowledged conflicting information and explained its decision. The American Hospital Association (AHA) had argued that the rule compelling the hospitals to publish their negotiated rates with insurers violates the First Amendment and goes beyond the statutory intent of the Affordable Care Act. AHA's senior vice president, Melinda Hatton, said the group plans to appeal, asserting that while hospitals and health systems have supported efforts to provide patients with information about the costs of their medical care, this rule is not the right way to achieve the goal.

The rule requires hospitals to publicize the rates they negotiate with individual insurers for all services, including drugs, supplies, facility fees and care by doctors who work for the facility. It is scheduled to take effect in January 2021, with hospitals facing fines of up to $300 a day if they do not disclose negotiated rates. The price-disclosure requirements would cover the more than 6,000 hospitals that accept Medicare.

Medicine, Drugs and Devices

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Although COVID-19 means many medical students will not be on campus in the fall, some schools are using virtual reality to enable cadaver dissection. Case Western Reserve University School of Medicine uses HoloAnatomy software that runs on Microsoft's mixed reality HoloLens headset, which allows students to virtual dissect parts of the "holo body" and zoom in on intricate details. In a recent study at Case Western Reserve, exam scores among students who learned upper and lower limb anatomy through cadaver dissection and mixed reality education and those who learned entirely on a cadaver were statistically indistinguishable. Stanford University School of Medicine's Scott Ceresnak — who worked on the development of the Stanford Virtual Heart, which runs on the Oculus Rift headset — said the technology enables users to appreciate anatomy in a "completely different, new, novel way."


As the pandemic reduces visitors to hospitals around the country, "hospital-at-home" programs and other remote technologies — from online visits with doctors to virtual physical therapy to home oxygen monitoring — have been rapidly rolled out and embraced. Medicare and many private insurers have temporarily relaxed payment rules for telehealth. In some cases, physical therapists traded some hands-on care for video-game-like rehabilitation programs patients can do on home computer screens. Remote care programs, however, have been long established in other countries like Australia, England, Spain and Italy. Hospital-at-home initiatives are offered to stable patients with common diagnoses, like heart failure, pneumonia and kidney infections. Insurers and others will now have to assess how helpful these programs have been in order to determine if they should continue once COVID-19 passes.