News From ACFAS

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The US Supreme Court handed podiatry and other non-allopathic healthcare providers a significant victory last week. The court agreed with the Federal Trade Commission that the North Carolina Board of Dental Examiners (NCBDE) engaged in anti-competitive and unfair method of competition when it issued official cease-and-desist letters to non-dentist teeth whitening service providers warning that the unlicensed practice of dentistry is a crime.

NCBDE defended itself on the basis that it was an instrument of state government and therefore performed a state function in regulating the practice of dentistry pursuant to state policy. The Board took the position that its actions were immune from anti-trust laws because they were state actions.

The Supreme Court found that, because a majority of the Board consisted of dentists, the Board could invoke state-action anti-trust immunity only if it were subject to active supervision by the state, and that requirement was not met. Without the cloak of state action, the Board is subject to US anti-trust laws, like any other professional self-regulating body. More importantly, the Supreme Court said state regulation must have a scientific or other valid basis and not an anti-competitive basis. Professional self-regulation cannot seek to exclude competitors to preserve profit potential for insiders.

Bottom line: This has served notice to allopathic medical boards they cannot use state authority to restrict non-allopathic healthcare providers for anti-competitive reasons. Admittedly, the scope of the actual Supreme Court decision is fairly narrow; many state boards are appointed through a more independent process that is at less risk of anti-trust attack. However, the impact of the decision is reverberating well beyond its actual scope.

The American Medical and Dental Associations spent enormous sums to defend the position of NCBDE. They viewed an adverse court decision as a threat to the ability of “their” regulatory boards to set rules in a way that would protect their own best interests. But this Supreme Court decision is a victory for millions of licensed, trained and competent healthcare providers, with non-MD designations, who are constantly fighting scope of practice issues, such as ACFAS and its 40-organization partners in the Coalition for Patient Rights. ACFAS’ popular Advanced Forefoot Reconstruction and Complications Workshop and Seminar is headed to New York and New Hampshire this spring with a fresh take on surgical approaches and techniques for treatment of forefoot deformities and injuries.

Scheduled for April 17–18 in Buffalo and May 1–2 in Portsmouth, this program begins on Friday evening with the presentation, Common Forefoot Surgical Complications: How to Deal with Them, followed by a review of participants’ case studies. Saturday’s lineup includes hands-on workshops, sawbones labs, lectures and panels to examine attendees’ problematic work cases.

For more information on ACFAS’ Coming to You series and to register, visit acfas.org/comingtoyou. Three of ACFAS’ Regional Divisions welcomed new Presidents into office at ACFAS 2015.

Division 6: William Finn, DPM, FACFAS (IL)
Division 7: Bruce Kaczander, DPM, FACFAS (MI)
Division 8: Harry Schneider, DPM, FACFAS (MA)

Congratulations to all the new Division Presidents! To learn more about your local ACFAS Division, visit acfas.org or watch your email for announcements of activities in your area of the country. State-of-the-art industry products and services, lively HUB sessions, free professional headshots—the ACFAS 2015 Exhibit Hall in Phoenix certainly had plenty of activities, including daily prize drawings!

ACFAS congratulates this year’s ACFAS Quad prize-drawing winners:

GoPro Hero4 Silver Bundles
James D. Torhorst, DPM, FACFAS
Jennifer Michael, DPM

$200
Gina R. AmicaTerra, DPM

$100
Zachary M. Thomas, DPM, AACFAS
Amanda M. Matz, DPM
Nicole L. Kessel, DPM, AACFAS

$50
Amir Abbas Dastgah, DPM
Ali Cross

ACFAS also congratulates Daniel Miller, DPM, and Heather Janney, DPM, who each won an Apple iPad Mini by participating in the Division Presidents Council's raffles held during Division Membership Meetings.

For more on upcoming ACFAS Division activities, visit the Division webpages.

Foot and Ankle Surgery

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A study was conducted to determine the efficacy and safety of rehabilitation interventions following open reduction and internal fixation of ankle fractures. A systematic review and meta-analysis were conducted using both randomized trials and cohort studies. The impact of mobilization, weight-bearing and unprotected weight-bearing as tolerated on post-operative recovery was compared via the Olerud Molander score, return to work/daily activities and the rate of complications. Twenty-five articles were included, and ankle exercises were shown to result in earlier return to work and/or daily activities versus immobilization. No difference was observed in the rate of complications between exercises and immobilization or between early and late weight bearing.


A novel technique has been developed for ascertaining the pre- and post-operative passing points of the mechanical axis of the lower limb at the level of the tibial plafond. The technique involves a full-length standing posteroanterior radiograph including the calcaneus. The technique was used in a new study examining the abovementioned passing points, and the study also correlated these results with clinical results, following supramalleolar osteotomy for ankle osteoarthritis. The hip-to-calcaneus radiographs of 50 lower limbs of 41 patients treated for lower limb malalignment were reviewed, with supramalleolar tibial osteotomy performed in 27 ankles to treat moderate varus-type osteoarthritis of the ankle. The average follow-up period was 2.8 years, and clinical evaluation was based on the American Orthopaedic Foot & Ankle Society (AOFAS) scale. There was high interobserver and intraobserver reliability in identifying the mechanical ankle joint axis point. The average post-operative mechanical axis point was 50 percent in ankles for which the pre-operative point was less than or equal to 0 percent. The average post-operative point was 81 percent in ankles for which the pre-operative point was greater than 0 percent. Average change in AOFAS score was significantly less for patients with a pre-operative point of less than or equal to 0 percent than for those with a pre-operative point of greater than 0 percent. Improvement was significantly greater in ankles with a post-operative mechanical ankle joint axis point of greater than or equal to 80 percent than in ankles with a post-operative mechanical ankle joint axis point of less than 60 percent.

Practice Management

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Although the 401K is the preferred retirement plan option for most medical practices, a 3 percent of compensation employer contribution is needed to allow a full salary deferral. As the ratio of employees to practice owners climbs, the percentage of plan contributions for the owners' benefit declines. An alternative option in situations involving practices that have one provider with more than five employees is the savings incentive match plan for employees of small employers (Simple) IRA. The Simple IRA permits the owner a salary deferral of $12,500 in 2015, with a catch up of $3,000 if the owner is at least 50 years old. The owner opens a Simple IRA account for the funding, and any workers wishing to participate receive their own IRA accounts to which they can make the same deferral. The plan has a match as well, which in most instances is 3 percent of compensation. Simple IRA plans can be set up at no initial cost, and the employer need not report anything to the Internal Revenue Service. The limited amount of contributions is the chief pitfall of the Simple IRA, while employees will see little benefit from the plan unless they make large deferrals.


Documentation is physicians' main challenge in the looming shift to the International Classification of Diseases-10th revision (ICD-10), as it plays directly into reimbursement. The expansion of injury and musculoskeletal codes means orthopaedic physicians will need to contend with many new codes, and substantial differences exist among specialties in terms of numbers of new codes physicians and coders will need to accommodate. For example, primary care physicians will see more than an endocrinologist or a urologist would. Physicians who do their own coding have figured out different ways to find the ICD-10 codes they require, such as using electronic health records (EHRs) to locate code lists they can click on to build the appropriate codes. Physicians in small, independent practices lean toward building their own EHR templates instead of using pre-canned templates, as the former approach allows on-the-fly patient customization.

It is recommended that all physicians familiarize themselves with ICD-10 by reading overview materials that the Centers for Medicare and Medicaid Services and other organizations offer online. Some hospitals, physician organizations and trade publications also offer free resources. Moreover, physicians should concentrate on ICD-10 from the viewpoint of their specialty and practice setting. Physicians are also advised to leverage dual coding available in ICD-10-ready EHRs, as coding some visits in both ICD-9 and ICD-10 enables them to get feedback from coders in their practices about what is absent in their documentation. Learning how to document for ICD-10 is less concerning for physicians than the degree to which the coding and documentation would inhibit them during the ICD-10 shift.


Allowing patients to record physician visits can help them remember the details of diagnosis, medication, treatment and follow-up discussions and can help caregivers who may have been absent from the visit. However, physicians are justified in their worries that such a recording may be used as evidence in a malpractice suit. A small number of states insist that both parties to a conversation must consent for that conversation to be legally recorded. Most states require only one party to the conversation to consent, and a surreptitious recording by that party is still legal, irrespective of what that recording may be used for later. Many physicians argue recordings should be refused, noting patient/physician action is confidential, and a recording creates an opportunity for misuse and abuse. One orthopaedic surgeon suggests asking patients who want to record visits to go elsewhere. Still, one physician disagreed, noting "I believe that a patient has the right to record communications from his or her physician. What does a physician have to fear if she or he is practicing medicine in good faith? If the physician and the patient are on the same side of the equation, then it should be a win/win. Unless one is grossly negligent, it will only improve quality care."

Health Policy and Reimbursement

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The Centers for Medicare and Medicaid Services (CMS) has extended the deadline for eligible professionals to attest meaningful use for the 2014 Electronic Health Record (EHR) incentive program, from February 28 to March 20. CMS still urges providers to start attesting for 2014 as soon as possible. The extension also applies to eligible professionals who have not yet used their "switch" to change programs from Medicare to Medicaid for the 2014 payment year. CMS notes the Medicare extension does not affect the deadline for the Medicaid EHR Incentive program. The CMS news release says another listserv from CMS about the Physician Quality Reporting System program extension will be released. The extension follows an announcement in January that CMS will relax meaningful use attestations requirements, limiting the reporting period from a full year to 90 days.


All health information data breaches that occurred in 2014 must be reported to the U.S. Department of Health and Human Services' (DHHS) Office for Civil Rights by March 1. Breaches affecting 500 or more people must be reported to affected patients and DHHS within 60 days of discovery. Breaches affecting fewer than 500 people must be reported to DHHS within 60 days of the end of the calendar year.


A $30 billion federal campaign to get physicians and hospitals to digitize health records is being hindered by healthcare software vendors' insistence that they be remunerated thousands of dollars for unlocking that data. The majority of physicians and hospitals have transitioned to electronic health records (EHRs), but the data is often stored in computers run by hundreds of competing healthcare software companies, with incompatible products and little incentive to make them interoperable. “The No. 1 factor hindering the exchange of information between healthcare stakeholders is the exorbitant fees that most EHRs charge for integration, connectivity and reporting,” says Commonwealth Primary Care ACO's Lance Donkerbrook. “The government needs to step in immediately and require these vendors to open access.” Some Republican lawmakers are weighing sanctions on the software vendors. The Electronic Health Records Association attributes the high fees of the health exchange connections to the dearth of common computer code standards across the many EHR manufacturers. A tapering off of incentive payments beginning in 2014 appears to have spurred greater reliance by EHR vendors on consulting contracts and fees. If every one of the 230,000 U.S. medical practices pays $15,000, on average, to link to a health exchange, the cost to the healthcare system would be approximately $3.5 billion.


The Centers for Medicare and Medicaid Services has issued a reminder to providers that they can conduct acknowledgement testing with Medicare contractors anytime up to the October 1 compliance date. However, Medicare is also establishing two more virtual acknowledgement "testing weeks," during which providers have access to real-time help desk support and which will allow the agency to analyze testing data. The dates are March 2-6 and June 1-5. Registration is not required.

Medicine, Drugs and Devices

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A pilot study was conducted to investigate the impact of custom foot insoles on postural stability (PS) among advanced figure skaters to see whether they play a significant role in performance and in reducing fall risk. The study was completed by seven of nine recruited advanced figure skaters. The main results of changes in PS were measured by center of mass sway with secondary outcomes of ankle and hip joint sway and joint range of motion. Sway measurements were evaluated using body-worn sensors while participants wore skates on ice. PS was assessed in single-stance and during gliding on dominant foot. A significant improvement in static PS was seen after six weeks of using the custom insoles. The center of mass sway was reduced by 48.44 percent on average, and ankle joint sway was reduced by 45.7 percent during single-stance balance measurements. Non-significant changes were observed for both ankle and knee joint range of motion during gliding maneuvers.


A study was conducted to assess provisional external fixation by the emergency department (ED) as a temporizing measure for unstable ankle fractures and impacted tibial pilon fractures prior to definitive fixation. Benefits of external fixation include improved articular alignment, decreased articular impaction and soft tissue rest. ED uniplanar external fixator placement entails placing transverse proximal tibial and calcaneal traction pins and connecting the pins with two external fixator rods. The method is especially useful in austere environments or when the operating room is not immediately available. The bedside intervention also prevents the patient from requiring general anesthesia and may be a cost-effective technique for decreasing valuable operating time. The ED ex-fix is an especially valuable procedure in busy trauma centers and during mass casualty events.


Researchers are developing a unique technology that could improve peripheral arterial disease (PAD) diagnosis and ease monitoring of patients with the disease. The development and testing of the dynamic optical tomographic imaging system is being funded by a five-year, $2.5 million grant from the National Heart, Lung and Blood Institute. The vascular optical tomographic imaging (VOTI) system employs near-infrared light to map the concentration of hemoglobin in the body's tissue and show the degree of blood perfusion in patients' hands and feet. The results of the technology in a study of 20 patients and 20 healthy volunteers were published in the European Journal of Vascular and Endovascular Surgery. The researchers report the VOTI system has been used to successfully identify PAD in the lower extremities. The method can yield maps of oxy-, deoxy- and total hemoglobin concentration throughout the patient's foot and can detect problematic regions requiring intervention.