News From ACFAS

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Nearly 1,200 foot and ankle surgeons, residents and students and over 800 exhibitors came together in Fort Lauderdale, Fla., for ACFAS’ 69th Annual Scientific Conference, March 9–12, 2011. While enjoying the beauties of the “Venice of America,” attendees received the latest podiatric medical knowledge and business tools, including:

• A timely opening address by Robert M. Pearl, M.D., on how healthcare will transform under PPACA and how to position a medical practice for success in this time of change.
• The most recent research and new discoveries for the practice of foot and ankle surgery presented in panels, debates, workshops, manuscript sessions and scientific poster displays.
• Advances in medical devices, supplies and services from the industries that support podiatric medicine.

Don't miss the most valuable clinical program in the profession! Make your plans now to join us next year for the ACFAS 2012 Annual Scientific Conference, March 1–4, in San Antonio, Texas.

On Monday, ACFAS was alerted to yet another orthopaedic surgeon's website that severely misrepresents the education, training and certification of podiatric foot and ankle surgeons. The College, in conjunction with its legal counsel, is aggressively pursuing the removal of erroneous information on this website.

This incident follows the College's recent successful elimination of a similar web-based video featuring a South Carolina orthopedist. Keep your eye on This Week @ ACFAS for further news of the College’s advocacy for the profession and reputation of podiatric foot and ankle surgeons.
Those of you who were able to attend your ACFAS Regional Division’s membership meeting at the Annual Scientific Conference in Fort Lauderdale learned about ACFAS activities in your part of the country. As thanks from the Division leadership, you were also entered in a raffle for a brand-new 32 GB Apple iPad.

The drawing has been held, and the iPad winner is:

Megan Erica Lynam, DPM, Allston, Mass.
Division 8: New England

Congratulations to Dr. Lynam, and please stay tuned for e-mails from your Division about ACFAS programming and support in your backyard. To get the latest information online, visit the Division pages at the ACFAS website.
The Joint Commission will include the ACFAS “Position Statement on the Credentialing of Podiatric Foot and Ankle Surgeons and Guidelines for Surgical Delineation of Privileges” in its Medical Staff Handbook: A Guide to Joint Commission Standards, 3rd Edition. The handbook, which will publish in June 2011, is a guide to hospitals on the credentialing, privileging and appointment of healthcare professionals throughout the medical staff process. This 2010 ACFAS document is one of 12 privileging-related topics available at acfas.org/privileges.
Make the most of your spare time by catching up on research with ACFAS' Scientific Literature Reviews. Podiatric residents have prepared concise reviews from a variety of journals you may not regularly read, including:

Needle Puncture and Transcutaneous Bone Biopsy Cultures Are Inconsistent in Patients with Diabetes and Suspected Osteomyelitis of the Foot, from Clinical Infectious Diseases.
Reviewed by David Pougatsch, DPM, Cedars-Sinai Medical Center.

Preliminary Results of Calcaneofibular Ligament Transfer for Recurrent Peroneal Subluxation in Children and Adolescents, from the Journal of Pediatric Orthopaedics.
Reviewed by Robert C. Andersen, DPM, Southern Arizona VA Healthcare System.

Browse new entries or the entire archive any time at Scientific Literature Reviews.

Foot and Ankle Surgery

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Researchers compared open repair of Achilles tendon rupture to percutaneous repair in terms of function, cosmesis, and complications via retrospective review of 32 surgically treated patients, divided more or less equally between the two repair procedures. Similar values of plantar flexor strength, ROM, calf and ankle perimeter, and single heel raising test were observed between the groups, while patients who underwent open repair took a longer time returning to work, on average, than their percutaneous repair counterparts. The percutaneous group also exhibited better cosmetic appearance while the open repair group exhibited longer average scar length. Percutaneous repair additionally entailed a lower rate of wound complications and no apparent increase in the risk of rerupture, versus open repair.



Researchers tested the hypothesis that a new method for anatomically rebuilding lateral ankle ligaments using an extensor digitorum longus tendon graft of the fourth toe will effectively treat lateral ankle instability with chronic ligamentous insufficiency through a study of 24 patients treated in this way. Seventeen cases of chronic ligamentous insufficiency, three failed Brostrom operations, and four others were observed, while preoperative and postoperative Karlsson scales were utilized to analyze the functional results. The anterior displacement and the talar tilt angle on standard stress radiography of the talocrural joint were quantified preoperatively and at the time of final follow-up for comparison. Karlsson scale results rose from 48 plus or minus 4.2 points preoperatively to 92.2 plus or minus 3.8 points at the latest follow-up, while radiographically, the average anterior displacement was 6.7 plus or minus 1.2 mm preoperatively and 3.4 plus or minus 0.6 mm at the latest follow-up. Average talar tilt angle was 12.3 degrees plus or minus 1.1 degrees prior to surgery and 4.3 degrees plus or minus 0.8 degrees at the latest follow-up.



Researchers conducted a retrospective study of 16 consecutive idiopathic flatfeet in 10 adolescent/young adult patients to assess reconstruction, and test the theory that the procedure allows patients to return to sports activities with minimal pain or discomfort. Reconstruction involved combining medializing calcaneal osteotomy and lateral column lengthening in all the patients, and flexor digitorum longus transfer, medial column stabilization, and gastroncnemius recession were performed as needed. The average AOFAS score rose from 49.1 to 93.4, while the satisfaction level was excellent in 15 feet and good in one foot. Substantial improvement in radiographic parameters was observed for AP talonavicular coverage angle and lateral talar-first metatarsal angle.

Practice Management

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The current insurance model pays physicians for procedures and tests rather than time spent with patients, but some medical practices are completely bypassing health insurers by charging patients a moderate monthly membership fee. In Seattle, Qliance Medical Management's clinics charge patients about $65 a month on average for unrestricted access to doctors and nurse practitioners, and fees vary according to the level of service and the patient's age. Qliance CEO Norm Wu says the typical $700 to $800 per patient the practice receives yearly in membership fees is as much as three times more than a doctor in a standard insurance-based practice might earn per patient. Qliance envisions direct-pay practices connecting to custom "wraparound" health insurance policies that supply specialist care, hospitalization, etc. Patients would basically pay two monthly health care fees—a primary care fee they would pay to a doctor's office and a second fee paid to an insurer to cover the rest of their care.



Physician practices can actually increase their profitability by terminating managed care contracts that are not generating any revenue. EthosPartners Healthcare Management Group managed care expert John Schmitt reports that termination is often spurred by payers who have unreasonable fees or are not responsive to problems such as claim denial rates and pre-authorization rates that are hard to work with. A payer failing to fulfill promises it made when trying to get the practice to sign on is another frequent reason for termination. Schmitt advises practices that wish to terminate contracts to do it in a factual manner without any emotion; there should be respectful communication and clear documentation of why the practice has elected to end the relationship. Giving individual notice to patients covered by the payer is essential, while posted in the lobby should be a notice stating that the practice no longer accepts the payer's coverage, but will still see the patients if they wish to self-pay. Schmitt says the practice should not end or threaten to end a contract in the hope that the payer will present a better offer.



Experts say it is common practice to not train any office staff in how to respond to phone callers' many questions, and leave the responsibility for making a positive impression to inexperienced staffers. Practice management consultant Jeffrey Denning stresses that the person who answers the phone at a doctor's office must give the impression of competence, and sound relaxed, comforting, and professional, regardless of how busy the office is. He also recommends that physicians script every call response they possibly can, which empowers staff members to help callers rather than merely take messages. Consultant Jim Grigsby advises against having a single person act as receptionist, greeting patients while also answering phone calls. Doctors should instead assign one staff member to handling calls, and this person should preferably have easy access to patients' files and/or their electronic medical records. If the call handler is a nurse, he or she can triage by hearing the caller's described symptoms and deciding whether the patient should visit the office and, if so, when. Denning says there are instances where it makes sense for the physician to field calls, such as when the patient is angry.

Health Policy and Reimbursement

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A federal appeals court has ruled that physicians who bill patients after providing services are not subject to the Federal Trade Commission's red flag rules that apply to creditors. The appeals court, ruling on a lawsuit filed by the American Bar Association that challenged the application of the red flags rule to attorneys, said the FTC's regulations were made invalid because Congress passed the Red Flag Program Clarification Act of 2010 in December to better define who is considered a creditor under



A Medicare Learning Network Matters release was issued by the Centers for Medicare & Medicaid Services to remind eligible professionals (EPs) who do not successfully e-prescribe this year that they face potential penalties to their Medicare Part B Physician Fee Schedule payments for covered professional services in 2012 and 2013. EPs can evade the 2012 penalty if they are not physicians, nurse practitioners, or physician assistants as of June 30, 2011, based on their primary taxonomy code in the National Plan and Provider Enumeration System; if they do not have prescribing privileges; or if they lack at least 100 Medicare cases containing an encounter code in the measure denominator. If an EP or selected group practice wants to request an exemption from the e-prescribing program and penalties, there are two "hardship codes" that can be disclosed through claims—G8642 and G8643. G8642 involves an EP that practices in a rural region without adequate high-speed Internet access, while G8643 involves an EP that practices in an area lacking sufficient available pharmacies for e-prescribing.



Over 70 percent of physicians qualify for federal incentive payments for the meaningful use of electronic health records (EHRs), but are missing a basic EHR system, according to a new Health Affairs study. The study found that almost 83 percent of office-based physicians are eligible for either the Medicare or Medicaid incentive payment program, and researchers assumed that most doctors eligible for the Medicaid program would pursue it because the program would probably offer higher incentive payments. The study determined that 12.1 percent of physicians qualify for incentives and possess a basic EHR system, while 2.8 percent have a basic EHR and are not eligible for incentives.

Medicine, Drugs and Devices

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Researchers at the New York University Langone Medical Center have created a new protein molecule derived from the growth factor progranulin that may provide the basis for new therapies in inflammatory diseases such as rheumatoid arthritis. The molecule, called ATSTTRIN (antagonist of TNF/TNFR signaling via targeting to TNF receptors), is a peptide constructed from segments of proteins that originate within a cell, which has a high affinity and specificity for binding to tumor necrosis factor receptors. The research is published in the March 10 issue of Science.



An FDA panel has met to evaluate mounting concerns regarding whether anesthesia in young children can result in cognitive problems or learning disabilities in some cases. A growing amount of research, primarily in animals, suggests a correlation between anesthesia exposure and brain cell death or learning problems. The panel is evaluating, among other things, whether parents whose children are facing surgery should be informed of possible cognitive or behavioral risks.



Researchers investigated the effects of foot orthoses and heel inserts on plantar pressures in older adults with plantar heel pain. Thirty-six adults aged over 65 years with plantar heel pain participated in the study. Using the in-shoe Pedar system, plantar pressure data were recorded while participants walked along an 8 meter walkway wearing a standardized shoe and four different shoe inserts. The shoe inserts consisted of a silicon heel cup, a soft foam heel pad, a heel lift, and a prefabricated foot orthosis. The greatest reduction was achieved by the prefabricated foot orthosis, which provided a fivefold reduction compared to the next most effective insert. The contoured nature of the prefabricated foot orthosis allowed for an increase in midfoot contact area, resulting in a greater redistribution of force. The prefabricated foot orthosis was also the only shoe insert that did not increase forefoot pressure.