A Path to Risk: Critical Elements of a Structured Approach.

Value-based care arrangements have been the cornerstone of accountable care for decades. Risk arrangements with government and commercial insurance plans are ubiquitous, with most contracts focusing on upside risk only, meaning payers reward providers for good performance without punishing them for poor performance on quality and cost. However, payers are increasingly moving into downside risk arrangements, bringing to mind global capitation in the 1990s wherein several health systems failed. In this article, the authors focus on their framework for succeeding in value-based arrangements at University Hospitals Accountable Care Organization, including essential structural elements that provider organizations need to successfully assume downside risk in value-based arrangements. These elements include quality performance and reporting, risk adjustment, utilization management, care management and clinical services, network integrity, technology, and contracting and financial reconciliation. Each of these elements has an important place in the strategic roadmap to value, even if downside risk is not taken. This roadmap was developed through an applied approach and intends to fill the gap in published practical models of how provider organizations can maneuver value-based arrangements.

CT analysis of hindfoot alignment in chronic lateral ankle instability.

A prospective case-control study was performed comparing axial and coronal CT scan images of 11 patients (14 ankles) with chronic lateral instability and 12 controls. Scans were performed in a standardized fashion to simulate weight-bearing. Nine measurements to evaluate the alignment of the hindfoot and forefoot were made on two occasions by two observers. The blinded images were read in order of assigned random number. The angle between the calcaneus and the vertical plane showed a statistically significant difference between patients (6.4 +/- 4 degrees varus from vertical) and controls (2.7 +/- 5 degrees) using unpaired ANOVA (p < 0.01). Intra-observer (R2 = 0.49 +/- 0.19) and interobserver (R2 = 0.71 +/- 0.13) variation showed moderate reliability across all measurements. This study demonstrates a method to evaluate hindfoot varus on CT scan. Many factors have been studied (e.g., proprioception) as the cause for recurrent instability, and this is the first time, to our knowledge, that an anatomic cause has been demonstrated. Although calcaneal osteotomy is clearly not indicated routinely, it may have a role in correcting extreme varus, which may contribute to failed ligament reconstruction in patients with ankle instability.