News From ACFAS

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Byron L. Hutchinson, DPM of Seattle, Washington; Laurence G. Rubin, DPM of Mechanicsville, Virginia; and John S. Steinberg, DPM of Washington, DC were elected to the ACFAS Board of Directors in electronic balloting that ended on January 14. Hutchinson and Steinberg were elected to three-year terms and Rubin was elected to a two-year term. Also joining the board for a two-year term as chair of the Division President’s Council is Aksone M. Nouvong, DPM of Pomona, California. Each will begin their terms at the 2014 Annual Scientific Conference on February 27-March 2 in Orlando, Florida.

The 2014-15 officers to be installed at the conference will be: Thomas R. Roukis, DPM, PhD, President; Richard M. Derner, DPM, President-Elect; Sean T. Grambart, DPM, Secretary-Treasurer; and Jordan P. Grossman, DPM, Immediate Past President. Retiring from board service will be Michelle L. Butterworth, DPM and Randal L. Wraalstad, DPM.
Master your skills and make the most of your time at the Annual Scientific Conference in Orlando by registering today for the intensive Pre-Conference Workshops set for February 26 at the Gaylord Palms Resort. Choose from an expanded listing of educational opportunities and gain indispensable knowledge and experience to bring to your practice:

• Diabetic Deformity: Master Techniques in Reconstruction (1/2 day Cadaveric)
• Monday Morning Trauma: Advanced Reconstruction Techniques (1/2 day Cadaveric)
• Advanced Tendon Repair and Fixation (Full-Day Cadaveric)
• Perfecting Your Practice: Coding/Practice Management Workshop (Full-Day)

Registration is filling daily and space is limited, so register today at acfas.org/Orlando.
PodiatryCareers.org, the ACFAS online career center and a College Benefits Partner, is hosting the first annual ACFAS job fair at the Annual Scientific Conference in Orlando.

Employers can take advantage of the PodiatryCareers.org online career center, and also post their positions on paper to place on bulletin boards at the job fair. Not attending the conference? All positions posted to PodiatryCareers.org in advance of the conference will be listed within the Job Fair, and potential employees can contact you directly. Attending the conference? The PodiatryCareers.org online scheduling tool will also allow job seekers and employers to list their availability for a potential interview onsite at the conference.

All ACFAS Members get reduced rates on job postings. Also, PodiatryCareers.org is providing a show special--those employers who purchase a 30-day posting at the conference will get an additional 30 days free. You can also post your available position on the Job Fair bulletin boards at no cost.

Looking for a job? Dust off that CV and bring extra copies to the conference. Those seeking employment will also have an opportunity to post their positions online, at no cost, and on the Job Fair’s bulletin boards as well.

Interested in taking advantage of the Job Fair? Visit PodiatryCareers.org and their Job Fair in Booth #1213 on the exhibit hall floor. You can post your available position or your resume in advance of the conference through the website www.podiatrycareers.org.

Foot and Ankle Surgery

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A systematic review of studies that examined complications in patients who underwent ankle arthroscopy found that the procedure is safe to use to treat anterolateral ankle soft-tissue impingement. Fifteen studies--all of which included a standard two-portal anterior arthroscopic approach, a minimum average follow-up of 12 months, and detailed descriptions of any complications that were observed--were included in the review. A total of 396 patients and 397 ankles were included in the studies. The review found that the overall rate of complications was 4 percent. The rate of major complications was 0.8 percent, which was considered to be very low. The rate of minor complications was also acceptably low at 3.3 percent.


A recent study has identified the perioperative factors that are associated with longer hospital stays in end-stage ankle arthritis patients who undergo open or arthroscopic or total ankle replacement. Orthopaedic surgeons examined data from 343 patients who underwent one of these procedures, and found that there was a significant association between longer hospital stays and variables such as age, female sex, higher American Society of Anesthesiologists grade, and multiple medical co-morbidities. Rheumatoid arthritis, lower Short Form-36 Physical Component Summary and General Health domain scores, and open surgery were also significantly associated with longer hospital stays. Factors that were not associated with the length of a patient's hospital stay were obesity, Short Form-36 Mental Component Summary scores, the day of the week surgery was performed, and the length of surgery. Surgeons subsequently developed two models for predicting the length of hospital stay, one of which included only patient-related factors and another that included patient and surgery-related factors. The study concluded that better education and more focused perioperative care for patients at a higher risk of longer hospital stays should be included when care pathways are designed and when healthcare resources are allocated.


Tourniquets may not need to be used in ankle arthroscopy, a new study has found. Orthopaedic surgeons in the U.K. examined 63 patients who underwent ankle arthroscopy using a standard arthroscopic technique, all of whom had a tourniquet placed on their thigh. The tourniquet was routinely inflated in 31 patients and not inflated in the other 32. No significant differences were observed between the two groups in terms of length of operation, maximum intraoperative fluid pressures or visibility, and postoperative complications. The surgeons proposed carrying out a larger randomized clinical trial to confirm if tourniquets are indeed unnecessary during ankle arthroscopy.

Practice Management

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More and more medical schools across the country are expected to move from four to three-year programs over the next five years in an effort to meet the growing demand for doctors caused by the Affordable Care Act. New York University, Texas Tech University Health Sciences Center, and Columbia University's College of Physicians and Surgeons are among the medical schools that have adopted three-year programs, while a number of others are actively considering doing so. Three-year medical school programs at these and other universities typically do not include electives, and they often require students to attend classes during the summer. Graduates are also given a provisional guarantee of residency, which eliminates the need for students to spend months applying for residency and levels the playing field with graduates of four-year programs. Supporters of three-year medical programs say that eliminating the fourth year of medical school will not have an effect on patient care or negatively impact doctors' clinical skills, and that it will speed up the time it takes to train physicians. Critics of the trend point out that the fourth year of medical school plays an important part in preparing doctors for residency and their future practices.


Now that 2013 is only a memory and 2014 has arrived, doctors' practices should take stock of how well they are protecting themselves from various types of risks. For example, physicians' practices should ensure that they have a business plan in place that includes tailored specialty insurance plans as well as sound employment procedures and record-keeping standards. In addition, physicians should be sure that they are eliminating or controlling their patients' health risks, since doing so is more time- and cost-effective than using extraordinary treatment methods after a problem has arisen. The use of such treatment options may even expose doctors to legal or financial risks. A third task doctors should undertake in the new year is to schedule a specific time to review the progress they have made in keeping their practice on track and to identify any corrections that need to be made. Finally, doctors should make sure they have adequate life, disability, and long-term care insurance in place for themselves to protect their employees and their patients.


The growth in the number of patients with high-deductible insurance plans could result in changes in the way doctors' practices and other healthcare providers operate, says Ceci Connolly, the managing director of PricewaterhouseCooper's Health Research Institute. Connolly says the trend towards high-deductible insurance plans will prompt healthcare providers to move from a wholesale to a retail business model, one in which they are more transparent about pricing than they had been in the past. Consumers will demand such transparency, Connolly says, because high-deductible insurance plans are forcing them to pay more out of pocket for their healthcare expenses, meaning they want to get the best value possible. Connolly adds that consumers are also likely to increasingly expect healthcare providers to provide services that make their lives more convenient, such as the ability to make appointments any time of the day or night or the ability to receive lab results on a smartphone. Demand for these services, like the demand for greater price transparency, is being fueled by consumers who increasingly want healthcare providers to provide them with services that are similar to those provided by retailers, Connolly says. She adds that some healthcare providers are beginning to adapt to these trends by implementing minor changes, such as posting prices for procedures, though others may need to make more significant changes like forming partnerships with other providers.

Health Policy and Reimbursement

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The Department of Health and Human Services announced Jan. 14 that it is reversing its policy of withholding information about how much money individual doctors receive for treating Medicare beneficiaries. The new policy, which takes effect 60 days after it appeared in the Federal Register, calls for HHS to consider requests for the information on a case-by-case basis under the provisions of the Freedom of Information Act (FOIA). HHS will take into consideration the need to protect physicians' privacy with the public's interest in the payment information when deciding whether to grant the FOIA requests. HHS will deny the requests if it determines that releasing the payment information will cause harm to physician privacy that is not outweighed by the public's interest in the information. The new policy also calls for the Centers for Medicare and Medicaid Services (CMS) to begin publishing aggregate data sates about Medicare physician services. Both changes are intended to increase transparency in the Medicare program.


The healthcare industry faces a number of uncertainties and challenges, some of which are associated with the implementation of the Affordable Care Act (ACA), as it moves into 2014. For example, healthcare providers and payers are waiting to see whether the Medicare and private-sector accountable care organizations (ACOs) that are being established under ACA are actually improving the quality of healthcare and reducing costs as officials promised they would. Another unresolved issue associated with the implementation of ACA is the extent to which younger, healthier consumers will sign up for insurance coverage to offset the cost of insuring older people with more health problems. Insurance companies are counting on a substantial number of younger people enrolling in their plans so they can keep their premiums down next year. Meanwhile, doctors and hospitals will have to speed up their efforts to meet Stage 2 and Stage 3 meaningful use requirements for electronic health records and prepare for the conversion to the ICD-10 coding system on Oct. 1.


The Department of Health and Human Services' inspector general released a report on Jan. 8, which found that a lack of safeguards in electronic health records (EHRs) has made it possible for doctors and hospitals to overbill Medicare. One of the report's primary criticisms centered around the lack of guidelines for the use of the copy-and-paste function included in many of the largest EHRs. This technique, which is also known as cloning, is used by healthcare providers to quickly copy information from one document to another in order to save time. But copying and pasting information can also result in incorrect information about a patient's examinations or treatments being inserted into his file. These exams or treatments can be more expensive than the exams or treatments that were actually used, which in turn can result in healthcare providers overbilling Medicare. The report also said that the contractors who handle Medicare payments have not been given enough guidance about how to identify fraud stemming from the move towards EHRs. The inspector general called on these contractors to identify fraud by closely reviewing changes to certain patient documents, thought Medicare officials said doing so would not always be appropriate. Medicare officials also said they were taking steps to reduce fraud stemming from the use of EHRs, including improving the instructions given to contractors.


The Centers for Medicare and Medicaid Services (CMS) says its proposed changes to Medicare's Part D and Advantage programs will help save $1.3 billion over five years and reduce prescription drug abuse. One of the proposed changes calls for each payer to offer two or fewer Medicare Part D plans in the same service area in order to ensure that there are more significant differences between the plans being offered. Stacy Sanders, the federal policy director at the Medicare Rights Center, says that consumers in some areas have as many as 18 to 20 plans to choose from, which means that these consumers typically choose a plan solely on the basis of the premium being charged because the plans are virtually the same in other respects. Another proposal would prohibit Medicare Advantage plans from offering coverage options that replace plans that had been phased out due to low enrollment. CMS is also calling for mail-order pharmacies to stop charging co-pays for one-month supplies of drugs that are lower than what retail pharmacies charge--a proposal that is being praised by the National Community Pharmacists Association (NCPA). Finally, CMS hopes to curb prescription drug abuse by excluding providers from Medicare if they display suspicious prescription patterns for Part D drugs and prohibiting doctors who are not enrolled in Medicare from prescribing Part D reimbursable drugs.


Officials with Covered California, the state's health insurance exchange, are reporting problems with processing applications for insurance coverage that took effect on Jan. 1. Exchange spokeswoman Anne Gonzales and other officials said Covered California is working to process a number of paper applications for coverage that began at the beginning of the year. Gonzales said the backlog is due in part to the surge in the number of consumers who signed up for coverage before Dec. 23, which was the deadline to apply for plans that took effect on the first of the month. Roughly 100,000 of the more than 400,000 people who have signed up for coverage through Covered California did so in the four day period before Dec. 23. Covered California says it is working to process the paper applications as soon as possible. Other health insurance exchanges have experienced a similar backlog. Meanwhile, some California residents are reporting that they have yet to receive an invoice, confirmation of coverage, or membership card from the insurer they signed up with. However, such consumers can still make doctors appointments and receive care. Anthem Blue Cross said enrollees who need care can file a claim for reimbursement.


Data from the doctor-finder service ZocDoc, as well as reports from healthcare providers, indicate that a number of concerns associated with the implementation of the Affordable Care Act (ACA) have so far not been borne out. One of those concerns was that healthcare providers would be inundated with newly-insured patients. But while 2 million people have so far signed up for insurance coverage under ACA, hospitals, pharmacists, and other healthcare providers are reporting that they have not seen a flood of new patients since Jan. 1, when ACA plans took effect. However, the Philadelphia-based insurer Independence Blue Cross is warning that it is too soon to make any conclusions about how newly-insured consumers are using their plans, since medical practices may not have reported some patient visits yet. Another concern associated with ACA that has yet to materialize is the enrollment of a disproportionate number of older, sicker patients in ACA health plans. ZocDoc says it believes this concern has not come to pass, given that most of the patients who used its service to book appointments in late December--when newly-insured consumers began setting up appointments for early this month--wanted to see doctors for preventive care, rather than to obtain treatment for existing illnesses.

Medicine, Drugs and Devices

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A new study examined the effects pharmacist intervention has on changing beliefs about medication and improving medication adherence in rheumatoid arthritis (RA) patients who have been prescribed disease-modifying anti-rheumatic drugs (DMARDs). Researchers randomized 123 non-adherent RA patients who were using DMARDs to one of two groups: an intervention group that took part in two motivational interviewing-guided group sessions led by the same pharmacist, and a control group that was given brochures about DMARDs. Participants in both groups were asked to complete questionnaires at up to 12 months follow-up. Researchers found that at 12 months, patients in the intervention group had beliefs about the necessity of DMARDs that were not as strong as the beliefs held by patients in the control group. However, no differences in necessity beliefs were seen between the two groups before 12 months, and no differences were seen at all in the groups' concern beliefs and medication non-adherence rates. Researchers concluded that the intervention was not superior to changing beliefs about DMARDs or improving medication adherence over time, though they cautioned that their findings may have been affected by selection bias and a sub-optimal treatment integrity level.


Researchers analyzed the effectiveness and safety of the monoclonal antibody romosozumab over a 12-month period in 419 postmenopausal women exhibiting low bone mineral density in a phase 2, multicenter, international, randomized, placebo-controlled, parallel-group, eight-group study. Subjects were randomly assigned to receive subcutaneous romosozumab on a monthly basis or in three-month intervals, a subcutaneous placebo, or an open-label active comparator. The primary end point was the change in percentage from baseline in bone mineral density at the lumbar spine at 12 months, while secondary end points included percentage changes in bone mineral density at other sites and in markers of bone turnover. All dose levels of romosozumab correlated with substantial increases in bone mineral density at the lumbar spine, including an increase of 11.3 percent with the 210-mg monthly dose, versus a decrease of 0.1 percent with placebo and increases of 4.1 percent with alendronate and 7.1 percent with teriparatide. Romosozumab also corresponded to large increases in bone mineral density at the total hip and femoral neck, and with ephemeral increases in bone-formation markers and sustained decreases in a bone-resorption marker. Adverse events were similar among groups apart from mild, generally nonrecurring injection-site reactions with romosozumab.