News From ACFAS

---

The ACFAS Nominating Committee seeks experienced members to serve on the College’s Board of Directors. If you are an ACFAS Fellow, believe you are qualified and would like to help lead the profession, send your nomination application by September 12.

Visit acfas.org/nominations for the nomination application and complete details on the recommended criteria for candidates. For more information, contact ACFAS Executive Director J.C. (Chris) Mahaffey, MS, CAE, FASAE, at mahaffey@acfas.org or (773) 693-9300. Questions regarding eligibility criteria should be directed to Nominating Committee Chair Laurence G. Rubin, DPM, FACFAS, at lgrubin@comcast.net or (804) 746-5488.

The Nominating Committee will announce recommended candidates to the membership no later than October 18. Candidate information and ballots will be emailed to all voting members no later than December 2. Electronic voting ends on December 17. New officers and directors will take office during ACFAS 2019, February 14–17, 2019 in New Orleans. Remember to submit your comments to the U.S. Centers for Medicare and Medicaid Services (CMS) by September 10 regarding proposed changes to how DPMs are reimbursed for Evaluation and Management services. The proposals may also lead to patient harm by reducing access to care and could increase Medicare beneficiaries’ cost-sharing for office visits.

APMA members and nonmembers should use APMA’s eAdvocacy website for complete details on the proposed CMS changes and to directly submit your personal comments to CMS. Students and residents, are you looking for the inside scoop on finding your dream residency? Young members, are you still trying to find the best way to manage your student loan debt? Participate in ACFAS’ two free upcoming webinars and have all your questions answered.

The Price of Success: Managing Student Loan Repayment
Thursday, August 30
8pm CDST
Register Now

Residency Director Discussion: Keys to Getting into the Residency of Your Choice
Thursday, September 20
8pm CDST
Register Now The 2018 ACFAS Member Opinions and Practice Economics surveys received a record number of responses in May–June. Thank you! A series of articles on the survey data will start appearing in ACFAS Update soon.

In the meantime, winners of the survey incentive gifts have been randomly selected by the survey consultant. For each survey, one iPhone X winner and three Bose noise-canceling headphones winners were selected.

iPhone X Winners
William H. Hatchett, DPM, FACFAS of Ladson, SC
Michael J. Stastny, DPM, AACFAS of Brea, CA

Bose Headphones Winners
Zubeen Mistry, DPM of Houston, TX
Gary Smith, DPM, FACFAS of Bradford, PA
Ryan Pederson, DPM, AACFAS of Coos Bay, OR
Jeffrey J. Brimmer, DPM, AACFAS of Jacksonville, FL
Greg E. Cohen, DPM, FACFAS of Brooklyn, NY
Michael Kooyman, DPM, FACFAS of Las Vegas, NV

Congrats to our winners… AND thank you to all of our 2018 survey participants!

Foot and Ankle Surgery

---

Researchers initiated a retrospective study on ankle fractures to assess the time needed for fracture union, the incidence of adverse radiographic outcomes (AROs), factors that might lead to AROs and whether AROs were associated with worse function and higher incidence of posttrauma osteoarthritis (PTOA).

From 2007 to 2016, a total of 296 patients were diagnosed with a medial malleolar fracture, whether isolated or in the setting of bi- or trimalleolar fractures, and underwent open reduction and internal fixation (ORIF) or percutaneous screw fixation (PSF). The interval to fracture union, radiographic outcomes, American Orthopaedic Foot and Ankle Society (AOFAS) score at six months postoperatively and the incidence of PTOA were recorded. Risk factors were identified both in univariate and multivariate analysis. The average follow-up period was 52 months.

The incidence of delayed union, nonunion and malunion were 20.3 percent, 3.7 percent and 4.4 percent, respectively. The interval to fracture union was 10.3 ± 6.4 weeks. In the multivariate analysis, the risk factors for AROs were tobacco use, vertical fractures, interposed soft tissue and fair/poor reduction. Patients with AROs had significantly worse AOFAS score at six months postoperatively and higher incidence of PTOA.

The researchers concluded that AROs of medial malleolar fractures have an underestimated incidence rate and are associated with worse ankle function and higher incidence of PTOA. Risk factors, including tobacco use, vertical fractures, interposed soft tissue and poor/fair reduction, should be taken into consideration when treating medial malleolar fractures.


In the Ponseti treatment of idiopathic clubfoot, children are typically given a standard foot abduction orthosis (FAO). A significant proportion of these patients experience irresolvable problems with the FAO leading to therapeutic noncompliance and eventual relapse. Patients were equipped with a unilateral lower leg orthosis (LLO) developed in the researchers' institution. The goal of this study was to determine compliance with and the efficacy of the LLO as an alternative treatment measure. The minimum follow-up was five years.

A total of 45 patients (75 feet) were retrospectively registered and included in the study. Compliance with the bracing protocol was 91 percent with the LLO and 46 percent with the FAO. The most common problems with the FAO were sleep disturbance (50 percent) and cutaneous problems (45 percent). With the LLO, 9 percent of patients experienced sleep disturbance, and no cutaneous problems occurred. Thirteen percent of patients being treated with an FAO until the age of four (23 patients; 40 feet) underwent surgery because of relapse, defined by rigid recurrence of any of the components of a clubfoot. Fourteen percent of patients being treated with an LLO (22 patients; 35 feet), mostly following initial treatment with an FAO, experienced recurrence.

The researchers concluded that changing from FAO to LLO at any point during treatment did not result in an increased rate of surgery and caused few problems.


This study examined the short-term results of endoscopic percutaneous longitudinal tenotomy for noninsertional Achilles tendinopathy using the Centerline Endoscopic Carpal Tunnel Release instrument (Arthrex). This method simplifies the operation technique, allowing a good endoscopic visualisation of the Achilles tendon with promising results.

Researchers performed multiple percutaneous longitudinal tenotomies under local anesthesia in 24 patients (25 tendons) with Achilles tendinopathy or peritendinitis that had failed conservative treatment between January 2013 and September 2016. All ambulatory procedures consisted of paratenon release and longitudinal tenotomies. The results were reviewed in 22 patients (23 tendons) at an average follow-up period of 22.5 months. Patients' satisfaction and functional outcomes were evaluated using the Victorian Institute of Sports Assessment-Achilles (VISA-A) questionnaire, the pain visual analog scale (VAS) and the functional foot index.

Initial results were very promising with excellent results in 12 patients, good results in nine patients and a fair result in one patient. One patient developed a postoperative thrombosis of the operated limb. Another patient developed a hypertrophic painful scar of the incision wound. The VAS for pain decreased drastically after the index procedure and averaged to 0.2. The VISA-A questionnaire score improved from 42 ± 7.2 points preoperatively to 96.8 ± 14.3 points postoperatively. The functional foot index decreased from 84 to 33.4 on the follow-up examination.

Researchers concluded that the endoscopic-assisted longitudinal multiple tenotomies procedure of the Achilles tendon is easily feasible and can be performed on an outpatient basis, produces minimal complications and shows excellent results.

Practice Management

---

Exposure to sharps, drugs and chemicals make healthcare workers more vulnerable to workplace injury than those in almost any other sector. Fortunately, many safety incidents can be avoided by taking simple steps toward stricter Occupational Safety and Health Administration (OSHA) compliance and more careful observance of safety and disposal recommendations.

First, practices should stick to a sharps safety strategy. Injuries from needlesticks and other sharps remain all too common, but practices can significantly reduce injuries through more careful observance of regulations and best practices. With so many negative consequences of sharps injuries, preventative measures for safe sharps use and disposal should be a clear priority for practices.

Second, physicians should set high standards to prevent drug diversion within their own facilities. They can create a safer healthcare setting and help reduce drug abuse in their communities by informing staff of the associated risks for the medications they handle. In turn, medical office staff can educate patients about drug risks, safe disposal methods and removing potentially dangerous medications from their homes.

Finally, clear labeling and communication for high-hazard compliance is key. It can be dangerous for workers and patients alike when communication errors are made regarding hazardous chemicals, whether for cleaning and disinfecting or for treating patients. In addition to a comprehensive medical surveillance program and regular evaluations of workers potentially exposed to hazardous chemicals, physicians can encourage open communication so staff can express concerns or suggest process improvements.

Physicians can create a stronger culture of safety and compliance by publicizing drug, chemical and sharps safety information, encouraging accurate incident reporting and holding regular training sessions.


A report by the ECRI Institute indicates that healthcare IT plays a crucial role in curbing diagnostic mistakes and erroneous medication changes. "Results can be—and often are—missed when the loop of receipt, acknowledgment and action remains open," the report explains. The report's recommendations involve communication, tracking and acknowledgement of an information review and associated actions. The objective is to facilitate the efficient flow of information, with all diagnostic results and medications communicated to providers, pharmacists and patients on a timely basis.

The report calls for optimizing alerts to improve notification and reduce alert fatigue, automating notification processes with existing EHR capabilities and implementing standards for reporting of actionable findings that include results priority and timing of responses to diagnostic testing. The report also recommends creating accountability for oversight of tracking and creating bidirectional communication between hospital computer systems and third-party systems, such as laboratory partners. Bidirectional capability eases the ordering and reporting of laboratory, radiology, pathology and diagnostic results.

In addition, the report advises using health IT to link and store acknowledgments and to record actions taken. Diagnostic results notification messages should be modifiable by the recipient to add the action taken to "close the loop," such as read, acknowledged or patient notified.


All medical practices regularly deal with patients who will not or cannot settle their bills. However, strategies and tactics exist to tackle bad debt head on, reduce the financial liability, better connect with patients and realize better outcomes.

As Medicare transitions to a value-based care reimbursement model where payments are linked to patient satisfaction, a positive patient experience has a direct impact on physicians' bottom line. Since a patient's final interaction with the clinician will be the financial settlement of what they owe, their entire perception of the experience will be largely influenced by the aftercare settlement. Engaging up front with the patient, in an honest and transparent manner that avoids financial surprises, is one successful strategy to shape a positive patient experience.

Another important strategy is financial clearance—a practice that ensures patients' ability to pay before they arrive for an exam or procedure. For independent medical practices, financial clearance can mean developing programmatic or manual processes to screen for a patient's access to funds and verifying insurance prior to scheduling visits and rendering care. While adopting this financial clearance process will not mean that 100 percent of what is owed is paid immediately, it goes a long way toward helping facilities recoup payment and not letting their debt turn bad or get old. Facilities that make a strategic change in their approach to payments also benefit by keeping a financially risky group of patients at bay.

Health Policy and Reimbursement

---

A new report drafted by Sen. Claire McCaskill (D-MO), the top-ranking Democrat on the Senate Homeland Security and Governmental Affairs Committee, compared Medicare Part D spending on the 20 most commonly prescribed drug brands with the cost if those drugs were priced on par with the U.S. Department of Veterans Affairs, which does negotiate prices. The report concluded that Medicare bargaining could save Medicare Part D $2.8 billion a year on just the 20 most commonly prescribed brand-name drugs.

It also found that even after applying an average 17.5 percent branded drug rebate, as published by the U.S. Centers for Medicare and Medicaid Services, and increasing federal prices to cover miscellaneous costs like dispensing fees, Medicare could still save $2.8 billion a year if prices of those drugs were federally negotiated. "Getting bulk discounts is something every business does, and the fact that the federal government is prohibited from doing it for Medicare is unconscionable," McCaskill said.


The U.S. Centers for Medicare and Medicaid Services (CMS) has unveiled a plan that would affect about 40 percent of the payments physicians receive from Medicare. The agency calls it a historic effort to reduce paperwork and improve patient care. However, some doctors and patient advocates have come out against it and are urging CMS to adjust its funding formula before the plan goes into effect in January.

The CMS plan would merge four levels of paperwork required for reimbursement, and four levels of payments, into one form and one flat fee for each doctor's appointment—although there would still be separate filing systems for new and established patients. In a letter previewing the plan to doctors last month, CMS Administrator Seema Verma said that physicians waste too much time on mindless administrative tasks that take time away from patients. "We believe you should be able to focus on delivering care to patients, not sitting in front of a computer screen," Verma wrote.

However, Dr. Angus Worthing of the American College of Rheumatology argues that a couple minutes saved in front of the computer are not worth the reduced payment he would get. The CMS plan would offer a flat fee for each office visit with a patient, whether the doctor is a primary care physician or a specialist.

Many doctors also predict that the proposed payment changes would establish a financial incentive to see fewer Medicare patients. Dr. Kate Goodrich, CMS's chief medical officer, disagrees, arguing that doctors who need more time with patients could file for an "add-on" payment of $67 per appointment. This "add-on" payment is "intended to ensure that physicians are being appropriately compensated for seeing the most complex patients," Goodrich said.


The Trump administration has finalized a rule that would let people purchase short-term, limited-duration health coverage that lasts up to one year and renew that coverage for a maximum of three years. Short-term plans circumvent many Affordable Care Act (ACA) protections, making them cheaper but also scantier than other ACA-compliant plans on the individual market. The plans can deny consumers coverage for preexisting conditions or charge them more based on their health status.

The Obama administration, citing consumer protections, had limited such plans to less than three months, and they were not renewable. The Trump administration has championed the move to expand access to short-term insurance coverage as a way to make healthcare coverage more affordable for people who have been priced out of the individual market. However, critics have argued such plans could harm consumers who do not understand the limitations of the coverage they are buying and that premiums in the individual market would rise as young, healthy people leave exchanges that need those people to balance out the risk pool.

The final rule does not require renewability, leaving it up to the insurer to decide whether it will allow consumers to renew their coverage without having to reapply for a plan. The rule takes 60 days to go into effect, and changes could take place as soon as this fall. The U.S. Centers for Medicare and Medicaid Services said states will continue to be able to regulate short-term plans how they wish.

Medicine, Drugs and Devices

---

Anxiety is the most common mental illness in the United States, affecting more than 40 million adults. Now, many mental health experts are warning about the potential addiction to the drugs that treat this disorder.

Overdose deaths involving benzodiazepines have quadrupled between 2002 and 2015, according to the National Institute on Drug Abuse. The trend is being driven by a 67 percent jump in prescriptions from 1996 to 2013. Meanwhile, the market for these drugs is expected to reach roughly $3.8 billion in the United States by 2020, according to Zion Market Research.

Dr. Anna Lembke, chief of the Stanford Addiction Medicine Dual Diagnosis Clinic, recommends that if benzodiazepines are needed daily, people should not take them for longer than two to four weeks. The withdrawal process for these drugs is even more dangerous than it is for opioids, she said. Although some doctors do not think benzodiazepines have the potential to be as disastrous as the opioid epidemic, these drugs are still dangerous, especially when combined with opioids.


The pharmaceutical rebate is increasingly viewed as being at least partly responsible for the current market for prescription drugs. Rebates, critics say, have pushed up the list price of brand-name drugs, which consumers are increasingly responsible for paying. Insurers generally get to keep the rebates without passing them along to their members.

The Pharmaceutical Research and Manufacturers of America has proposed changing the way the rebates are handled and how those companies are paid. The Trump administration, meanwhile, has taken the first step toward eliminating a "safe-harbor" provision that allows rebates to be paid in Medicare's Part D drug program without violating federal anti-kickback laws.

Pharmacy benefit managers and insurers argue that rebates are a diversion and that their negotiating tactics have kept total drug costs in check. As proof they point to data that shows that in 2017, net spending on brand-name drugs grew only 1.9 percent, according to IQVIA, a drug research firm, while list prices grew 6.9 percent. They warn that eliminating rebates could face legal hurdles and say the move could wind up raising consumers' premiums because insurers and employers use their rebate payments to plug other holes.


Rates of opioid use among commercially insured and Medicare patients were elevated during 2007 to 2016, investigators report, especially among the disabled. The research took the form of a retrospective cohort study, which was based on administrative claims data for 48 million people.

For the entire study period, annual opioid use prevalence was 14 percent for patients with commercial health coverage and 26 percent for Medicare beneficiaries whose eligibility was based on age. The highest rate, for patients younger than age 65 years who qualified for Medicare Advantage because of a permanent disability, was 52 percent. Not only did this subset produce the highest use, it had the highest use over the long term as well as the largest average daily dose.

While usage trends changed only modestly in the other categories over time, both quarterly consumption rates and average daily dose were meaningfully higher in 2016 than in 2007 for the Medicare Advantage group. The trend persisted in the face of targeted opioid abuse and awareness campaigns.