News From ACFAS

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Congratulations to the newly elected ACFAS board members from online balloting that ended on December 30:

• Meagan M. Jennings, DPM, FACFAS (three-year term)
• Randal L. Wraalstad, DPM, FACFAS (three-year term)
• Michael J. Cornelison, DPM, FACFAS (two-year term)

Also serving on the 2017–2018 Board of Directors are Laurence G. Rubin, DPM, FACFAS, President; John S. Steinberg, DPM, FACFAS, President-Elect; Christopher L. Reeves, DPM, FACFAS, Secretary-Treasurer; Sean T. Grambart, Immediate Past President; Thanh L. Dinh, DPM, FACFAS; Scott C. Nelson, DPM, FACFAS; Aksone Nouvong, DPM, FACFAS; and Eric G. Walter, DPM, FACFAS.

The new board will be installed on February 28 during the ACFAS 75^th Anniversary Scientific Conference in Las Vegas. In 1942, five men, average age 31, founded ACFS (now ACFAS). Their goal: To build a profession worthy of respect and recognition and to create an organization that would accomplish more than they could individually. They succeeded. There’s no question that surgery is what transformed chiropody to podiatry to foot and ankle surgery. This amazing story will be told throughout our 75^th anniversary year in all ACFAS publications, including The Evolution of a Profession, a special history book that will debut next month. We hope you’ll read this story and appreciate how your predecessors changed American medical history! Set your own course—register now for ACFAS 75, your connection to educational opportunities with clinically relevant sessions and a community of innovative problem-solvers in attendance who will inspire and energize you and your practice—all in just four days. Set for February 27–March 2 at The Mirage in Las Vegas, ACFAS 75 will be the place to join your colleagues for these sessions and grand special events to celebrate the College’s 75 years of rich history.

Be sure to book your hotel room for the conference with onPeak, our official housing partner. Choose from The Mirage ($168/night) or Treasure Island ($109/night) and enjoy the lowest rates plus complimentary amenities.

Visit acfas.org/vegas to register and make this a year to remember! ACFAS uses several vehicles to communicate College news and updates to members. Take this month's poll at right to let us know which channel you use most often to stay abreast of all things ACFAS. Real-time poll results will be available throughout the month on acfas.org. Thank you for sharing your input!

Foot and Ankle Surgery

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A study evaluated the outcomes of patients who had undergone arthroscopic treatment of large osteochondral lesions of the talus (OLTs) with unrestricted postoperative weightbearing and mobilization. Thirteen patients with lesions larger than 150 mm² who underwent arthroscopic bone marrow stimulation for osteochondral defects were available for follow-up. Patients were allowed immediate weightbearing postoperatively. Two patients underwent osteochondral transplant and were considered failures. The remaining 11 patients had an average lesion size of 239 mm². At an average follow-up time of 33 months, postoperative scores included a foot function index of 50, visual analog scale score of three and American Orthopaedic Foot and Ankle Society hindfoot score of 82. The overall success rate was 54 percent.


A recent study examined the use of fresh bulk osteochondral allograft transfer for treatment of large osteochondral lesions of the talus (OLTs) and characterized the functional outcomes, complications and reoperation rates. The review included five studies involving 91 OLTs. Fresh talar allograft was transplanted into 71 medial, 18 lateral and two central OLTs. After a mean of 45 months, American Orthopaedic Foot and Ankle Society scores improved from 48 preoperatively to 80 postoperatively, and pain visual analog scale scores improved from 7.1 to 2.7. Twenty-five percent of patients required at least one reoperation. The most common causes of reoperation were development of moderate to severe osteoarthritis (14 percent), pain due to hardware (nine percent), extensive graft collapse (three percent) and delayed or nonunion of osteotomy site (one percent). Twelve cases were considered failures, and eight cases resulted in tibiotalar arthrodesis or ankle replacement.


Researchers compared the long-term outcomes of percutaneous transluminal angioplasty (PTA), a supervised exercise program (SEP) and combined treatment (PTA + SEP) in patients with intermittent claudication due to femoropopliteal disease. Assessments were completed for 111 patients at a median follow-up of 5.2 years. Sixty-nine patients were symptomatic, and 18 patients had experienced a major cardiovascular event. Improvement in the ankle brachial pressure index was observed in all groups. PTA and PTA + SEP groups had a significantly higher ABPI than the SEP group. No significant differences between groups were found in treadmill walking distances, VascuQol quality-of-life outcomes, restenosis rates or new ipsilateral and contralateral lesions on duplex imaging. Reinterventions were required for 14 patients in the PTA group, 10 patients in the SEP group and six patients in the combined treatment group.

Practice Management

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Heathcare ransomware and other cyberthreats are up 63 percent from 2015 and will continue to grow in the coming year, according to software vendor TrapX. Medical device hijack, called MEDJACK, and ransomware have hit a broad mix of targets in 2016, from hospitals and diagnostic laboratories to physician practices. Most providers install antivirus software and firewalls to protect infrastructure, but medical devices often run on old and unsecure versions of Microsoft Windows. MEDJACK attacks exploit vulnerable infusion pumps, heart-lung machines, blood gas analyzers and other devices as a way to launch data theft or ransomware. Many MEDJACK attacks could be stopped by second-generation perimeter and endpoint defenses, but most hospitals do not have this technology. So many stolen health records are offered for sale that the price for records has plummeted, leading hackers to favor lucrative ransomware schemes instead. Law enforcement agencies urge providers not to pay ransoms, but many victims are choosing to pay to avoid further downtime and financial losses.


To keep up with advancements in medicine and the healthcare industry, the doctor-patient relationship must be redefined to encourage greater communication and patient empowerment. Patients now have the ability to research their medical conditions online, and doctors should support their patients' pursuit to understand their disease, as it can lead to better outcomes. Patients who understand why they are prescribed certain medications will be more likely to take them. To protect patients from gimmicky and false information and products, physicians should direct patients to reliable resources that provide accurate information. Once patients are empowered to understand their diseases and medications, they must be encouraged to take an active role in their health decisions by listening and asking questions. Finally, physicians should present their patients with choices and discuss treatment options rather than present a diagnosis and prescription without an explanation.


The biggest challenge of the new year for healthcare providers will be adapting to the Medicare Access and CHIP Reauthorization Act and its changes to physician reimbursement. The U.S. Centers for Medicare and Medicaid Services have delayed full implementation until 2018, but practices will still be expected to submit at least partial information for 2017. Prior authorization requirements have increased in recent years and will continue to grow in 2017 as drugs get more expensive. Practices can expect to spend more time handling prior authorizations, but technology may help streamline the process. Physicians are also facing declining reimbursement and narrowing provider networks as payers move to consolidate and make contract negotiations difficult. The rise in copays, deductibles and drug prices is leading to more patients skipping care because of financial concerns. Encouraging patients to discuss financial barriers will give doctors the opportunity to find other treatment options, identify less costly service providers and prevent wasted time prescribing tests or medications that will not be filled. Increasing amounts of time spent on administrative tasks and frustration with the demands of government regulators and third-party payers have led to growing levels of physician dissatisfaction and burnout. To combat the problem, the American Medical Association has created online tutorials designed to help practices operate more efficiently and better distribute workloads.

Health Policy and Reimbursement

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The U.S. Centers for Medicare and Medicaid Services (CMS) have revealed its intent to recruit states in a trial allowing Medicare accountable care organizations (ACOs) to also manage Medicaid costs for patients enrolled in both programs. The new model is based on the Medicare Shared Savings Program, wherein Medicare ACOs that reach spending and quality targets can share in savings with CMS. However, those ACOs frequently do not consider Medicaid savings, even when beneficiaries are enrolled in both Medicare and Medicaid programs. These “dual eligible” patients are often higher risk and have higher health costs. CMS plans to forge agreements with up to six states, with preference given to states with low saturation of providers already participating in a Medicare ACO program. Participating states will be permitted to engineer certain parts of how they deploy the model. The agency also announced more opportunities for clinicians to enroll in advanced alternative payment models to earn incentives under the Medicare Access and CHIP Reauthorization Act of 2015. Participating physicians will earn yearly bonuses of five percent starting in 2019 and are exempt from the reporting and performance requirements under the law's Merit-Based Incentive Payment System. Ten healthcare organizations, including the group purchasing organization Premier, sent a letter calling on CMS to develop the ACO Track 1+ as an advanced alternative payment model and to rapidly finalize it so ACOs can begin participating as soon as 2018.


The U.S. Centers for Medicare and Medicaid Services will update electronic clinical quality measure (eCQM) value sets to account for changes made in the ICD-10-CM and ICD-10-PCS codes. The addendum will affect the Hospital Inpatient Quality Reporting (IQR) program, the Medicare Electronic Health Record Incentive Program and the Merit-Based Incentive Payment System. The Health Quality Measure Format specifications, value set objective identifiers and the measure version numbers for 2017 eCQM reporting will not change. The addendum will also eliminate expired codes and add relevant replacement codes. The ICD codes typically are updated every year, but CMS has not updated the codes since 2013 to assist providers transitioning from ICD-9 to ICD-10 in 2015. Therefore, updates and revisions for 2017 include changes since the last complete update.


Seema Verma, who advised Indiana and other states on expanding their Medicaid programs, is President-Elect Donald Trump’s pick to run the U.S. Centers for Medicare and Medicaid Services (CMS). Verma was hired as a private consultant by Indiana Governor and Vice President-Elect Mike Pence to design an expansion of Medicaid under the Affordable Care Act. The plan, which extended Medicaid to about 246,000 people who previously were not eligible, requires poor Medicaid recipients to make monthly payments for their insurance, or lose benefits. Beneficiaries make monthly payments from $1 to $27 into individual health savings accounts, to which the state also contributes. The funds can be used for doctor visits and prescriptions, and beneficiaries receive a discount on their premiums if they get vaccines and other preventative care. If a patient unnecessarily goes to the emergency room, extra funds are removed from the health savings account. People whose incomes are above the poverty line can lose coverage for six months if they miss a payment, while those below the poverty line are knocked down to a plan with fewer benefits. Verma originally wanted the penalty for missed payments to be a full year without coverage, but CMS rejected the proposal. Verma also has indicated that the process of getting Medicaid waivers should be made easier for states.


Even without a repeal of the Affordable Care Act (ACA), the incoming Trump administration could unilaterally eliminate billions of dollars the government pays insurers to subsidize the health coverage of low-income consumers. The cost-sharing reductions could be dropped as soon as President-Elect Donald Trump takes office as the result of a lawsuit brought by House Republicans against the Obama administration two years ago. Intervention by the new president to stop the payments would create upheaval in the ACA marketplaces, given that insurers would still be required to provide consumers financial assistance. Health plans likely would raise their prices or drop out of the marketplaces, according to health-policy experts. Members of Trump’s transition team have not indicated whether the incoming president will exercise this power, but Trump's pick to lead the U.S. Department of Health and Human Services, Representative Tom Price, is an outspoken critic of cost-sharing subsidies.

Medicine, Drugs and Devices

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The American Academy of Pediatrics (AAP) has issued a policy statement on the off-label use of medical devices for children. As studies of medical and surgical device use in children are less common than studies in adults, it is common to use devices in circumstances other than those cleared by the U.S. Food and Drug Administration (FDA). The new policy endorses the practice of using off-label medical and surgical devices when no FDA-approved device is available and when the pediatrician believes use of the device is in a patient’s best interest. AAP also addresses the use of devices for rare conditions that have been cleared by FDA under a Humanitarian Device Exemption (HDE); these devices should not be considered investigational, and public and private payers should cover appropriate uses of HDE devices.


The Food and Drug Administration (FDA) has released final guidance addressing the cyber vulnerabilities in medical devices and how manufacturers should maintain security of Internet-connected devices. FDA recommends that manufacturers build cybersecurity controls into medical devices during the development process and continue to monitor hazards throughout the device lifecycle. Additionally, manufacturers should work with researchers to better understand potential threats and to address issues before exploitation of weaknesses can occur prior to deployed mitigations. FDA reinforces the importance of applying the guidance of the National Institute of Standards and Technology to improve cybersecurity infrastructure. However, the recommendations are not official rules, and the report does not mention enforcement. The guidance was released as FDA investigates claims that St. Jude Medical's heart devices are vulnerable to cyberattacks.