News From ACFAS

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Candid conversations, tried-and-tested tips and tools, practical pointers—find these plus no-nonsense advice for managing the nonclinical side of your career all in the HUB!

Located in the ACFAS 2019 Exhibit Hall from February 14–16, 2019, this year’s HUB will feature a fresh lineup of 50-minute sessions, including:

• RVUs and You
• Streamlining Your Day: Strategies for Efficiency
• Interpreting Literature: Cliffs Notes
• Preparing for Success: ABFAS Board Certification Process
• Boosting Your Practice Revenue
• And more!

Exchange ideas and personal experiences with speakers and your fellow attendees, and come away with a wealth of solutions to help you in your day-to-day practice.

Visit acfas.org/neworleans to download the ACFAS 2019 conference program and to see which HUB sessions you would like to attend. No preregistration is necessary to participate in HUB sessions. On October 24, 2018, the SUPPORT for Patients and Communities Act (H.R. 6) was passed into law. H.R. 6 aims to combat the opioid crisis by advancing treatment and recovery initiatives, improving prevention, protecting communities and increasing efforts to address synthetic drug use.

Medicare-specific provisions of the bill of interest to foot and ankle surgeons include the following:

• Instruct the U.S. Centers for Medicare and Medicaid Services to evaluate the use of telehealth services in treating substance use disorder
• Create a pass-through payment extension under Medicare to encourage the development of nonopioid drugs
• Add a review of current opioid prescriptions and, as appropriate, a screening for opioid use disorder as part of the Welcome to Medicare initial examination
• Incentivize postsurgical injections as a pain treatment alternative to opioids by reversing a reimbursement cut for these treatments in the ambulatory service center setting, as well as collect data on a subset of codes related to these treatments
• Require e-prescribing, with exceptions, for coverage of prescription drugs that are controlled substances under the Medicare Part D program
• Require prescription drug plan sponsors under the Medicare program to establish drug management programs for at-risk beneficiaries
• Provide access to medication-assisted treatment in Medicare through bundled payments made to opioid treatment programs for holistic service

Visit energycommerce.house.gov for more information. The ACFAS Fellowship Committee recently granted Conditional status to the following fellowship program:

Honor Health–Oasis Foot & Ankle Surgical Fellowship, Phoenix
Program Director: Eugene DelaCruz, DPM, FACFAS
acfas.org/fellowshipdelacruz

ACFAS highly recommends taking on a specialized fellowship for the continuation of foot and ankle surgical education after residency. If you are considering a fellowship, visit acfas.org/fellowshipinitiative to review a complete listing of programs and minimal requirements.

Foot and Ankle Surgery

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Analysis was conducted to assess radiographic and subjective results in patients with ankle arthritis and coronal plane deformity who underwent total ankle arthroplasty with a three-piece mobile-bearing implant. Sixty-three consecutive patients were reviewed, of whom 25 met the inclusion criteria. Sixteen patients had a varus deformity while nine had valgus deformity preoperatively. In patients with varus deformity, the average tibiotalar angle was 12.6 degrees, 0.8 degrees, 1.0 degrees, 1.0 degrees and 0.8 degrees for preoperative, immediate postoperative, and six, 12 and 36 months, respectively. The same measurements and intervals for patients with valgus deformity were 10.3 degrees, 1.4 degrees, 1.6 degrees, 1.4 degrees and 1.4 degrees. The team saw a statistically significant difference in preoperative and postoperative coronal plane deformity, and the correction was maintained at final follow-up.


A study was conducted to compare patients treated with autograft or allograft for osteochondral lesions of the talus. Twenty-five nonrandomized patients with autograft and 16 with allograft were examined, with an average follow-up of 26 months in the autograft group and 22 months in the allograft group. No significant differences were observed among all demographic factors between the cohorts. The mean postoperative Foot and Ankle Outcome Score as well as the mean postoperative SF-12 scores were significantly higher in the autograft group than in the allograft group. Magnetic Resonance Observation of Cartilage Repair Tissue scores were significantly improved in the autograft group compared to the allograft group. The rate of chondral wear on magnetic resonance imaging was higher in the allograft group, and cyst formation in the graft itself was more likely to occur in this group as well. The frequency of secondary procedures for the graft was higher in the allograft group than in the autograft group.


This retrospective study aimed to reinvestigate the postoperative outcomes of posteromedial release combined with arthrodesis of the talocalcaneal and calcaneocuboid joints in children who had equinovarus associated with myelodysplasia. Researchers evaluated 12 feet from nine patients. The mean age at the time of surgery was five years, and the mean follow-up was 78 months. One fracture occurred in a single proximal tibia. Union rate after arthrodesis was 83 percent in the talocalcaneal joint and 42 percent in the calcaneocuboid joint. There was no evidence of osteoarthritis in the talocrural joint. Postoperative tibiocalcaneal (TiCa) and tibiotalor (TiTa) angles, measured in maximum dorsiflexion, were significantly smaller than the preoperative angles. Postoperative TiCa and TiTa angles measured in maximum plantar flexion minus the TiCa and TiTa angles measured in maximum dorsiflexion were not significantly less than the preoperative angles. The researchers concluded that their surgical outcomes were generally good, but that the patients must be monitored for recurrence because of the relatively low 42 percent union rate of the calcaneocuboid joint.

Practice Management

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Terminating or renegotiating a payer contract can be warranted under certain conditions, including overcrowded appointment schedules. Meanwhile, credentialing new providers should be considered because practices could lose revenue from credentialing delays if their state lacks credentialing rules that include a timeline. A third reason for mulling termination or renegotiation is the practice of payers automatically or arbitrarily downcoding E/M services, while a fourth factor is the authorization process. If a payer cannot prove that the practice has much higher usage of a procedure or test than its peers, the authorization should be struck. Finally, practices would do well to make use of the Payer Report Card as a tool for deciding whether payer negotiations or contract terminations are sensible.


More than 1,200 retired physicians were surveyed by the American Medical Association (AMA) about achieving a successful retirement. Retired doctors suggest considering a gradual transition, which can help you "grow into" retirement. Leaving the field can be a challenging process, and physicians who are already retired noted that it takes time to adjust. Furthermore, map out meaningful activities that will give you a sense of purpose in your retirement years. Spend time before retirement assessing personal life goals and developing a strategy to meet them.

Another tip is to commit to enjoying your retirement. Plan to discover new interests, revive old hobbies and spend time with family and friends. Also, take care of your health, which includes ramping up your physical activities in retirement. Retired physicians encouraged others to retire while still healthy and to consciously live a healthy lifestyle during retirement. In addition, plan your finances, and do so with an adviser and your spouse. Many retired physicians noted the importance of comprehensive retirement planning and working with a professional financial adviser to ensure a secure retirement. They also advised involving your family in the retirement planning process. Finally, prioritize your spending. Retired physicians emphasized the wisdom of prioritizing how you spend your money and manage your assets.


Understanding quality of care is essential to addressing the challenge of physician burnout, and a direct correlation exists between team-based care and physician satisfaction. One way to help address this problem is to have clinicians play a critical role in the healthcare supply chain as physician champions. Kettering Health Network's Trisha Gillum notes that the best physician champions for medical supply changes are personally engaged in the initiative.

Meanwhile, nurturing a high-reliability organization creates a supportive environment for physicians. Cleveland Clinic has done so, orienting the project around basic team building, policy standardization, real-time operational management, creating a culture of safety and sustaining redundancy in the clinical environment. Finally, predictive modeling can improve clinician decision-making. For example, NorthShore University HealthSystem employs prediction models to give physicians important patient information. The system uses 20 prediction models to target high-risk patients for factors that include cardiac arrest and readmission, and combining prediction models promises to expand the utility of patient data for physicians and population health initiatives.

Health Policy and Reimbursement

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The U.S. Centers for Medicare and Medicaid Services (CMS) is developing a proposed rule that would make it less difficult for states to halt payments for nonemergent medical transportation for Medicaid beneficiaries, for tentative release in May 2019. Researchers estimate that yearly Medicaid spending for these trips is about $3 billion, with some 103 million nonemergent medical trips annually.

Indiana University's Theresa Rohr-Kirchgraber warns the no-show rate for beneficiaries could escalate if the proposed rule is finalized. She says many enrollees do not have access to vehicles because of low incomes. "Our feet are really held to the fire in that we have high productivity in terms of the number of patients we see," Rohr-Kirchgraber says. "We're the ones who are making the money for our institutions, and we can't afford to keep our doors open if we can't get our patients in." States currently must get a waiver from CMS if they do not offer nonemergent transportation services. Medicaid enrollees typically use the benefit to get to dialysis, substance abuse treatments and chronic care visits for diabetes.


The U.S. Centers for Medicare and Medicaid Services (CMS) has proposed a new rule to pare back regulation around Medicaid managed care programs and permit states to contract with private payers to deliver managed care at faster rates. CMS developed the rule with the National Association of Medicaid Directors to address common administrative burdens for managed care programs. The agency said reducing administrative challenges in managed care while maintaining program integrity will allow states to continue their rapid adoption of managed care organizations.

CMS estimates that more than two thirds of Medicaid beneficiaries were enrolled in a managed care program in 2016. More states have been seeking to move away from fee-for-service toward managed care, which may be more cost effective. The proposed rule is designed to promote managed care contracts and to improve the value of Medicaid contracts through a series of regulatory changes. States would have the authority to use competitive bidding among health plans with limited rate ranges to foster competition and lower Medicaid prices. The rule also removes barriers that limit a state's ability to move fee-for-service populations into managed care, scraps redundant reporting requirements and lets states use modernized electronic reporting and communication systems for administrative purposes. CMS said the rule aims to improve managed care flexibility by allowing states to incorporate other delivery systems including telehealth.


The midterm elections resulted in changes in leadership and ballot initiatives that will have implications for healthcare across the country. Two major areas affected are Medicaid and the Affordable Care Act (ACA). Nebraska, Idaho and Utah approved Medicaid expansion, while new Democratic governors were elected in the nonexpansion states of Maine, Kansas and Wisconsin, increasing the likelihood of expansion there.

Meanwhile, with the House of Representatives now controlled by Democrats, efforts to repeal Obamacare will likely stall. "For the next two years anyway, we won't see efforts to repeal the ACA and cut Medicaid significantly," said Joan Alker, MPhil, research professor at the Georgetown University McCourt School of Public Policy. Short-term insurance plans will also likely come under greater scrutiny with Democratic control of the House.

Among other changes, Utah and Missouri legalized medical marijuana, Alabama and West Virginia approved ballot measures to limit or ban access to abortion and voters in Massachusetts defeated a nurses' union initiative that would have capped the number of patients assigned to individual nurses.

Medicine, Drugs and Devices

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Many surgeons write opioid prescriptions four times larger than what their patients will actually use after common operations, according to a new study published in JAMA Surgery. The research also indicated that the size of that prescription was the strongest predictive factor of how many opioids the patient will take, more so than their pain scores, the intensity of their operation and personal factors.

The researchers examined data from 2,392 individuals who had one of 12 different common operations at 33 Michigan hospitals. On average, patients took just 27 percent of all opioids prescribed to them, but for every 10 additional tablets prescribed, patients took five of them. "It's striking to see the major discrepancy between prescribed amount and the amount patients actually take," says Joceline Vu, MD, senior author of the paper. "This is not a phenomenon of a few outlier surgeons—it was seen across the state, and across many operations."

The researchers observed that psychology research has called this the anchoring and adjustment heuristic, where the baseline data someone receives makes a difference in how much they consume. Ryan Howard, MD, the paper's first author, says, "We hope that by shining a spotlight on the difference between prescription size and actual use, we can empower surgeons to change their prescribing habits and to be better stewards to both their patients and the broader community."


The U.S. Food and Drug Administration (FDA) has unveiled a new app designed to let researchers easily collect electronic health record (EHR) patient data, claims and billing information as well as patient-generated health data through patients’ mobile devices. The app—called MyStudies—enables researchers to gather real-world evidence from a variety of sources and to use this data in clinical trials and studies. The findings may help inform future regulatory decisions as researchers gain a more comprehensive understanding of how new drugs and medical products affect patients.

FDA partnered with Kaiser Permanente to conduct a pilot study measuring the functionality and effectiveness of the MyStudies app. After achieving success with the new tool, FDA is releasing the open source code and technical documents that support MyStudies to allow researchers and health IT developers to customize the app to fit their own needs and objectives. By doing this, FDA intends to expand the diversity of health data available for clinical trials and studies while also capturing the unique perspective of patients. "Our hope is that the collection of more real world data directly from patients, using a secure app, will lead to more efficient product development and assist with safety monitoring," said FDA Commissioner Scott Gottlieb, MD.


A new report by the U.S. Department of Health and Human Services' (HHS) Office of Inspector General (OIG) identified weaknesses in the U.S. Food and Drug Administration's (FDA) policies and procedures for handling postmarket medical device cybersecurity vulnerabilities. The report found that FDA had "not adequately tested its ability to respond to emergencies resulting from cybersecurity events in medical devices" and did not have written standard operating procedures in two of its 19 district offices.

OIG recommended that FDA "continually assess the cybersecurity risks to medical devices and update, as appropriate, its plans and strategies; establish written procedures and practices for securely sharing sensitive information about cybersecurity events with key stakeholders who have a 'need to know' and enter into a formal agreement with federal agency partners … establishing roles and responsibilities as well as the support those agencies will provide to further FDA's mission related to medical device cybersecurity." OIG also called on FDA to "ensure the establishment and maintenance of procedures for handling recalls of medical devices vulnerable to cybersecurity threats."