News From ACFAS

---

Volunteer to serve on a 2020 ACFAS committee, Clinical Consensus Statement panel or as a reviewer of Scientific Literature. ACFAS is looking for members who are leaders, thinkers, team players and hard workers to work with the College to shape the future of our profession.

To volunteer, visit acfas.org/volunteer. The application deadline is October 31, 2019. We’re one month away from kicking off this year’s On the Road series! Join us for Fixing a Flat: Comprehensive Approach to Pes Valgus for more small group discussions, quick lectures and hands-on training starting next month.

This two-day workshop is a perfect opportunity for lecturers and attendees to roll up their sleeves, put their heads together and learn from each other. Over two days you will participate in a “Complications and Challenging Cases” presentation, challenge faculty and review problematic cases in a panel discussion, talk one-on-one and learn valuable tips and techniques you can take back to the office with you. Attendees will also earn 12 hours of Continuing Contact Hours.

The tour starts November 1-2 in Cincinnati and continues through May. Find out where we’re headed and register at acfas.org/comingtoyou. Visit the ACFAS Marketing Toolbox and access our Patient Reference Form template. This PDF includes two blank forms and is available to freely print and use in your practice.

Use the Patient Reference Form to jot notes about a diagnosis during an appointment to send home with the patient. This also points them to FootHealthFacts.org, the College's patient education website, where they can find additional information on their condition and many others.

Access the form in the Marketing Toolbox at acfas.org/marketing.
Watch your emails—Fellow and Associate dues reminders will once again hit mailboxes early to give you more time to pay before the end of the calendar year. Renewal instructions for the 2020 calendar year will be sent out on October 3. The deadline for payment will remain the same, December 31, 2019. You can pay your dues online now or via mail or fax once you receive your reminder.

Learn more about the many benefits your ACFAS membership provides: visit the Member Center on acfas.org.

Foot and Ankle Surgery

---

Researchers re-examined the rates of deep venous thrombosis and pulmonary embolism after foot and ankle trauma. Using the National Trauma Data Bank Data set (2007-2009 and 2010-2016), the study assessed the risk factors associated with these complications. Data quality is improved in the later data set, where the incidence of deep venous thrombosis was 0.28 percent and that of pulmonary embolism was 0.21 percent. Significant risk factors for pulmonary embolism included prophylaxis, male gender, treatment in a university hospital, open reduction, chronic, obstructive pulmonary disease and hypertension. Risk factors for deep venous thrombosis were male gender, bleeding disorder, angina and prophylaxis. Researchers conclude that careful, individualized assessment of the risk factors associated with these conditions is important and that the merits of routine prophylaxis remain in question.


This case-control genetic association study aimed to evaluate the effects of matrix metalloproteinase-3 (MMP3) and tissue inhibitor of metalloproteinase-2 (TIMP2) on chronic Achilles tendinopathy (AT) susceptibility. A total of 1084 chronic AT patients and 2188 controls with Chinese Han ancestry were recruited. Researchers selected and genotyped 21 SNPs, four of which were mapped to MMP3 and 17 mapped to TIMP2, then performed genetic association analysis and eQTL analyses. The potential effects of epistasis were also examined, using a case-only study design. They found that two SNPs, rs4789932 and rs679620, were significantly associated with chronic AT risk, while no significant results were obtained from epistasis analyses. SNP rs4789932 was strongly associated with the gene expression level of TIMP2 in atrial appendage tissue and tibial artery tissue. The results suggest that MMP3 and TIMP2 play important roles in the pathophysiology of chronic AT.


Researchers explored the effect of sagittal angle on ankle joint stability by establishing a three-dimensional finite element model of the posterolateral-oblique type of posterior malleolus fracture with different sagittal angle. Researchers built five posterior malleolus models with different sagittal angles using CT data from the ankle of a normal male volunteer. They carried out finite element analysis (FEA) to simulate the conditions of vertical loading in neutral position, then recorded and analyzed the data. Their analysis established a positive correlation between the sagittal angle and the contact area, as well as a negative correlation between the sagittal angle of fracture and relative displacement. The findings indicate that a greater sagittal angle of fracture tends to coincide with a more stable ankle joint. The authors conclude that the sagittal angle of fracture could be used as a relative index to reflect ankle stability for posterior malleolus fracture.

Practice Management

---

The article reviews how physicians can respond to the opioid epidemic through patient education and proactive care coordination. For example, the California Society of Anesthesiologists (CSA) is producing easy-to-understand videos to educate patients and caregivers about safe opioid use and alternate pain management options. Physicians should continue to advocate with insurance companies, other professionals and patients to use opioids as necessary. Patients who are recovering from surgical care are especially vulnerable to developing substance use disorders, and education measures should address this. Clinicians can start by discussing treatment goals, pain management expectations and the duration of post-procedure pain, including options for pain management other than opioids. There is also an opportunity for enhanced coordination among all providers on a patient's care team, which can ease transitions of care and prevent long-term dependence, misuse and adverse events.


Providers deciding whether to maintain in-house logistics or outsource certain services should aim for a strategy that accounts for provider costs, patient care and functionality. Providers should start by conducting an organizational review to assess the organization's attitude towards and readiness for outsourcing certain measures. This ensures that any changes to logistical services improve operational efficiency and allows leaders to assess how deeply they want to delve into the supply chain. Providers should then assess the potential consequences of various actions, identifying and understanding the data needed to do so and having a trusted partner benchmark assumptions when possible. When it comes to pursuing a project, providers should aim to minimize any disruption in day-to-day operations, which might mean forgoing areas that need major improvement in favor of smaller victories.


A new study indicates that half of the content in emergency department doctors' medical documentation was inaccurate. Researchers at the University of California - Los Angeles assigned trained observers to shadow doctors in emergency department patient rooms to record the doctors' actions, specifically their review of systems and physical examinations and compared them to the doctors' notes. The study tracked nine emergency department physicians at two institutions, and the observers, who were not physicians, may have also missed some interactions between doctors and patients. Despite its limitations, the study suggests a need to change how electronic medical records are kept, as these are used to inform decisions about patient care and to generate bills.

Physician groups have advocated for changes to the documentation and billing requirements imposed by the U.S. Centers for Medicare and Medicaid Services (CMS), looking to save physicians time and encourage more concise documentation. In rules published in both 2018 and 2019, CMS has proposed alternative billing practices that pay physicians based on the time spent at the bedside, requiring only documentation of a "medically appropriate" history. These changes only apply to outpatient office visits, but they may be extended to other care settings, such as emergency departments, allowing physicians to devise more accurate ways of recording data from patient visits.

Health Policy and Reimbursement

---

According to an analysis by the U.S. Congressional Budget Office (CBO), an approach backed by doctors groups for protecting patients from surprise medical bills would boost the deficit by "double-digit billions" of dollars over 10 years. The approach is featured in a bill from U.S. Reps. Raul Ruiz (D-Calif.) and Phil Roe (R-Tenn.), which rivals the approach used in bipartisan bills that have passed out of the House Energy and Commerce and the Senate Health committees. Those bills, according to the CBO, would both save more than $20 billion over 10 years. The key difference between the approaches is in deciding how much the insurer will pay the doctor once the patient is protected, with the leading bills essentially setting the payment rate based on the median of the rates insurers have negotiated with doctors in that area. However, the Roe-Ruiz bill would have an outside arbitrator decide the payment amount and instruct the arbitrator to consider the amount that doctors charge before any negotiation with insurers takes place — a much higher amount.


A study from the Kaiser Family Foundation found insurance premiums and deductibles are making employer-based coverage increasingly unaffordable. The average premium paid by employer and employee for a family plan now exceeds $20,000 annually, with the worker contributing about $6,000. More than 25 percent of all covered workers and nearly half of those working for small businesses have a yearly deductible of $2,000 or more.

Kaiser Family Foundation CEO Drew Altman said Americans who earn $25,000 or less—about 36 million—are the most likely to be priced out of insurance coverage. The Harvard T.H. Chan School of Public Health's Benjamin Sommer added that some low-wage workers may be eligible for Medicaid in states that expanded the program under the Affordable Care Act, but private insurance enrollees who do not qualify for government help face more difficulty paying for care.


The U.S. Centers for Medicare and Medicaid Services (CMS) forecast that average monthly Medicare Advantage premiums will hit their lowest point in 13 years in 2020. The agency also projected that enrollment in Advantage plans would continue to appreciate as more seniors opt for Advantage over traditional Medicare. Average monthly premiums should fall 14.4 percent from $26.87 in 2019 to $23 next year, marking the lowest premium since 2007.

Meanwhile, Advantage plan enrollment should reach hit 24.4 million in 2020, a 9.9 percent gain from 22.2 million now. Advantage enrollment has increased steadily as baby boomers age into Medicare and favor Advantage plans over traditional options. Advantage plans typically offer more benefits such as dental care, eyeglasses and gym memberships—although beneficiaries must see doctors within the plan's network.


A U.S. Government Accountability Office (GAO) report says U.S. Centers for Medicare and Medicaid Services (CMS) quality measures might not indicate the actual care beneficiaries receive. CMS lacks processes to ensure that the indicators actually quantify what the agency says it cares about in its strategic objectives. The office learned CMS carries over large amounts of unused funds each year for activities related to quality measurement and does not keep tabs on all its quality-measurement funding.

The GAO said the agency ought to create standard practices to evaluate the measures that it is weighing to ensure they are aligned with strategic quality objectives, as well as track progress in realizing its goals by developing and using performance metrics. The GAO also recommended CMS should retain comprehensive and rigorous data on its quality funding. The Department of Health and Human Services concurred with these recommendations.

Medicine, Drugs and Devices

---

A study by Michigan State University (MSU) and Johns Hopkins University researchers suggested 71 percent of U.S. healthcare data breaches have involved sensitive demographic or financial data that could lead to identity theft. MSU's Xuefeng Jiang said the black market for medical data is limited, but financial and demographic data can be sold on the dark web. Jiang and another researcher sifted through U.S. Department of Health and Human Services records on 1,461 breaches between 2009 and 2019—with 66 percent compromising demographic data, and 35 percent exposing service or financial data, that could be used in ID theft or financial fraud. Duke University School of Medicine's Michael Pencina said, "They make a good point that we need to care as much about the type of information that is hacked as the number of individuals affected."


A report released by the House Ways and Means Committee estimates that U.S. drug prices are nearly four times higher than the combined average price for 11 other similar countries. Committee staff evaluated 2018 pricing data for 79 drugs sold in the United States, United Kingdom, Japan, Canada (Ontario), Australia, Portugal, France, the Netherlands, Germany, Denmark, Sweden and Switzerland. The report states, "With one exception, we found that individual drug prices in the U.S. ranged from 70 percent (Lantus Solostar—a type of insulin) to 4,833 percent (Dulera—a prescription asthma medication) higher than the combined mean price in the other 11 countries. Compared to individual countries, drug prices in the U.S. ranged from 0.6 to 67 times the price for the same drugs."