News From ACFAS

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ACFAS and APMA representatives met on January 28 with representatives of the CMS Center for Program Integrity and Congressman Danny Davis (D-IL), who serves on the House Ways and Means Committee, about the Physician Payment Sunshine Act (PPSA).

At issue is CMS’ omission of CPME from a list of accrediting and certifying entities under a PPSA regulation that exempts indirect payments made to speakers at accredited or certified CME programs from reporting requirements.

CMS recognizes the inequity caused by this regulation and stated that it is exploring a long-term solution. ACFAS and APMA are equally concerned about the unintended consequences this omission may have on CME programs, including deterring manufacturers from providing educational grants for CME programs run by CPME-approved sponsors. This situation may result in increased CME registration costs or limit the number of CME programs run by CPME-approved sponsors.

As a reminder, as of August 1, 2013, the PPSA requires manufacturers of medical devices, drugs, and biologicals to begin collecting information regarding payment and other transfers of value made to physicians, as well as certain physician ownership and investment interests. Download the free mobile app for the ACFAS 2014 Annual Scientific Conference today, and you’ll get an out-of-this-world annual conference experience, even if you couldn’t make it to Orlando this year. The newly-designed app allows you to keep track of your preselected sessions; review all the conference happenings; find your way around with convenient maps; store contacts; search events and sessions; locate vendors; read the latest conference happenings in the Twitter, Facebook and Google+ feeds; and receive the latest conference alerts--all from your mobile device.

Download the app by typing http://m.core-apps.com/acfas2014 on your mobile tablet or phone, or just visit the App store on your iPad, iPhone or Android, search ACFAS 2014 and hit download. ACFAS members can have pre-meeting access for a sneak peak at the app before Orlando! Once you download the app and open it for the first time, you will see a login screen asking for a username and password. For pre-meeting access only, you will have to enter the following: Username: your first name and Password: acfas.

For access to your personal schedule during the conference, you will be sent an email a week prior to the conference with the necessary information for access. Watch your inbox and see you in Orlando! Get a free professional photo that is way beyond compare while you're at the ACFAS Scientific Conference in Orlando!

No matter your career choices, everyone needs a professional photo for your website or LinkedIn profile. Stop by the Head Shot booth in the Exhibit hall on Friday, February 28 or Saturday March 1 from 10am-2pm to be prepped by professional makeup artists to have your photo taken by a professional photographer in the ACFAS Head Shot Studio, all for free.

Each person will receive a hard copy print out of their head shot that day as well as an emailed digital version to use in your practice or career path. Looking for a job or looking to make a change in your career? Dust off that resume, and take advantage of the ACFAS Job Fair, sponsored by PodiatryCareers.org, at the Annual Scientific Conference in Orlando!

How do you participate?

• Update your resume and print out 25 copies to bring with you to Orlando.
• Next, before you leave for Orlando, post your resume, at no cost, on the PodiatryCareers.org online career center.
• In Orlando, stop by booth #1114 “ACFAS Job Fair” and post your resume on the dedicated boards and put it on file in the booth for potential employers to find you.

Have a position to fill? Take the opportunity to post it in front of 1,200 of the best and brightest foot and ankle surgeons at the ACFAS Job Fair by following these instructions:

• Create a one- to two-page job listing and print out 25 copies to bring to Orlando.
• Before you leave for Orlando, take advantage of the ACFAS PodiatryCareers.org online job board by posting your position online
• Stop by booth #1114 “ACFAS Job Fair” and post your position opening on dedicated job boards for candidates to find you.

Want to find out about ACFAS activities close to home? Visit your ACFAS Division meeting at the Annual Scientific Conference in Orlando!

Your Division will be holding a meeting of its members in conjunction with ACFAS 2014 in a couple of weeks. We hope that you can join us to meet and network with your Division officers and have a hand in the plans for your Division in the upcoming year.

Division Meetings are scheduled during the conference lunch breaks, at reserved tables in the Exhibit Hall. A complete schedule of meetings will be listed in your onsite conference brochure, on the ACFAS 2014 mobile app and on signage at the meeting.

Press Your Luck: All ACFAS members who attend their Division meetings will be placed in a drawing to win one of two Apple iPad Minis. Your raffle ticket can be found in your registration packet.

Foot and Ankle Surgery

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A recent study suggests that a change may need to be made to the recommended size of the minimum distraction gap between tibiotalar joint surfaces under full weight-bearing during ankle distraction arthroplasty. Nine cadaver ankle specimens were affixed with circular external fixators and were placed into a load chamber, where loads of zero, 350, and 700N were applied. For each load, radiographic joint space was measured and joint contact pressure was monitored. The experiment was stopped when there was no contact between the joints under 700N of load. The distraction gap was calculated by subtracting the initial undistracted joint space from the radiographic joint space. The minimum distraction gap (mDG) that would provide total unloading was calculated. The study found that there will be no contact between joint surfaces during full weight-bearing as long as the there is a minimum of 5.8 mm of distraction gap as measured using a standing X-ray of the ankle undergoing distraction arthroplasty. This means that the historical recommendation of 5 mm of radiographic joint space may not be sufficient to prevent contact of articular surfaces during weight-bearing.


Variable locking plate fixation is recommended for use in proximal chevron osteotomies of the first metatarsal, particularly when the bone is osteoporotic, a new study has concluded. During the study, proximal chevron osteotomies using either variable locking plate or cancellous screw fixation were performed on ten matched pairs of human fresh frozen cadaveric first metatarsals. The effectiveness of the two techniques was determined by performing biomechanical testing, including repetitive plantar dorsal loading from zero to 31 N with the 858 Mini Bionix, and by measuring the dorsal angulation of the distal fragment. The use of variable locking plate fixation brought about statistically superior results in terms of bending stiffness and dorsal angulation compared to the use of cancellous screw fixation. A statistically significant relationship was also observed between bone mineral density and maximum tolerated load until construct failure occurred for the screw construct.


A recent study by researchers in Argentina analyzed the clinical, functional, and radiological results of using non-irradiated frozen structural bone allograft during foot and ankle surgeries. Researchers analyzed the results from 17 reconstructive surgeries of the hindfoot and three reconstructive surgeries of the midfoot. American Orthopaedic Foot & Ankle Society (AOFAS) scores, the presence of complications, and allograft consolidation, alignment preservation, and allograft collapse or re-absorption as determined by X-ray were used to evaluate the results of the procedures. The average improvement in the AOFAS ankle and hindfoot scores was 48 points in patients who underwent reconstructive surgeries of the hindfoot, while those who underwent reconstructive surgeries of the midfoot experienced a 53 point improvement in AOFAS midfoot scores on average. Average bone consolidation time, meanwhile, was 75 days for all patients. None of the patients experienced graft fracture or non-union. Researchers concluded that the use of non-irradiated frozen structural bone allograft is a good option for treating severe defects or filling sequelae deformities.

Practice Management

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A study by researchers at Northwestern University has found that the effectiveness of patient appointments could be reduced when doctors spend too much time looking at electronic health records (EHRs). The study, published in the January edition of the International Journal of Medical Informatics, measured the eye-gaze patterns of both doctors and patients during 100 visits when EHRs were used. Researchers found that doctors who had EHRs in their exam rooms spent a third of their time looking at computer screens. Doctors who spent so much time looking at EHRs were less likely to spot non-verbal communication cues from their patients, the study found, and they also experienced declines in their ability to listen, solve problems, and think creatively. In addition, the study found that doctors who spent so much time looking at EHRs were missing chances to engage patients using the technology, since they did not notice when patients were looking at EHRs and were sometimes preventing them from seeing the screen. The findings of this study could be used to develop EHR training programs and to further develop the technology. One potential change, the study's lead author said, would involve designing EHRs with more interactive elements to increase the amount of time patients pay to EHRs during doctors' visits.


Physician practice consultant Brian White says that some doctors' practices are losing a significant amount of revenue by failing to bill for all the services they provide. White, who founded the physician practice consulting firm Competitive Solutions, says that doctors' practices are typically failing to bill for 10 percent to 12 percent of the reimbursement to which they are entitled. For example, doctors often fail to properly charge for services such as putting a brace on a patient simply because they do not realize that such services are billable, White says. He adds that physicians' practices are also missing out on revenue by engaging in "self-bundling," in which the practice does not bill for certain encounters or services because it expects the claim to be denied. However, practices should never assume that a claim will be denied, White says. White recommends that doctors' practices take a number of steps to ensure that they are billing for all the services they provide, including implementing processes that verify complete billing for all patients after each visit. In addition, an employee in the practice should be given the responsibility of asking physicians each day whether they provided opinions to other doctors in hospitals, since such doctor-to-doctor encounters are sometimes not billed either, White says.

Health Policy and Reimbursement

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Although healthcare providers and others are optimistic about the deal to repeal Medicare's Sustainable Growth Rate (SGR) formula, Congress has yet to come up with a way to pay for such a move. Several House committees have said repealing SGR could cost $128 billion, though the cost could climb to $150 billion once extenders are included. Lawmakers need to figure out a way to pay for the repeal of SGR by March 31, when the "doc fix" they passed in December expires. Failing to pass an SGR repeal bill by that time would result in Medicare reimbursement rates for doctors being cut by 25 percent. Such cuts could put most practices out of business, says NH Rep and gastroenterologist Tom Sherman, (D-Rye). However, FaegreBD Consulting Director and strategic communications specialist Nicholas Manetto says lawmakers could always pass another short-term fix to prevent such cuts. But Manetto adds that lawmakers need to act quickly on the SGR-repeal bill, since its chances of being passed will dwindle as this year's mid-term elections approach.


The Centers for Medicare and Medicaid Services (CMS) has announced several changes to the Medicare electronic health record (EHR) incentive program that will affect hospitals, doctors, and other eligible professionals. For instance, the deadline for physicians and other eligible professionals to attest to meaningful use for the Medicare EHR incentive program for the 2013 reporting year has been pushed back from Feb. 28 to 11:59 p.m. March 31. CMS says the extension will give providers who met the criteria for the incentive program by Dec. 31 extra time to submit their data and receive an incentive for the 2013 program year while also allowing them to avoid being penalized with a payment adjustment for 2015. Meanwhile, hospitals that experienced problems attesting to meaningful use by Nov. 30, 2013 will be able to retroactively submit their attestations, provided they contact CMS by 11:59 p.m. on March 15. Hospitals who do so will be able to avoid the 2015 payment adjustments and receive a payment under the incentive program. The Medicaid EHR incentive program is not affected by either of these changes.


The U.S. Treasury Department announced Feb. 10 that it is extending the deadline for mid-size employers, defined as those with 50 to 99 full-time equivalent employees, to comply with the Affordable Care Act's (ACA) employer mandate. Mid-size employers will not have to comply with the mandate until Jan. 1, 2016, though organizations with 100 or more employees will have to do so on Jan. 1, 2015. Treasury officials said that employers will need to offer insurance coverage to 70 percent of their full-time equivalent employees next year and to 95 percent of such employees in 2016 and thereafter in order to avoid penalties. A Treasury official said that delaying the implementation of the employer mandate will help provide relief for mid-size organizations as they move to comply with ACA.


The American Medical Association and several other physician groups are coming out in support of a bill unveiled Feb. 6 by leading members of two House and Senate committees that would repeal Medicare's sustainable growth rate (SGR) formula. The bill calls for Medicare to increase physician payments by 0.5 percent each year for the next five years and would provide bonuses to healthcare providers who agree to be reimbursed on the basis of patient outcomes instead of the volume of services they provide. However, it remains unclear how the repeal of SGR would be paid for. The introduction of the SGR repeal bill comes after Congress postponed the scheduled 24 percent cut to Medicare reimbursements by three months in December. Although the issue of how the repeal would be paid for remains up in the air, AMA President Ardis Dee Hoven praised Congress for taking action on the thorny issue of SGR, saying that lawmakers are "closer than ever" to passing a fiscally-responsible bill that would repeal the "fatally-flawed" formula.


The Centers for Medicare and Medicaid Services (CMS) has published a set of rules that clarify who is allowed to sign off on inpatient admissions under the two-midnight policy. The rules state that a nurse is allowed to document an oral patient admission request from a doctor in the hospital's medical record, though an admitting physician is required to countersign the decision before the patient is discharged. Hospitals will still be allowed to submit claims through the Medicare Part B system for outpatient care in the event that the admitting physician disagrees with the decision and refuses to countersign the order. The rules also state that a medical resident, physician assistant, or nurse practitioner is allowed to write the inpatient admitting order in lieu of the physician, though a doctor will again have to approve and take responsibility for these admission decisions by countersigning the order before the patient is released from the hospital. The clarification comes amid complaints from hospital officials that Medicare rules about admissions decisions are unclear.


Health and Human Services (HHS) Secretary Kathleen Sebelius said Feb. 3 that more and more states, regardless of which political party they are controlled by, will opt to expand Medicaid under the Affordable Care Act (ACA) in the near future. Governors in 31 states have opted to expand Medicaid eligibility to families with incomes up to 138 percent of the federal poverty level as called for by ACA, while the remaining states have chosen to take advantage of a 2012 U.S. Supreme Court ruling that such an expansion was optional. However, Sebelius said a number of states are in talks with HHS about expanding Medicaid because they believe they can benefit financially by doing so. Sebelius also spoke about the demographics of consumers who have signed up for health insurance coverage through the new online exchanges, saying that roughly 75 percent of the 3 million new enrollees are under 35. Sebelius sought to address concerns that there may not be enough younger consumers enrolled under ACA to offset the costs of insuring older consumers by pointing out that young residents of Massachusetts--a state which enacted healthcare reform similar to ACA--were among the last to enroll before the deadline.


The Centers for Medicare and Medicaid Services (CMS) announced Jan. 31 that it was pushing back the implementation of its "two-midnights" rule for Medicare hospital admissions until after Sept. 30. After that date, CMS recovery auditors will be allowed to begin auditing suspicious Medicare claims under the two-midnights rule. Hospitals and doctors alike have been pushing for some type of change or delay in the rule, which states that CMS auditors should assume that hospital admissions with proper documentation are reasonable and necessary only when patients stay in hospital beds for two midnights, or more than one day. Hospitals have been particularly upset with the rule because they believe CMS auditors are assuming that they have made a mistake and provided unnecessary care in cases where patients do not stay in hospital beds for two midnights. Despite the delay in the implementation of the two-midnights rule, Medicare contractors who process claims for payment will still be allowed to review short hospital stays and deny payments if patient records do not support medical necessity. Those reviews will only be instructional and will be limited to a sample of 10 to 25 claims per hospital.

Medicine, Drugs and Devices

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Ten big-name drug companies, including Sanofi, Johnson & Johnson, and Bristol-Myers Squibb, have entered into a five-year collaboration agreement with each other and the National Institutes of Health (NIH) in the hopes of identifying new drug targets for a number of conditions. The roughly $230 million arrangement calls for participants to take a number of steps together to identify the molecular paths that rheumatoid arthritis, Alzheimer's, Type 2 diabetes, and lupus follow, including sharing scientists who are experts on these diseases as well as relevant data and samples from clinical trials. In addition, NIH and the participating companies will work together to perform lab tests and other studies. The drug companies will work together to recruit patients and to provide the "deep computing" needed for analyses, while NIH will review the progress of the research and provide assistance in making scientific decisions. Participants say the collaboration will make it possible to uncover the biological mechanisms behind the focus diseases in ways that the participants would be unable to do alone. Participants also hope that working together will help identify more drug targets earlier in their research than they would normally be able to do, in order to reduce the chances of experiencing an expensive failure of a study later on. Drug companies will not be able to use any discovery that arises from the collaboration until the data is made public.


A single 7 mg dose of betamethasone administered via intramuscular injection may be superior to twice-daily 75 mg doses of diclofenac sodium in treating acute gouty arthritis, a new study has found. The study examined 60 acute gouty arthritis patients who were randomized one-to-one to either the betamethasone group or the diclofenac sodium group. Patients in the latter group were given diclofenac sodium for a total of seven days. Both groups of patients displayed an average change in pain intensity from baseline to Day 3 that indicated that betamethasone had preferable efficacy over diclofenac sodium at this point in the study. However, the mean change in pain intensity from baseline to Day 7 indicated that the two treatments had comparable levels of efficacy at this point. Fewer adverse effects were seen in the betamethasone group than the diclofenac sodium group. No statistically significant differences were seen with regard to serum uric acid levels at different pain intensity at baseline.