News From ACFAS

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Four candidates have been recommended by the Nominating Committee for two vacancies on the ACFAS Board of Directors: Eric A. Barp, DPM, FACFAS; George T. Liu, DPM, FACFAS; Roya Mirmiran, DPM, FACFAS; and Eric G. Walter, DPM, FACFAS.

Candidate profiles and position statements are now viewable at acfas.org/nominations. Electronic voting will be conducted January 5–22, 2018. Watch This Week @ ACFAS for balloting details over the next month. December 31 is the final day you can pay your ACFAS membership dues and avoid a late fee! Renew your membership today at acfas.org/paymydues or via mail or fax to continue your member benefits.

All ACFAS Fellow and Associate Members should have received their 2018 ACFAS dues reminders by mail and email. If you have questions or need another statement, contact the Membership Department at (773) 693-9300. Do your New Year’s resolutions include:

• Increasing referrals to your practice to drive growth?
• Helping other healthcare providers become more aware of your expertise?

Then register now for the free webinar, “Take a New Look at Practice Building,” scheduled for January 17, 2018 at 8pm ET/7pm CT, and learn how to put your practice on the fast track in 2018.

Your colleagues Christopher L. Reeves, DPM, FACFAS; Amber M. Shane, DPM, FACFAS; and John S. Steinberg, DPM, FACFAS will outline the ways they have used the Take a New Look at Foot & Ankle Surgeons campaign marketing materials to network with partners and garner referrals for their practice.

Melissa Matusek, ACFAS director of Marketing and Communications, will also walk you through the resources available in the Marketing Toolbox to promote your practice to patients and other healthcare professionals.

Register today at acfas.org/practicebuilding and make 2018 the best year for your practice! Get fresh insights on patient care and nerve surgery—all from the comfort of your own home—by visiting the ACFAS e-Learning Portal for this month’s new podcast, “Patient Experience—Evaluation,” and Clinical Session, “New Strategies in Nerve Surgery.”

Hear your peers share their advice for using patient evaluations and feedback to improve care, then watch five presentations to learn the latest on:

• Approaches for interdigital neuromas related to nerve injury
• New strategies and imaging techniques
• Treatment options for common fibular nerve entrapment

Complete a short CME test after viewing the Clinical Session to earn 1.75 continuing education contact hours.

New programs are added to the e-Learning Portal every six weeks to give you a wide range of resources to explore. Visit acfas.org/e-Learning regularly for convenient online learning that is always ready when you are.

Foot and Ankle Surgery

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A study was conducted to test a hypothesis that knotless suture button devices for tibiofibular syndesmosis injuries eliminate knot irritation and facilitate a quicker return to sports. The clinical outcomes, complication rates and time to return to sports between a new knotless suture button device and syndesmotic screw fixation were compared. Included were 54 patients treated for ankle syndesmotic injury from 2012 to 2014 with a knotless suture button device or syndesmotic screw fixation. Subjects underwent clinical and radiological assessments preoperatively and three times during the one-year postoperative follow-up. The screw fixation and knotless suture button groups comprised 26 and 28 patients, respectively. The complication rate was significantly reduced, and time to return to sports was significantly faster in the knotless suture button than screw fixation group. No significant differences were observed in clinical outcomes or visual analog scale scores for pain and function between the groups. Age, injury mechanism and body mass index did not significantly affect the time required to return to sports activities. The type of fixation was the only independent variable that had statistical significance.


A study was conducted to evaluate high-bandwidth and compressed sensing-(CS)-SEMAC turbo spin echo (TSE) techniques for metal artifact reduction magnetic resonance imaging (MRI) of total ankle arthroplasty (TAA) implants, using 40 subjects who underwent 1.5-T MRI prospectively. Assessments included bone-implant interfaces, anatomical structures, abnormal findings and differential diagnoses prior to and after MRI. Areas under the curve of P-P plots were used to ascertain superiority. CS-SEMAC TSE was found to be superior to high-bandwidth TSE in showing the bone-implant interfaces, periprosthetic bone, tendons and joint capsule, bone marrow edema, interface osteolysis, tendinopathy, periprosthetic fractures, synovitis and reader confidence for bone marrow edema, fracture, interface osteolysis, synovitis and tendinopathy. The number of differential diagnoses in symptomatic subjects after the MRI with CS-SEMAC fell from three to one.


Researchers in Malaysia sought to compare hemodynamic profiles and pain scores in patients living with diabetes who had diabetic foot surgery while receiving peripheral nerve block (PNB) or spinal anesthesia (subarachnoid block [SAB]). This was a prospective, randomized controlled trial. They recruited patients aged 18 years and over who were scheduled for unilateral diabetic foot surgery below the knee. All patients were assessed for autonomic dysfunction using the Survey of Autonomic Symptoms score. Participants were randomly assigned to receive either PNB or SAB for the surgery. Hemodynamic data, including usage of vasopressors, were recorded at five-minute intervals for up to one hour after the induction of anesthesia. Pain scores were recorded postoperatively, and follow-up was done via telephone six months later. Compared to the PNB group, the SAB group had a larger number of patients with significant hypotension (14 vs. 1; p = 0.001) and more patients who required vasopressor boluses (six vs. zero patients). Compared to SAB group, the patients in the PNB group had a longer postoperative pain-free duration (nine vs. 4.54 h; p = 0.002) and lower pain scores one day after surgery (3.63 vs. 4.69; p = 0.01). The researchers concluded that peripheral nerve block should be considered, whenever possible, as the first option of anesthesia for lower-limb surgery in patients living with diabetes because it provides hemodynamic stability and superior postoperative pain control compared to SAB.

Practice Management

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Email has been the biggest source of data breaches in 2017 for healthcare organizations. Seventy-three breaches between January 1 and the end of November were reported to the U.S. Department of Health and Human Services, affecting 573,698 people. A new survey from security firm Mimecast and HIMSS Analytics found hospital staff cited email as the most likely medium for a breach. Additionally, 78 percent of respondents said they had either a malware and/or ransomware attack in the last 12 months. Mimecast recommends training employees on email risks, analyzing email attachments, checking URLs, inspecting outbound emails and increasing resilience with backups.


The U.S. Food and Drug Administration (FDA) has announced the launch of a new tool that will give healthcare providers direct and timely access to critical updates about antibiotics and antifungal drugs. A new website will provide information about when bacterial or fungal infections are likely to respond to a specific drug. According to FDA, "This approach is intended to aid healthcare professionals in making more informed prescribing decisions that will both benefit their patients and prevent the spread of resistant bacteria." Physicians use antimicrobial susceptibility testing to help select an appropriate antibacterial or antifungal drug to treat a patient's infection. The tests use criteria, known as "breakpoints," that help determine whether a specific bacteria or fungi is susceptible to antibacterial or antifungal drugs. However, since bacteria and fungi change over time, the breakpoints need to be updated. Previously, each drug manufacturer updated its drug labeling with new breakpoint information, which FDA reviewed and approved on a case-by-case basis. Under the new approach, FDA can simultaneously update the breakpoints for multiple drugs that have the same active ingredient and share that information transparently through a dedicated FDA website that will list FDA-recognized breakpoints. Companies that disagree with the recognized standard can submit data to support alternative breakpoints, FDA noted. Drug companies will need to update their labeling to reference the FDA webpage containing the breakpoint information—but they will no longer need to continuously update their labeling with new breakpoint information, which should make "the process more efficient and, it is expected, more timely," FDA said. The agency is also issuing guidance on how companies should update their labeling on breakpoints to point to the information online generated by FDA.


To improve outcomes and prepare practices for value-based reimbursement, some physicians are joining accountable care organizations (ACOs) or other kinds of networks to spread out the costs of the required infrastructure. The first step for practices is using their electronic health record (EHR) to the greatest possible extent and making sure they are applying all the functionality and the data fields in the system, advises Michael Barr at the National Committee on Quality Assurance. He says practices should pick applications that best support their goals and match their resources. For example, if a practice has the resources to do patient outreach and needs to identify the patients who have care gaps, they should look for a dashboard-type application that supports that kind of activity. David Nash at Thomas Jefferson University in Philadelphia recommends that practices interested in full-scale population health management join some kind of larger organization, such as an ACO, as well as turn to online courses on this care delivery model from Thomas Jefferson University and the American Association of Physician Leaders. If a practice buys a population health management application designed to work with EHRs, he advises, "Tinker and get experience and see how it's working and begin the self-evaluation that's necessary to effectively use the tool." Practices also need to hire the appropriate staff, call patients about follow-up care, track referrals, learn how to use care managers to work with high-risk patients and learn how to identify those patients. Moreover, they need to identify how to improve transitions of care, manage care between visits and provide feedback to providers about their performance.

Health Policy and Reimbursement

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A bipartisan group of six senators is requesting GOP leadership to halt an upcoming Trump administration rule that would reduce funding for a federal drug discount program called 340B. The program requires drug companies to give discounts to healthcare organizations that serve high volumes of low-income patients. A new rule from the U.S. Centers for Medicare and Medicaid Services (CMS) that takes effect January 1 calls for reducing Medicare payments to hospitals enrolled in the program by $1.6 billion. The senators are urging the cuts to be reversed in the year-end spending deal. In a letter to Senate Majority Leader Mitch McConnell (R-Ky.) and Minority Leader Charles Schumer (D-N.Y.), the senators wrote, "However, with a January 1, 2018 start date, and over half of the Senate and half of the House of Representatives having expressed concerns with CMS' rule, we request your help in ensuring the long-term sustainability of the 340B program by preventing these changes in an end of the year package." Sens. John Thune (R-S.D.), Rob Portman (R-Ohio), Shelley Moore Capito (R-W.Va.), Bill Nelson (D-Fla.), Tammy Baldwin (D-Wis.), and Debbie Stabenow (D-Mich.) signed the letter. Hospital groups warn the rule would jeopardize the ability to serve low-income patients. The American Hospital Association, America's Essential Hospitals and the Association of American Medical Colleges are suing the administration to block the rule. CMS contends the changes will increase access to care and curb out-of-pocket drug costs for Medicare beneficiaries.


A draft proposal from the U.S. Medicare Payment Advisory Commission (MedPAC) calls for repealing Merit-Based Incentive Payment System (MIPS) payment tracking under the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) and replacing it with a new Voluntary Value Program. Physicians could opt to be measured as part of a voluntary group to become eligible for a value payment scored on their group's performance on population-based measures based on claims data instead of meaningful use criteria physicians use within their electronic health records. The objective is maintaining the value component in Medicare fee-for-service (FFS) clinician payment and prompting the move to advanced alternative payment models (APMs). The concept involves limiting potential bonuses in unconstrained FFS to be less than APMs and boosting familiarity with population-based measures. Earlier this month, the American Hospital Association requested MedPAC "use data and experience from the field before advocating for major changes to MIPS." However, the counterargument is that many providers are not prepared for MACRA payment changes and the law is too complicated, while others see a high-reporting burden. MedPAC's proposed replacement would withhold about 2 percent of payments for providers not in APMs. Providers electing to continue in an FFS model would skip payments, while others who join the new payment model could possibly recoup the withheld amount.


U.S. Senate Republicans are split over whether they should use the months before the 2018 elections trying to cut spending on social programs, including Medicare. Sen. John Thune (R-S.D.) believes Congress should consider slashing long-term spending on these federal programs next year. "If we're going to do something about spending and debt, we need to get faster growth in the economy, which I hope tax reform will achieve," Thune noted. "But we also need to make our entitlement programs more sustainable." House Speaker Rep. Paul D. Ryan (R-Wis.) said Congress should attempt to pass a reconciliation package that targets Medicare, Medicaid and the Affordable Care Act (ACA). However, many Senate Republicans seem to be unsure about tackling Medicare. Although none of the senators disagreed with the need to trim spending on social programs, even those most keen to do so understood they faced deep political resistance. The senators most eager to pursue entitlement cuts, including Medicare, are conversatives. In his election campaign, President Trump vowed not to interfere with Social Security, Medicare or Medicaid. Ryan said he believed he was making progress in private conversations trying to convince Trump to revamp Medicare. Still, other Senate Republicans warned that attempting to repeal the ACA had already exposed major rifts in the GOP, and it would be problematic to take on a more popular federal program in an election year. Just 5 percent of Democratic voters and 15 percent of Republican voters support Medicare cuts, according to a May survey by the Pew Research Center.

Medicine, Drugs and Devices

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Pharmaceutical companies sued to block a new California law that would require them to give advance notice before big price increases. The law was approved earlier in the year in response to consumer outrage over an increase in drug spending and high costs for certain prescription treatments, such as new Hepatitis C medications. The Pharmaceutical Research and Manufacturers of America (PhRMA), a trade group for drugmakers, said in its lawsuit that California's law illegally attempts to dictate national health policy. Because the law is tied to a national measure of drug prices, PhRMA contends that California's advance notification requirement could restrict drugmakers' ability to hike prices in other states. The group further criticized the law as "unconstitutionally vague" and in violation of the First Amendment in that it forces drug companies to justify price increases. The law is set to go into effect at the start of 2018.


The U.S. Food and Drug Administration (FDA) has finalized guidance from 2013 on prescription drug product name placement, size, prominence and frequency in promotional labeling and advertisements for prescription drugs. The guidance has been revised to clarify issues relating to the direct conjunction of the proprietary and established names, as well as the frequency of use of the established name on printed pages or spreads, in running text or columns, in the audio portion of audiovisual promotions and in electronic media. FDA also discussed ways in which it will study how consumers and health professionals report deceptive drug promotions and responded to comments. "A key to our oversight is recognizing claims in prescription drug promotion that have the potential to deceive or mislead consumers and healthcare professionals," said FDA Commissioner Scott Gottlieb. "We also need to have clear rules for how sponsors can present certain information, even elements as straightforward as the product name, and do so without introducing features that could mislead patients."


Consumers are often shocked to discover they can sometimes get better prices on drugs than their own insurers. Although there are no nationwide figures to track how often consumers could have gotten a better deal on their own, one industry expert estimates that up to 10 percent of drug transactions involve such situations. If true nationwide, that figure could total as many 400 million prescriptions a year. The system has become so complex that "there's no chance that a consumer can figure it out without help," says the expert, Michael Rea, chief executive of Rx Savings Solutions. PBMs often do negotiate better prices for consumers, particularly for brand-name medications, Rea says, but that is not necessarily true for some generic drugs. Insurers' clients are frequently employers overseeing large numbers of workers, and the companies are focused on overall costs. So when insurers seek deals for generic drugs, they do so in batches, reaching agreements for groups of different drugs rather than getting the lowest price on every drug. As a result of these complicated layers of private negotiation, different insurers end up paying different prices for individual drugs. Several independent pharmacists say there might be safety issues if consumers buy drugs at different pharmacies. If those prescriptions are filled without an insurance card, pharmacy systems may not catch dangerous drug interactions. 'That, to me, is a recipe for disaster," says Craig Seither, who owns Fort Thomas Drug Center in Fort Thomas, KY.