News From ACFAS

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Sean T. Grambart, DPM of Champaign, Illinois and Christopher Reeves, DPM of Orlando, Florida were elected to the ACFAS Board of Directors in electronic balloting that ended on December 29. They will begin their three-year terms at the 2013 Annual Scientific Conference on February 11-14 in Las Vegas, Nevada. The 2013-14 ACFAS officers, also to be installed next month, will be: Jordan P. Grossman, DPM, President; Thomas R. Roukis, DPM, President-Elect; Richard Derner, DPM, Secretary-Treasurer; and Michelle L. Butterworth, DPM, Immediate Past President. Join ACFAS on Wednesday, January 9 at 8 p.m. CST for a new, complimentary practice management webinar titled Leveraging Your Online Presence to Boost Office Productivity from ACFAS' Benefits Partner, Officite.

A solid Web presence not only puts you in front of existing and future patients, but it can also help you achieve greater efficiencies in the office.

Attend this brief webinar and learn how to maximize the efficiency of your webpage so you can promote services and communicate to patients 24/7—even when the office is closed! You will understand how patient knowledge about treatments can be improved and calls to the office minimized with information available via your website around the clock.

This webinar will also teach you how to save time and streamline office tasks by adding online registration forms, online appointment requesting and treatment instructions, in addition to online patient education, which increases patient knowledge about ailments and services, thus improving treatment awareness and reducing calls to office.

Foot and Ankle Surgery

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A study was held to investigate the impact of the low-dye taping method on medial arch deformation from a biomechanical perspective. The study involved collection of kinematic data using a Motion Analysis System, with foot function of 21 healthy adults evaluated during the stance phase of gait. Subjects were assessed before and immediately after low-dye tape application, as well as at 48 hours. Foot deformation was assessed during the stance phase of gait using the calcaneus, navicular and first metatarsal head markers to estimate the medial longitudinal arch angle (MLA) as well as the dynamic arch height index, while aired t-tests were used to evaluate low-dye tape effectiveness. A 19.3 percent reduction in MLA immediately after application of the tape was observed, but just 4.01 percent reduction remained in deformation after 48 hours. The MLA deformation findings were consistent with the AHI change, demonstrating significant change in the arch deformation between pre- and post-low-dye taping. The effects did not last long.


A study was held to determine the safety of percutaneous tenotomy of the Achilles tendon in infants with idiopathic clubfeet sedated by propofol, through review of all idiopathic clubfoot patients less than 12 months old who underwent percutaneous tendoachilles tenotomy under anesthesia. Included in the study group were 114 patients to whom 162 tenotomies were administered. Sixty-five patients were in group 1, receiving a sevoflurane/propofol combination, and 49 patients were in group 2, receiving propofol only. There were no differences between the two groups in regard to gender, bilaterality, chronological age, number of preterm infants, ASA class or associated risk factors. The average time from operating room entry to surgery was about five minutes longer with group 1, which included 14 cases that took longer than 20 minutes. However, no differences between the two groups were observed with respect to postoperative complications.


A study was performed to measure the shape and coverage of talar and tibial articular surfaces by comparing the three-dimensional morphology of the ankle in patients with ankle osteoarthritis and in those without arthritis. Researchers generated three-dimensional simulations of the joint surface of arthritic and non-arthritic ankles, fitted cylinders to the joint surfaces and quantified the radius of the tibial and talar articular surfaces, the tibial coverage angle of the talus and the degree of joint skew. The researchers theorized that these measurements would differ between those with and without ankle osteoarthritis and among foot types. A total of 108 limbs were assessed, and the average tibial and talar radii were significantly higher, while the average coverage angle was substantially lower in feet with ankle osteoarthritis than in all other foot categories. The average coronal skew in limbs with ankle osteoarthritis was notably higher than in the neutral and flatfoot groups. The high arched feet exhibited several significantly different skew angles from other foot types. No significant differences in joint morphology measures between neutrally aligned feet and flatfeet were observed.

Practice Management

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There are a number of strategies that can prepare a physician practice for a Medicare audit and site visit. Although many tips may appear to be common sense, they are in fact actual issues that real practices are often confronted with.

1. Immediately check the address on the letter notifying the practice of the site visit, including the suite number, to ensure that it is the correct and complete physical address of the intended site visit.

2. Immediately call and make telephone contact with the auditors.

3. Immediately call your attorney and ask him or her to attend the audit and site visit.

4. If the site visit is set for a branch office, make sure the appropriate administrative personnel and at least one of the physicians who sees Medicare patients are in the office on the day of the site visit.

5. Make sure your office is "photogenic." Inspect your office immediately, and call for an emergency housekeeping visit, if necessary.

6. Make sure all displayed licenses and certificates are current.

7. Make sure all patient health records are properly secured and that your medical record handling and storage comply with Health Insurance Portability and Accountability Act (HIPAA) standards.

8. Set aside a separate room with chairs and a flat surface (a desk or table) for the auditors to use as their meeting, conference and interview room.

9. Require proper photographic identification and identifying information from each member of the audit team.

10. Assign one staff person to be the communication liaison with the auditors (and your attorney).

11. Keep a copy of every document or paper you provide to the auditors during the site visit.

12. Be aware of scrutiny of policies and procedures for narcotics or pain medications.

13. If the records needed by the auditors are in a different office of the practice, do not overextend yourself trying to obtain them during the site visit.

14. Do not guess the answers to any questions the auditors ask you.

15. Expect to be asked for your drug list or formulary.

16. Ask questions of the auditors in an attempt to obtain information about any special areas of concern.

17. Do not voluntarily advise the auditors of suspicions of wrongdoing or ask whether your policies or procedures are correct.

18. Keep good, legible copies of your transmittal of documents to the auditors, and maintain a record of what you sent.

19. If you need additional time, request it by telephone and confirm it in writing.


Specialist physicians who are considering signing with an accountable care organization (ACO) should consider if their contract says that this will be the only ACO in which they and their practice colleagues can participate, as exclusivity provisions of the Medicare ACO regulations may potentially prevent multispecialty physicians from enrolling in more than one ACO. Patient assignment and physician exclusivity to an ACO are based on “primary care services” delivered to a Medicare beneficiary under a Medicare billing number connected to the federal taxpayer identification number (TIN), but primary care services have a broad definition under ACO regulations and include any service within specified HCPCS billing codes. ACO rules stipulate that if Medicare patient assignment to an ACO is dependent on a participant's TIN then it must be exclusive to that ACO.

The exclusivity standard encompasses all physicians within a group practice, and when a TIN is exclusive to an ACO, all physicians providing services billed through the group practice will be exclusive to that ACO. However, patient assignment that is non-dependent on a participant's TIN means that the participant’s TIN is not mandated to be exclusive to a specific ACO, and the physicians may sign with multiple ACOs. To avoid such exclusivity, specialty physicians can encourage their patients to see a primary care physician, and the services supplied by the specialist would not be considered in determining the assignment of the patient. Another strategy is for specialists to provide services under a separate entity that bills under a separate TIN, instead of billing the services under the TIN associated with the group practice. Additional options include establishing a separate entity to retain physicians and bill for their services, letting physicians work part time for other healthcare entities or having physicians enroll and bill under their Social Security number.


A growing number of big employers and insurers are beginning to cover virtual doctor visit services that connect patients at home with physicians whom they meet via online or phone. But such services -- which proponents say can save money when they avoid expensive emergency room trips -- are creating tension with some state officials and physician groups. They argue that the remote visits are appropriate when the patient is communicating with his or her regular doctor, but care may suffer when patients are speaking with a doctor who may be in another city or state. Proponents say the services could help ameliorate a likely shortage of primary-care physicians. These virtual visits often cost about $45, which is significantly cheaper than an ER visit and also less expensive than an urgent-care center and most in-person doctor visits.

Health Policy and Reimbursement

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On Jan. 1, the House of Representatives cleared a 11th-hour fiscal cliff package from the Senate that averts a steep Medicare physician pay reduction by slashing billions from other Medicare providers. The American Taxpayer Relief Act avoids the expected 26.5 percent Medicare physician payment cut while extending current Medicare payment rates for physicians through Dec. 31, 2013. The bill offsets the cost of a 12-month patch to the sustainable growth-rate (SGR) formula via cuts to other Medicare programs, most of which impact hospitals.


A report to Congress by the Government Accountability Office (GAO) warns that the Centers for Medicare & Medicaid Services' (CMS) hopes for major reforms might be hurt by the 12-month time lag between efficiency improvements and physician payment adjustments. GAO cites the time lag issue as one of a number of areas where CMS could tap private insurers to learn about the best ways to give physicians incentives to deliver efficient, high-quality healthcare. The study analyzed the pay-for-performance programs of 12 private insurance firms and determined that similar initiatives led by CMS as part of the Patient Protection and Affordable Care Act (ACA) could benefit from the experiences and insights gained in the private sector.

In the time lag example, insurers told CMS that rewarding physicians for delivering better care works better when the enhanced payments fall closer to when the care was furnished. The private insurers had a tendency to boost payments within seven months of physicians' having met the goals, instead of CMS' proposed 12-month lag. GAO also learned that private insurers tended to reward physicians via group-level compensation changes, instead of varying payments to individual physicians. The value-based payment modifier program mandated by the ACA will adjust physicians' Medicare payments higher or lower according to how they perform in the Physician Quality Reporting System.


The meaningful use program is becoming a major motivating factor in physicians' adoption of electronic health records (EHRs) as a result of the initiative's combined promise of rewards for adopters and penalties for laggards. Practices that install a certified EHR system and meet several criteria for its use can earn bonuses of up to $44,000 per physician over five consecutive years from Medicare, or up to $63,750 per physician over six years from Medicaid. Meanwhile, Medicare penalties for failing to adopt an EHR, which start at 1 percent, go into effect in 2015 based on 2013 or 2014 usage.

A December report from the Centers for Disease Control and Prevention’s National Center for Health Statistics points to a significant increase in the percentage of office-based physicians using an EHR between 2009 and 2012. However, the American Medical Association determined that only a small portion of the office-based physicians using EHR systems possessed systems that could support at least 13 meaningful use core objectives, while even fewer have the ability to meet all 15 objectives required for compliance. Still, the Department of Health and Human Services Office of the National Coordinator for Health Information Technology recently found that physicians have been adding capabilities to these basic EHR systems to get ready for meaningful use.


HHS' Office of Inspector General has issued an advisory opinion in response to a hospital's proposal to give community physicians and practices free access to an electronic interface, through which they could send orders for certain services from the hospital. The hospital submitted its request to determine whether the proposed deal would violate the federal Anti-Kickback Statute. The arrangement would allow the hospital to offer free access to the interface to all physicians who requested it. Those providers would then use the platform to transmit orders for laboratory and diagnostic services from the hospital and to receive the results of those services. The hospital would also give support services necessary to manage the interface, such as software updates. The OIG ruled the hospital's proposed deal would not generate banned kickbacks under the federal statute.

Medicine, Drugs and Devices

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Surgical "never events" remain a danger to patient safety and a significant financial burden to hospitals, according to a study of U.S. hospitals that counted 80,000 such episodes resulting in roughly $1.3 billion in hospital payouts between 1990 and 2010. Such events include foreign objects such as sponges left inside patients' bodies, and the performance of incorrect procedures. The researchers found malpractice judgments and settlements for surgeries associated with retained foreign bodies, wrong sites, wrong procedures or wrong patients utilizing the National Practitioner Data Bank. They identified 9,744 paid malpractice judgments and claims over two decades. These events led to the deaths of 6.6 percent of patients, permanent injury in 33 percent and temporary injury in 59 percent. The researchers estimate that 4,044 surgical never events happen nationally each year. The study determined that surgeons between the ages of 40 and 49 were responsible for 33 percent of the never events, versus 14.4 percent of surgeons over 60 years old. One researcher says this finding makes the assumption that younger surgeons and very old surgeons are associated with the most never events less credible.


Researchers report that patients diagnosed with diabetes may have an increased risk for fractures and that the risk may be even higher among diabetes patients treated with insulin. However, they did not find a significant link between undiagnosed diabetes and fracture risk. The research, which included 15,140 participants, was published December 17 in the journal Diabetes Care.


A new technique to regrow damaged peripheral nerves in people's limbs involves a graft synthesized from processed cadaver nerves. The nerve allograft employs cadaver nerves treated to remove cells and other tissue, leaving hollow nerve channels for the patient's own nerve to grow into. The procedure has been used in approximately 7,000 patients thus far. The majority have involved nerves that control feeling, but more and more allografts are being used to repair nerves that also control movement. Several studies have demonstrated that allograft outcomes are as good as those reported historically with autografts, and better than with tube conduits, with zero rejections or complications.