News From ACFAS

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Attend ACFAS 2018 in Nashville for a song when you register before the January 8, 2018 early bird deadline. Enjoy exclusive low rates and the very best the conference has to offer, including:

• Advanced clinical sessions and hands-on surgical workshops
• State-of-the art exhibits and scientific posters
• Sensational special events
• The HUB theater
• Annual Job Fair
• Unlimited networking opportunities
• And more!

ACFAS 2018 will take place March 22–25 at the Gaylord Opryland Hotel in Nashville. Register by January 8 at acfas.org/nashville and save! Help advance your profession, patient care and the future of the College. Volunteer to serve on a 2018 ACFAS committee, a Clinical Consensus Statement panel or as a reviewer of Scientific Literature.

To volunteer, visit acfas.org/volunteer. The application deadline is December 12, 2017. ACFAS’ Research Committee is pleased to announce the two recipients of the 2017 ACFAS Clinical and Scientific Research Grant:

Medial Double Arthrodesis with Flexor Digitorum Longus Tendon Transfer for the Treatment of Stage III Posterior Tibial Tendon Dysfunction: A Prospective Randomized Controlled Trial
Christopher F. Hyer, DPM, MS, FACFAS and Eric So, DPM

Efficacy of Preoperative Cryotherapy Use in Elective Hallux Abducto Valgus Correction
Guido LaPorta, DPM, FACFAS and Billy Rutter, DPM

Visit acfas.org/grant for a complete listing of past award recipients. The opioid addiction crisis in the United States remains a growing concern for both citizens and ACFAS members. Based on the results of an August 2016 poll in This Week @ ACFAS, 58 percent of respondents said they would change their prescribing habits in light of the opioid epidemic.

As a member of the Coalition for Patients’ Rights (CPR), ACFAS has provided input on CPR responses to reports issued by the President’s Commission on Combating Drug Addiction and the Opioid Crisis. CPR issued a statement in response to the Commission’s July 2017 interim report and will issue a second statement soon after it reviews the final report the Commission released on November 1.

ACFAS will watch this issue closely and will share updates as they become available. Visit patientsrightscoalition.org to learn more about CPR and its mission. The November poll in This Week @ ACFAS asked readers how they have participated in the Merit-Based Incentive Payment System (MIPS) so far this year. While the majority of respondents (57 percent) have not participated in MIPS, 24 percent have submitted the minimum amount required, 5 percent have submitted part of the requirements and 14 percent have fully participated in MIPS.

ACFAS will continue to monitor MIPS participation among its membership to see how it can support members in meeting MIPS requirements. Thank you for voting, and watch for the December poll in next week’s issue of This Week @ ACFAS.

Foot and Ankle Surgery

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A study was conducted to introduce percutaneous reduction and fixation of pediatric talar neck fractures and to make a comparison between this method and conventional open surgery. Twenty-three children (group A) with closed two-part talar neck fractures were treated with percutaneous reduction between October 2003 and May 2013 and compared with 26 children (group B) treated with conventional open surgery. Bone healing was achieved in all group A patients at an average of eight weeks. At the average follow-up of 27 months, mean plantar flexion and dorsiflexion reached 96 percent of the opposite, normal, side. There were 20 excellent and three good results. In group B, bone healing occurred in 21 of 26 cases at an average of 11 weeks. Nonunion was observed in five patients, among whom nonunion was combined with avascular necrosis of the talar body. Average follow-up was 29 months, and average plantar flexion and dorsiflexion reached 94 percent of the opposite normal side. There were 13 excellent, six good, two fair and five unsatisfactory results. Significant differences were seen in the time to bone healing and in ankle-joint motion and function.


A study was conducted to assess the use of delayed gadolinium-enhanced magnetic resonance imaging of cartilage (dGEMRIC) and T2 mapping in evaluation of type II osteochondral lesions (OCLs) of the talus and to characterize cutoff values for identifying patients with good/poor clinical outcomes. Twenty-eight patients were administered T2 mapping and dGEMRIC at least 1.5 years following microfracture or conservative treatment for type II OCL. Repair tissue showed lower dGEMRIC values and higher T2 values than normal cartilage, and T2 mapping exhibited greater area under the receiver operating characteristics curve than dGEMRIC. All T1 measures had higher maximized Youden indices than the corresponding T2 measures. The highest maximized Youden index for T1difference was seen at a cutoff value of 84 msec.


A systematic review was conducted to evaluate the impact of functional electrical stimulation (FES) of ankle dorsiflexors in children and adolescents with spastic cerebral palsy during walking. The researchers searched six databases for studies applying interventions to patients younger than 20 years, and results were classified based on the International Classification of Functioning, Disability and Health (ICF). A total of 780 abstracts were found, 35 articles were fully screened and 14 articles were employed for analysis. Only five articles, or three studies, were of level I to III evidence. At ICF participation and activity level, there was little evidence for a decrease in self-reported frequency of toe-drag and falls. At ICF body structure and function level, there was clear proof that FES increased ankle dorsiflexion angle, strength and enhanced selective motor control, balance and gait kinematics, but decreased walking speed. Negative events included skin irritation, toleration and acceptance issues.

Practice Management

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Physicians seeking to stabilize their revenue amid the transition to value-based care and the rising cost of care are confronting several challenges. Enrollment in high-deductible health plans is increasing rapidly, making patients responsible for a larger percentage of their healthcare bill. When it comes to paying their balances due, patients expect the same consumer-grade experiences and conveniences they are used to in other industries, along with greater price transparency. Supplying a range of electronic payment options—including online patient portals, automated payment plans and keeping a credit card on file—can improve the speed of payments, boosting payment processing efficiency and lowering the cost of collections. Concurrently, offering cost estimates at the time of a patient's office visit can improve patients' understanding of their responsibility and can deliver more clarity about the cost of care. In the end, the key to claims management success demands the ability to collect more from payers rapidly and at less cost and effort. Many practices employ a claims clearinghouse to help oversee this process and to provide dashboards with up-to-date claims information that can help reduce denials and days in accounts receivable while improving collections. Meanwhile, front-office staff are increasingly being called on to help educate patients as to their responsibility and to collect balances due, which requires training in customer service, conflict management and collections processes. It is also important to notify patients of their financial responsibility as early as possible, preferably before service, to give them time to plan accordingly.


Physician contracts often contain behavioral provisions that aim to curb undesirable physician conduct. However, contracts must be properly written to explain what is intended, allow for correction of improper conduct and evaluate behavior objectively. Subjective behavior provisions should provide for the employer to explore concerns and allegations using a "reasonable and good faith approach." In case of any allegations concerning an employee, there should be an investigation and documentation of wrongdoing based on a stated process or relevant policy. Using such an approach will minimize the need to interact with opposing counsel on the provision language and will reduce the risk of the employer being sued for a wrongful termination. Employers might also consider including language that requires a repeated pattern of behavior before taking action rather than a single event of a physician being rude or raising his or her voice, for instance. An employer should also develop the parameters they will follow for enforcement, such as frequency of complaints and events occurring in front of patients. Furthermore, employers should look for opportunities to cure behavior before taking formal action, such as reassignment of personnel or a class for a provider who has an abrasive personality. There is typically a story to be found whenever there is a behavior complaint, and the employer should investigate the concerns from multiple sources.


For doctors unsure how to best treat transgender patients, experts say they can take several actions. Joni Steffens, APRN, CSC, director of the new Gender Medicine program at CentraCare Health, says it is important to provide training and education sessions for staff members. Experts add that building relationships with LGBT community organizations is also important.

Health Policy and Reimbursement

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Capitol Hill lawmakers have successfully diluted a measure that would have empowered the military to approve emergency use of medical products, such as vaccines, platelet alternatives and freeze-dried plasma. Based on what was viewed as the U.S. Food and Drug Administration's (FDA's) slow movement on treatments that could help troops in crisis, the National Defense Authorization Act for fiscal year 2018 included language giving the U.S. Department of Defense (DOD) room to bypass the drug watchdog. Members of both houses of Congress, however, drafted a compromise bill that requires FDA to accelerate development or review of products in the case of a military emergency or significant risk for one. The provisions also stipulate that FDA and DOD hold semi-annual meetings to review relevant products in the DOD portfolio.


Massachusetts’ state Medicaid program wants the power to negotiate discounts for the drugs it purchases and to exclude drugs with limited treatment value. "This is a serious demonstration proposal," says Sara Rosenbaum, a health policy expert and professor at George Washington University. "They're not simply using [this idea] as an excuse to cut Medicaid. They’re trying to take a step toward efficiency." Other states are expected to take similar action if the U.S. Department of Health and Human Services approves the plan. Currently, state Medicaid programs are required to cover almost all drugs that have received approval from the U.S. Food and Drug Administration, including multiple drugs from different manufacturers used for the same purpose and in the same category. In exchange, manufacturers must discount those drugs—typically based on a set percentage of the list price, specified by federal law. State officials assert that the current Medicaid rebate system may encourage drug price inflation since a set percentage of a higher price yields a greater profit. Also, the legal requirement to cover most prescriptions leaves little wiggle room to negotiate a better price. Massachusetts is requesting a federal exemption known as a Section 1115 waiver, which is meant to let states test ways of improving Medicaid. It wants to pick which drugs it covers based on most beneficiaries’ medical needs and which medicines demonstrate the highest rates of cost effectiveness.


Medicare wants to save enrollees money on prescriptions and is asking for input on how to accomplish that goal. It issued a request Thursday for public comment on more effective ways to pass on Part D savings achieved through manufacturer rebates and pharmacy price concessions. The U.S. Centers for Medicare and Medicaid Services acknowledged that when these discounts are not reflected at the point of sale, Medicare beneficiaries often pay lower premiums but typically are responsible for a bigger chunk of a drug's actual cost. While it could take until 2020 to fully revamp the process, some proposed components—such as treating cheaper biosimilars the same as generics when calculating out-of-pocket costs and permitting mid-year changes in drug formularies to accommodate for new generics—could be adopted sooner. Medicare is accepting feedback until January 16, 2018.

Medicine, Drugs and Devices

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A rare genetic mutation found in members of an Amish farming community in Berne, IN, protects them from type 2 diabetes and seems to extend their life spans, according to a new study in Science Advances. An estimated five percent of the Berne community carries the mutation, which causes them to produce unusually low levels of plasminogen activator inhibitor-1, a protein known primarily for its role in promoting blood clotting. Douglas Vaughan, chair of medicine at the Northwestern University Feinberg School of Medicine, brought a team of researchers to the Amish community to conduct extensive tests on its residents. The researchers discovered that Amish carriers of the mutation typically live to age 85 years, about 10 years longer than their peers. The rate of type 2 diabetes for carriers of the mutation was zero, while the rate for those without the mutation was seven percent, despite leading the same lifestyle and consuming similar diets.


U.S. Food and Drug Administration (FDA) Commissioner Scott Gottlieb provided an update on agency efforts to address I.V. fluid shortages exacerbated by Hurricane Maria and advice for hospitals in managing the shortage. Among the steps FDA is taking, in conjunction with manufacturers, is temporarily allowing the importation of I.V. saline products from facilities outside of the United States; encouraging the expansion of production at existing facilities to meet shortfalls and expediting agency review of new product applications that will help address this shortage. As part of its efforts to reduce the risk of further shortages, FDA has been working with federal and local government partners to prioritize a small number of critical facilities based on public health needs, including those plants that manufacture I.V. saline bags, for consideration or prioritization to gain earlier access to the electrical grid.


The president's Council of Economic Advisers estimates the opioid epidemic put a $504 billion drain on the country in 2015—a rapid escalation from $78.5 billion in costs cited in a private White House analysis just two years earlier. The more than six-fold increase in part reflects efforts to better capture lost opportunities resulting from opioid-related deaths, especially among the working-age population. These deaths account for nearly $432 billion on their own, with continued opioid abuse inflating healthcare costs by $29 billion and law enforcement activity contributing about $21 billion more. For now, report authors offered no potential solutions to the problem. "A better understanding of the economic causes contributing to the crisis is crucial for evaluating the success of various interventions to combat it," they wrote.