News From ACFAS

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Registration is officially open for ACFAS 2020 in San Antonio. Register by the early bird deadline of December 12, 2019 to guarantee low rates and be one step closer to another outstanding ACFAS educational program. Here’s what’s in store for this year:

• Cutting-edge clinical sessions and hands-on surgical workshops
• Award-winning research presented in manuscripts
• 300+ scientific posters
• The HUB Theater
• Annual Job Fair
• Second annual Residents’ Day
• Unlimited networking opportunities

Don’t miss ACFAS 2020 taking place February 19-22, 2020 at the Henry B. Gonzalez Convention Center in San Antonio. Visit acfas.org/sanantonio to register and book your hotel reservations. The ACFAS Marketing Toolbox just got better with the newest PowerPoint—Pediatric Flatfoot. The presentation outlines different types of flatfoot, symptoms associated with flatfoot, diagnosis and treatment options and comes with a full script for you to use to present.

Use the presentation to educate patients about this common condition in kids whether in your office or in the community. Display it as a slideshow in your waiting room, post it on social media or use it to speak at a community health event.

Visit the Marketing Toolbox at acfas.org/marketing to access the full library of PowerPoints along with many other freely available resources to promote your practice and educate patients. A big THANK YOU and congratulations to ACFAS’ loyal and dedicated members who have been a part of the College since 1980! In appreciation, these 40-year members receive automatic Life Membership status with ACFAS.

For 2020, the ACFAS Board of Directors honors:

• John C. Donovan, DPM, FACFAS, Binghamton, NY
• Mark Drucker, DPM, FACFAS, San Rafael, CA
• Lawrence M. Fallat, DPM, FACFAS, Taylor, MI
• Bart W. Gastwirth, DPM, AACFAS, Arlington Heights, IL
• Mark R. Gorman, DPM, FACFAS, Scottsdale, AZ
• Michael R. Joyce, DPM, FACFAS, Eden, NC
• Charles G. Kissel, DPM, FACFAS, Warren, MI
• Gary M. Lepow, DPM, FACFAS, Houston, TX
• David R. Levitsky, DPM, FACFAS, Clinton, MI
• Steven M. Spinner, DPM, FACFAS, Plantation, FL
• Robert B. Weber, DPM, JD, MBA, FACFAS, Trappe, PA
• Mark E. Wolpa, DPM, FACFAS, Berkeley, CA

Foot and Ankle Surgery

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Current methods for analysis and planning of post-traumatic or congenital deformity correction of the foot have some limitations. This retrospective study aimed to establish reference lines and angles based on reproducible anatomic points on sagittal feet radiographs. Researchers calculated the relationships between the talus joint line (TJL) and the axes of the foot, namely the anatomic and mechanical lateral talometatarsal angel axes of the first metatarsal. They then assessed the relationships with the calcaneus, particularly the lateral heel angle and calculated the parameters derived from the TLJ and the foot-bearing points. Sixty-four normal radiographs from 55 patients were analyzed, and from these results, the authors propose sagittal plane reference lines and angles, along with quantitative values for reference. These parameters could be implemented in foot deformity analysis and correction planning.


The authors performed a prospective analysis to evaluate the use of the Patient-Reported Outcomes Measurement Information System (PROMIS) in children with idiopathic talipes equinovarus (ITEV). Two questionnaires were sent to the parents of 91 patients, aged five to 17 years, with ITEV; thirty-one complete responses were returned, with seven female patients, 12 patients with unilateral ITEV and a mean patient age of 8.8 years. The construct validity of the PROMIS Parent Proxy Profile short forms version was assessed by comparing its domains of mobility, fatigue, pain interference and pain intensity to the disease-specific instrument (DSI) function domain and comparing the PROMIS domains of anxiety, depressive symptoms, pain intensity and peer relationships to the DSI satisfaction domain.

Analysis demonstrated a positive correlation between the DSI Function domain and the PROMIS Mobility domain and a moderate negative correlation between the DSI Function domain and the PROMIS domains of pain interference and pain intensity. It did not find a negative correlation with the PROMIS Fatigue domain, and correlations between the DSI Satisfaction domain and the PROMIS domains were fair or had little relationship. The results support the validity of the PRMOIS mobility, pain interference and pain intensity domains in this population, though, as with the DSI, there are no items in PROMIS that can assess overall satisfaction.


The study evaluated implant cost variability for surgically treated ankle fractures and distal tibia fractures, aiming to identify cost drivers and determine whether there is link between specialty training and implant selection. Authors conducted a retrospective 2010-2017 chart review for 1,281 patients at a Level I trauma center. The review assessed variables including age, sex, body mass index, OTA/AO classification, Weber classification, one-year reoperation status, surgeon specialty and the use of syndosmotic screws, locking pates and cannulated screws. According to this analysis, implant cost differed among OTA patterns and were comparable across Weber patterns. Costs were highest among reconstructive, podiatry and spin surgeons, while traumatologist constructs had the lowest overall price.

A total of 433 procedures used locking plates, and 512 used at least one cannulated screw. On average, locking plates had a higher total implant cost than nonlocking plates with a comparable reoperation rate, and the use of a cannulated screw presented a higher total cost with comparable reoperation rates. Overall, 199 patients underwent elective hardware removal, 23 were infected, seven required revision, and three were identified with a nonunion. The study shows significant variability in implant costs for ankle fracture fixation, and it finds that locking plates and cannulated screws are key cost drivers.

Practice Management

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LeanIn.Org and McKinsey & Co. estimated that women comprise 75 percent of employees in a sample of 22 healthcare companies, but only make up 33 percent of C-suite leaders versus men's 67 percent. According to McKinsey, the biggest decline for women in healthcare leadership is at the senior manager/director tier. University of Minnesota Professor Janette Dill explains that women are historically undervalued as caregivers in the market for paid labor, leading to low wages and further discouraging men who can make more in jobs like construction that require a similar level of education. "If you think about sectors like retail or fast food, there's more space for people to move into management without needing additional education," she notes. Many leadership positions require a bachelor's or master's degree in health administration, which can be unattainable for women starting in low-paid jobs. "When men go into female-dominated occupations, they earn higher wages than women, they find more opportunities, and they're fast-tracked into management positions," Dill adds. McKinsey argues since women make most healthcare decisions and are a majority of patients, companies need to revise services and products to be responsive to their needs and give them a say in management, research and marketing.


Health systems need to design their profile curation process with physicians in mind. A recent study finds that 91 percent of physicians want to be more involved in curating their digital profiles. Some key guiding principles for maximizing physician engagement include setting meaningful and tailored context, informing the provider audience about the business reasons behind the digital patient experience strategy. This strategy must be communicated to providers in a way that is clear, accessible and multifaceted. Email alone is not a sufficient communication strategy, as in a recent survey, providers indicated that in-person visits to the practice were their preferred method of communication. Systems should present providers with timelines and discrete tasks, with visibility reports on completion, to measure their engagement efforts. Practice managers and operational leads can be helpful partners in driving providers' understanding and completion of these tasks. Overall, health systems benefit from promoting a collaborative culture when approaching stakeholder management, treating providers like partners whenever possible.


At the annual meeting of the Medical Group Management Association, Jesse Ehrenfeld of the Medical College of Wisconsin provided some tips for providers that want to make their offices more welcoming for lesbian, gay, bisexual, transgender and queer (LGBTQ) individuals. Ehrenfeld noted that 4.1 percent of U.S. adults identify as LGBT, and almost 40 percent of homeless adolescents are LGBTQ. Moreover, LGBTQ patients are twice as likely to be uninsured as other patients, and 56 percent of LGB and 70 percent of transgender patients report they encounter bias and discrimination when accessing care. Practices can use small physical signals, such as a "safe space" sticker or gender-neutral bathroom signs, to indicate acceptance. Ehrenfeld emphasized that providers should avoid asking any questions that are clinically irrelevant, while it is a good idea to ask all patients about their preferred name and pronouns.

Studies show that while LGBTQ patients do not mind being asked about their sexual orientation, staff are often afraid to do so, even though it is a clinically relevant question. Practices can use the Healthcare Equality Index, a free tool that allows practices and health systems to rate themselves on their policies in areas such as patient non-discrimination, equal visitation and employment non-discrimination. Out of the 680 participating facilities in the index this year, 408 earned a score of 100 points, giving them a designation of "Leader in Healthcare LGBTQ Equality" that can be posted on their website to further indicate inclusivity. Practices can also use a Trans Buddy Program, which uses community-driven trained volunteers to accompany patients to appointments that may be difficult, such as a pap smear for a transgender man.

Health Policy and Reimbursement

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Researchers at the Urban Institute compared models ranging from a modest enhancement of Affordable Care Act coverage to a government single-payer system covering all U.S. residents — including additional benefits like dental and long-term care and requiring no patient cost-sharing — and determined that an aggressive incremental model that falls short of a full government takeover of health insurance could reduce the number of Americans lacking comprehensive health insurance from 34.6 million to 6.6 million. That model would offer more generous public subsidies, restore the individual mandate, provide subsidized coverage for low-income people in states that haven't expanded Medicaid, create a public health plan option that employed people could join and enroll uninsured people automatically. It would boost federal spending by $1.5 trillion over 10 years while modestly decreasing overall national health spending. Sara Collins, vice president of healthcare coverage and access for the Commonwealth Fund, suggested that Congress should let states take the lead in experimenting with public health plans to see how they work before pushing ahead with single-payer legislation.


At present, drugs cannot be subject to discounts under both Medicaid rebates and the 340B Drug Pricing Program. Furthermore, 340B drugs cannot be prescribed to Medicaid beneficiaries unless the state can identify the drugs and exclude them from Medicaid rebate requests. A new survey by Manatt, Phelps & Phillips reveals that dispensing fees associated with 340B drugs ranged from $2.32 to $21.28, based on drug claims submitted by contract pharmacies. Helen Pfister, a partner with Manatt Health, notes that failure to adequately exclude 340B drugs from Medicaid rebate requests can lead to repayment obligations for hospitals.

Among state methods to identify 340B drugs billed to Medicaid, approximately 22 states use claims-level identifiers, 12 rely on the Medicaid Exclusion File under the Office of Pharmacy Affairs, and some use both methods, the survey found. In addition, one state prohibits all covered entities from using 340B drugs for beneficiaries and one state allows its use for family planning clinics. While critics say the 340B program is affected by misuse and inadequate oversight, its backers have sought to defeat a proposal to reduce the federal reimbursement rate for hospitals. The hospital outpatient prospective payment system proposal for fiscal 2020 would reduce the reimbursement rate for 340B hospitals to Average Sales Price minus 22.5 percent.


As regulations shift to accommodate the telemedicine market, some doctors are seeking licenses in every state to treat more patients. Through telemedicine, doctors can treat patients anywhere in the United States, but they need to be licensed in the patient's state of residence in order to do so. As of 2018, only 14 doctors were licensed in every state including Washington, D.C., a jump from six in 2016. The growth coincides with the growth of the telemedicine market, which is expected to hit $130 billion by 2025, and more insurance plans are starting to cover the cost of virtual visits.

Telemedicine start-ups generally get their staff by employing doctors or contracting with a physician network and tend to either hire a lot of doctors with a few licenses or a smaller team of people that have many licenses. The average license costs about $90,000, and it also needs to be maintained. There are some shortcuts to getting some of these licenses, but none cover the entire process and there are many exceptions. To make the process more accessible, a number of consultants and companies have emerged that specialize in helping doctors with licensing and credentialing.

Medicine, Drugs and Devices

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The core provision of House Speaker Nancy Pelosi's bill to lower drug prices would save Medicare $345 billion between 2023 and 2029, according to a preliminary analysis from the Congressional Budget Office (CBO). That provision would allow the HHS secretary to negotiate lower prices on up to 250 drugs per year, with savings applied to people on both public and private insurance plans. Another part of the CBO's analysis found the measure would reduce research and development of new drugs, cutting into drug companies' revenues and seeing eight to 15 fewer new drugs coming to market over the next 10 years. The agency said, "The overall effect on the health of families in the United States that would stem from increased use of prescription drugs but decreased availability of new drugs is unclear."

CBO indicated the bill is likely to lower premiums for people with private insurance, though it said it is still working on a more complete analysis of the bill. A separate analysis of the bill from CMS' actuary found that it will save American households $158 billion over 10 years through lower premiums and out-of-pocket spending on drugs, and that total U.S. spending on healthcare would decline by $400 billion under the bill. Congressional Republicans say they want to work on smaller drug pricing legislation, such as speeding the introduction of more affordable generic drugs. The bill is a high priority for House Democrats, but it faces dim prospects in the Senate, where Majority Leader Mitch McConnell has said he will oppose it.


Drug distributors AmerisourceBergen, Cardinal Health and McKesson Corporation, as well as manufacturers Johnson & Johnson and Teva, have reportedly agreed with multiple states on a framework to resolve thousands of opioid cases with a settlement worth approximately $50 billion in cash and addiction treatments. The agreement would release the five companies from a rapidly growing list of more than 2,300 lawsuits that they face in federal and state courts. The states have agreed in principle to the framework, but cities and counties across the nation have not yet fully embraced it, said lawyers for a committee that represents thousands of municipal governments. They are seeking more information about how the money will be distributed, whether it will be directed to relief measures or end up in general funds for state legislatures and "when they could expect the financial support to start," the lawyers said in a statement.

Parties to the case are under pressure to reach a deal, as opening statements are set to begin in Cleveland in the first federal trial to determine responsibility for the opioid epidemic. The three drug distributors and Teva are defendants in the first trial, brought by two Ohio counties. With thousands of similar governmental lawsuits on the national runway, the Ohio suit is considered an important showcase that will test the strength of both sides' witnesses and legal arguments.


U.S. Food and Drug Administration (FDA) Acting Commissioner Ned Sharpless reported that generic drug approvals reached a record high for fiscal year 2019. There were a total of 1,171 generic drug approvals, with 935 full approvals and 236 tentative approvals, breaking the record of 971 for FY2018. Sharpless noted that in FY2019, FDA approved 125 applications for first generics of medicines that had no generic competition, including an emergency opioid overdose treatment and drugs to treat conditions such as pulmonary arterial hypertension, breast cancer, seizures, depression and various infections. He said the agency is also approving a growing number of complex generic drugs.