News From ACFAS

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If you attended the 2013 Annual Scientific Conference, you can now check your CME credits quickly and conveniently online. View and print your conference certificate of attendance and CME hours at acfas.org. Click on “Access Conference CME” to log on.

Be sure to verify your CME credits promptly, as after May 1, 2013, no changes can be made online.

For directions on how to view your transcripts and CME credit online, be sure to check your email or fax machine for instructions sent from ACFAS. If you have questions regarding your online CME records, contact the Education Department at 800-421-2237. Get assistance navigating this challenging aspect of medicine by contacting the Credentialing and Privileging Advisory Team (CPAT) at credentialing@acfas.org. This valuable committee consists of 10 seasoned ACFAS members who have expertise and training in assisting their peers with these important issues affecting foot and ankle surgeons across the country.

As you know, the American College of Foot and Ankle Surgeons stands unequivocally in support of the concept that any credentialing process for privileges in the specialty of foot and ankle surgery should be uniformly applied to all surgeons regardless of medical degree. To date, the CPAT has assisted dozens of members in battling credentialing and privileging issues.

For more information on CPAT, visit acfas.org/privileges. We can help you with that! Just follow this link Facebook.com/AmericanCollegeofFootandAnkleSurgeons and click "Like" to keep up with the latest news, research, debates and compelling conversation from ACFAS and your fellow members. Soon this new Facebook Page will replace the existing ACFAS Facebook Group, so be sure to make the switch today. Remember, you will not automatically be a part of the new ACFAS Facebook Page until you click "Like."

Foot and Ankle Surgery

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A 10-year retrospective analysis was held to determine whether there was a significant difference in the outcome of isolated leg and foot burns among diabetes mellitus (DM) and non-diabetic (nDM) patients. The data covered 207 consecutive patients admitted to a burn center with isolated leg or foot burns between 1999 and 2009. Age, gender, ethnicity, total body surface area (TBSA) and other factors were reviewed. Forty-three DM and 164 nDM patients with isolated lower extremity or foot burns were treated during the study period, with their respective average age being 54.6 and 43.7 years. Scalding, flame or contact burn were categorized as the most common burn etiology, and percentage of TBSA burn in DM patients averaged ± standard deviation 1.8 ± 1.3 percent versus 1.8 ± 1.6 percent in nDM. Eighty-six percent of DM patients suffered third degree burns and 14 percent had second degree burns compared to 76 percent and 24 percent of nDM patients, respectively. DM patients had significantly higher burn ICU admission rates among DM patients, as well as longer hospital stays and higher renal failure compared to the nDM cohort. Ninety-three percent of DM patients were sent home without further medical attention while 4.7 percent received additional treatment. Meanwhile, 85.4 percent of nDM patients were sent home with no further treatment while 8.5 percent of patients received home care.


A study was held to assess the efficacy of three distinct types of prefabricated foot orthotics in the treatment of plantar fasciitis via a prospective, randomized head-to-head trial in 30 adults with plantar fasciitis without any anatomic alteration. The tested orthotics included thin, non-supportive orthotic (NO), soft supportive foam orthotic (FO) and foam covered rigid self-supporting plastic orthotic (PO), and the patients were followed-up at three weeks. Maximum and average pain, duration of pain per day, walking distance and subjective comfort were the main outcome measures. NO had no significant effect on maximal and average pain, while FO and PO did. PO was superior at reducing pain and the time until the onset of effect.


A study was held to compare the outcomes of hallux valgus surgery between feet fixed with Kirschner wires and those fixed with a plate and screws. Fifty-three patients (63 feet) were treated with proximal chevron osteotomy and distal soft tissue procedure for symptomatic moderate to severe hallux valgus deformity between December 2008 and November 2009. Thirty-four patients (41 feet) were stabilized with Kirschner wires and 19 patients (21 feet) were stabilized with a locking plate. AOFAS was used to evaluate clinical results, and radiographic parameters were compared between these groups. Recurrence rate at the final follow-up also was compared between the K-wire and plate groups. Although average AOFAS score was lower in the plate group, the difference between the groups was not statistically significant in AOFAS score at the last follow-up. Hallux valgus angle and intermetatarsal angle were substantially larger in the plate group at the last follow-up, while average 1-2 metatarsal distance on immediately postoperative radiographs was significantly larger in the plate group. Four of the 41 feet in the K-wire group and seven of the 21 feet in the plate group exhibited hallux valgus recurrence at the last follow-up, with the plate group having a significantly higher risk of recurrence than the K-wire group.

Practice Management

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According to the study published in Health Affairs, adopting electronic health records (EHRs) appears to be a money-losing proposition for most physicians, especially specialists and those in smaller physician groups. The average physician would lose $43,743 over five years after adopting EHRs, and only 27 percent of physicians would profit through the transition away from paper records without federal financial aid. Primary care practices with six or more physicians generally were more likely to see a profit with their EHRs than were smaller physician groups or specialists. This was more likely when the new technology was used to add more patients to the daily schedule and to improve billing processes so that accurate codes were used and fewer claims were rejected. About 55 percent of the practices saw a reduction in the cost of paper medical records, but nearly half of the practices saw no savings there because they continued to use paper records even after switching to EHR.


Physicians' business practices are facing a new level of scrutiny over their billing, referral and coding activity as a result of the Affordable Care Act granting the government more authority and committing more funding to improve federal initiatives against healthcare fraud, waste and abuse. Physicians are increasingly being targeted by federal False Claims Act (FCA) probes, and experts say practices can avoid such violations through development of strong compliance programs. Practices should have knowledge of general compliance rules and industry-specific ones, and understand that the former include implementing written compliance policies and procedures and designating a compliance officer.

Practices also need to identify risk areas, such as coding and medical necessity issues. Other ways to prevent FCA violations include thoroughly documenting a compliance program, creating a code of conduct and communicating policies to employees within 90 days of hiring, every time there are updates and yearly. A culture of compliance and transparency needs to be promoted, while internal auditing should be carried out with regular updates, proactive issue reviews and corrective plan establishment.

The practice also should set up a system to respond rapidly to any possible FCA issues, make reasonable inquiries into potential violations and contact the person who reported the issue, if appropriate. Record maintenance and assessment is essential as well, with the practice needing to track potential issues and their resolutions, and report issues to the government if required. Finally, the practice should set up disciplinary procedures and clear consequences for violations, ensure employees are aware of any discipline and apply rules uniformly across the entire practice.


Doctors looking to give a fresh look to a waiting room have options to do it for a low price and not sacrifice style. Ikea provides a number of products at affordable prices. Items worth looking into here include rugs for high traffic or low traffic areas, magazine racks, coffee tables and lamps for under $500. Shoppers are encouraged to avoid shopping online as shipping costs will cause prices to rise substantially.

However, www.overstock.com does offer a good option if online shopping is preferred. For under $500 shoppers can find stylish furniture and accessories for significantly less than the retail value; an added benefit is that shipping is always $2. Corporate Art Designs (CAD) is a good service for artwork to adorn walls. CAD allows customizable packages and will develop a portfolio based on an individual's taste. Once the pieces of art have been selected, CAD will come and do the installation.

For an added link to the community, an office can feature art from local artists. This provides changing art in the office, promotion for artists and free art for the office. Doctors are also reminded to update often and get rid of old or worn out things like lamps or toys.

Health Policy and Reimbursement

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The Department of Health and Human Services (HHS) has announced new rules designed to reduce incentives for insurers to avoid people with pre-existing conditions and stabilize premiums in the individual market. HHS released several rules, including a final rule (CMS-9964-F) on the Notice of Benefit and Payment Parameters. The department also issued an interim final rule with comment (CMS-9964-IFC) amending the HHS Notice of Benefit and Payment Parameters. Meanwhile, the Office of Personnel Management issued a final regulation (RIN: 3206-AM47) establishing the Multi-State Plan Program pursuant to the health care reform law.


Provisions of the Patient Protection and Affordable Care Act stipulated that a boost in 2013-2014 pay for Medicaid primary-care services provided by physicians to Medicare payment levels had to be enacted on Jan. 1, but the logistical process that will supply those funds to physicians has been held up by postponed federal rules. Provider groups report that no states have apparently deployed a provisional Medicaid physician pay increase. States have until the end of March to submit plan amendments to the Centers for Medicare and Medicaid Services (CMS) for approval, but it remains uncertain how many states have followed such actions. CMS also seems to be responsible for some of the holdups since it reported in a written statement that "a number of states" have submitted the plan amendments. CMS has 90 days to clear the plans from the date they are submitted, and the pay boosts are retroactive to Jan. 1. The payment delays could impact the momentum to add more Medicaid physicians. Research by the Urban Institute finds that the expected pay increase also comes as the chasm between Medicare and Medicaid physician pay has grown in recent years because of provider cuts and freezes implemented by many states seeking to compensate for recession-related declines in tax revenue.


The sequester will not affect Medicaid, but Medicare spending will be cut by 2 percent through reductions in payments to hospitals, physicians and other healthcare providers, including Medicare Advantage plans and the companies running the Medicare Part D plans. By law, the Medicare cuts don’t begin until April 1. A White House summary of the sequestration's effects also highlights that the Food and Drug Administration will be able to do fewer drug approvals.


A recent survey has found that program directors in charge of interns and residents approve of most of the workload requirements implemented 18 months ago, with the exception of duty-hour restrictions. Survey respondents overwhelmingly approved of one day off each week for residents, direct supervision of first postgraduate year residents, and the 80-hour workweek, according to the researchers. Many respondents also approved of reducing night-shift frequency to fewer than seven consecutive days and eight hours of relief between shifts. However, the majority of respondents, 71.6 percent, did not approve of the 16-hour shift limit for interns, the researchers report in the New England Journal of Medicine.


The Obama administration has announced that states are permitted to cut Medicaid payments to healthcare providers to limit program costs. The federal policy statement angered healthcare providers and advocates for low-income people, but could encourage some Republican governors to go along with the expansion because it gives them a way to control costs. Secretary of Health and Human Services Kathleen Sebelius approved the cuts in October 2011 after finding that beneficiaries would still have "adequate access" to the wide range of services covered by Medicaid. The Obama administration urged judges to uphold those cuts, which are being challenged in California.


House Ways and Means Committee Chairman Rep. Dave Camp (R-Mich.) says his panel will strive to revamp the country's entitlement programs and permanently repeal Medicare's sustainable growth-rate physician payment formula. Earlier in February, Camp and House Energy and Commerce Committee Chairman Rep. Fred Upton (R-Mich.) issued a framework plotting out three phases to change how Medicare pays participating physicians. Upton publicly remarked that he hopes to bring legislation to the House floor by August 2013.

Medicine, Drugs and Devices

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Past clinical trials have shown that exposure to pure oxygen can help persistent wounds heal, but a new study of diabetes patients with sever foot ulcers finds no benefits from oxygen treatments, and in fact found they may cause some harm. By following more than 6,000 diabetes patients receiving treatment for deep foot wounds, the researchers found that patients who got oxygen-chamber treatments along with standard wound care were no more likely to heal and more than twice as likely to undergo amputations as those receiving just standard care. In the study, after 16 weeks about 43 percent of oxygen therapy patients had fully healed wounds, compared to about 50 percent of patients who did not use oxygen therapy. About 7 percent of oxygen therapy patients had an amputation, compared to just 2 percent of those who did not receive oxygen treatments. The study was published in the journal Diabetes Care.


Researchers have made a discovery that they say could be important in facilitating bone regeneration. In a study published in the journal Nature Chemistry, researchers created a polymer that is similar in structure to heparin and attached it to basic fibroblast growth factor (bFGF). This made bFGF more stable and more useful in medical applications such as the regeneration of bone. Improving the stability of bFGF is important because a more stable version of the signaling molecule can be more easily stored, shipped and made available for use by doctors.


Citing a lack of clinical data, the U.S. Preventive Services Task Force recommended that healthy women should not take low- to moderate-doses of vitamin D and calcium supplements in order to prevent bone fractures. Members of the panel say that clinical studies have not shown that low or moderate doses of vitamin D and calcium can prevent fractures. They also point out that there is insufficient data about whether high doses of calcium and vitamin D supplements can prevent fractures in healthy individuals without osteoporosis. Finally, the panel expressed concern that some doses of vitamin D and calcium supplements could cause kidney stones.