Will The New Sustainable Growth Rate ‘Doc Fix’ Work?

After punting 17 times on a fix for the Sustainable Growth Rate (SGR) reimbursement system for Medicare, Congress finally reached a permanent solution last month.

Congress approved the Medicare Access and CHIP Reauthorization Act (MACRA), a bill to permanently replace the SGR with a system that will update payments by 0.5 percent for the next four years followed by flat payments for six years after that and then subsequent raises of 0.25 percent a year, according to Modern Healthcare. The bill was going to President Obama as this issue went to press. The new plan comes after the Senate passed a temporary fix to prevent a 21.2 percent Medicare reimbursement cut, an action it had taken many times previously.

The solution is “not a win for physicians,” according to Lee C. Rogers, DPM. He notes the increases in reimbursement are “far below increases in the cost of living and the increases in the costs to do business so physicians are making big sacrifices with this bill.” Dr. Rogers, who who states 74 percent of his patients are on Medicare, says the plan will indirectly benefit private insurers since they base their fees on Medicare rates and physicians will see a reduction in relative income over the years.

Barbara Aung, DPM, feels the new system will add more administrative functions and financial burdens to medical practices. However, she is not sure whether the fixes will lead to better patient care. Likewise, while he feels the “doc fix” may keep physicians from leaving the Medicare system, Dr. Rogers does not think patients will see a difference in care either way.

Physician payments should be tied to the Consumer Price Index published by the Bureau of Labor Statistics, according to Dr. Rogers, the Executive Medical Director of the Amputation Prevention Center at Sherman Oaks Hospital in Los Angeles. He says this would more accurately represent the cost of living so physicians would not see a loss each year. He also advocates having a physician bonus driven by outcomes and tax deductions for medical student loans, regardless of income bracket.

Dr. Aung notes that most clinicians, especially in small private practices, do not have systems in place to measure their current treatment outcomes. Without this information, she asks, how can a system pay clinicians on outcomes? Dr. Aung adds that there is no data on which providers are best to handle certain situations — such as when is the most appropriate time to refer a patient to a specialist or whether primary care providers can attempt to do everything first.

So how, Dr. Aung asks, does Congress base payment of providing the most appropriate care at the most appropriate time by the most appropriate provider? She feels the physician getting the best outcomes for the expenditure should be rewarded for her or his efforts, but now providers get paid for the service provided, not the outcome achieved.

“To dream that we would be compensated based on a real market value or a fair market value for the risks we face when taking care of people who are sick and/or at risk of losing limbs and lives may be just asking too much,” says Dr. Aung, who is in private practice in Tucson, Ariz. and is a member of the American Podiatric Medical Association Coding Committee, and the American Academy of Professional Coders as a Certified Professional Medical Auditor.

Study Shows No Increase In Risk With Early Weightbearing After A Modified Lapidus Arthrodesis

By Brian McCurdy, Managing Editor

Early weightbearing following modified Lapidus arthrodesis does not increase the risk of non-union, according to an abstract presented at the American College of Foot and Ankle Surgeons (ACFAS) Scientific Conference.

In a retrospective review, the authors evaluated 367 patients who had a modified Lapidus arthrodesis. Among these patients, 183 had early weightbearing and 184 had delayed weightbearing. The study detected 13 non-unions in the early weightbearing group and 11 in the delayed weightbearing group.

Given that a locking plate construct with a compression screw places only one screw across the fusion site, abstract co-author Bradly Bussewitz, DPM, FACFAS, notes the construct allows more surface area for bone-on-bone healing in comparison to techniques with multiple crossing screws. The abstract authors noted that the locking plate with a compression screw caused the lowest non-union rate. Ultimately, Dr. Bussewitz notes the bony union surface area should be greater with less crossing hardware.

“The locking plate construct performs much like a fixed angle device and usually requires complete failure of the construct in comparison to a non-locking device that can fail one screw interface at a time,” says Dr. Bussewitz, who practices at the Steindler Orthopedic Clinic in Iowa City, Iowa. “Therefore, the locking construct should offer better stability.”

Dr. Bussewitz says classically surgeons reserved the Lapidus procedure for severe deformity or first ray instability but adds that the Lapidus procedure has benefitted from improved fixation techniques and better control of correction. Some have recommended that a Lapidus is the only bunion procedure to truly correct the pathology and would suggest its usage exclusively, according to Dr. Bussewitz. He cites ongoing research pointing to the rotational correction benefits that are only available with a procedure such as the Lapidus. Dr. Bussewitz says research combined with improved technology allowing early weightbearing may lower the threshold for performing this joint destructive correction.

Dr. Bussewitz notes that follow-up studies on Lapidus procedures performed by other surgeons decades earlier point to long-term correction maintenance. Theoretically, he says the Lapidus procedure relies on the midfoot for stability due to the fusion and may better correct the rotational cause of the bunion, thus offering better long-term correction.

A New Gold Standard For Chronic Lateral Ankle Instability?

By Brian McCurdy, Managing Editor

Including a bioabsorbable suture anchor in an arthroscopic Brostrom procedure can speed recovery time, according to an abstract presented at the recent ACFAS Scientific Conference.

The abstract focused on 45 patients with chronic anterior talofibular ligament tears who had arthroscopic Brostrom surgery with suture anchors. Patients had failed conservative therapy and their average follow-up was 14 months. The average time to partial weightbearing in a controlled ankle motion (CAM) boot was three days and the time to full weightbearing in a CAM boot was 14.4 days, according to the abstract.

Abstract co-author Jamie Cottom, DPM, FACFAS, notes that the modified Brostrom is a minimally invasive procedure that allows the surgeon to address simultaneous joint pathology, which is often present in chronic ankle instability. He says patients have very little to no discomfort postoperatively and are able to begin protected weightbearing three days after the procedure.

Dr. Cottom will only perform this procedure for chronic conditions. He notes all patients have at least six months of conservative treatment before he even mentions this technique in the office and he will not perform it on acute sprains. Dr. Cottom says he uses PushLock anchors (Arthrex) and a knotless technique for this procedure. Although there are no contraindications, he advises caution in patients with a very narrow arthritic joint or athletes with open growth plates. Dr. Cottom says the procedure is otherwise straightforward with a tourniquet time of about 20 minutes.

The study authors have also conducted follow-up of almost 18 months with the PushLock anchors technique and five years with the original Brostrom procedure, according to Dr. Cottom, the Director of the Coastal Orthopedics and Sports Medicine Foot and Ankle Fellowship in Bradenton, Fla.

“So far, the data is very encouraging,” says Dr. Cottom. “Patients are doing just as well as those who used to have open procedures. I do believe this will be the gold standard treatment for chronic lateral ankle instability as more studies are published.”

For a related online case study, see www.podiatrytoday.com.