News From ACFAS

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You don’t need to go far to make an impact on the profession of foot and ankle surgery. Five of the 14 ACFAS Divisions recently held leadership elections for open positions and are pleased to announce new officer leaders for their respective Divisions.

The Divisions that have recently elected new leadership are:

• ACFAS Division 1: “Pacific” – CA, HI, Guam
• ACFAS Division 3: “Southwest” – AR, LA, OK, TX
• ACFAS Division 5: “Florida”
• ACFAS Division 6: “Midwest” – IL, IA, KS, MN, MO, NE, ND, SD, WI
• ACFAS Division 10: “Upstate New York” – area outside NYC and surrounding suburbs

To see which Division events are taking place in your part of the country or for contact information on the new officers, please visit the Divisions' web page. Mark your calendars for you and your office staff to attend the 2013 Coding/Practice Management Workshop set for July 19-20, 2013 in Chicago. Keep yourself up-to-date on the latest in:

• ICD-10
• HIPAA changes - Social Media Impact
• Coding/Billing

Watch This Week @ ACFAS, acfas.org and your mailbox for more information on this not-to-be-missed, practice management program. Have an open position? Now is the ideal time to post all your open positions on ACFAS’ official online career center, PodiatryCareers.org. April is a period when the ACFAS Career Center sees significant peaks in job-seeker activity. Rapid increases in traffic, resume submissions and online responses to job postings are at their highest during the upcoming graduation season and employers and candidates alike are utilizing PodiatryCareers.org to find new jobs and to target qualified podiatrists from across the country.

Take advantage of this brief, yet bustling time frame by posting any podiatry ads you have to PodiatryCareers.org so they stand out to this new pool of job seekers. Whether you are looking for a recent graduate or a seasoned professional, now is the time to fill your podiatry positions. Visit PodiatryCareers.org or call (888) 884-8242 to begin!

Legal Briefs

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In the late 1990s, pediatrician John I. Sutter was dealing with running a small, inner-city pediatric health center while pursuing a master's degree in health policy and management. During this time, income was tight, and Sutter started paying closer attention to how his insurance claims were being processed and paid, and he discovered that Oxford Health Plans was shorting him about 10 percent of what he was owed. Sutter alleged Oxford systematically bundled, downcoded and delayed payments for services provided by him and about 20,000 other physicians in the network. In 2002, Sutter sued Oxford in New Jersey Superior Court, looking to represent himself and a class of similarly situated health professionals. Oxford argued that Sutter's contract prohibited lawsuits and class arbitration, and that payment disputes could be resolved only through individual arbitration. Legal analysts say if the court rules for the insurer, it could limit the ability of individual physicians and others to fight similar payment disputes as a unit.

Foot and Ankle Surgery

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A study was held to review long-term results for a cohort of idiopathic clubfoot patients managed by a single surgeon with a uniform surgical protocol comprised of extensive posterior medial-lateral release along with the use of a temporary Kirschner wire to derotate the talus before fixation. Posterior medial-lateral release was used to manage 80 patients and 120 clubfeet. At a median of 21 years postoperatively, patients underwent a physical examination and completed four quality-of-life surveys. Thirty-two clubfeet had needed additional procedures at the time of follow-up, with only a single patient requiring complete revision posterior medial-lateral release and none requiring subtalar or triple arthrodesis. In patients exhibiting unilateral clubfoot, clinical examination showed a significant decrease in the range of motion, foot length and calf circumference on the affected side versus the unaffected, contralateral side. Outcomes on all four quality-of-life scales remained durable, with no decline in relation to the time from the index procedure. Patients requiring additional surgery had significantly worse scores.


Researchers from the Hospital for Special Surgery in New York, N.Y. have carried out a systematic review of the literature surrounding the use of microfracture to treat osteochondral lesions of the talus. The researchers considered 24 studies drawn from the MEDLINE and EMBASE databases. The studies that were considered had been published between January 1966 and June 2011. While general demographics and study design were generally well reported in over 80 percent of the studies, patient history and patient-reported outcome data were reported in only 55 to 66 percent. Clinical variables and imaging data were the least reported information in the studies, included in only 48 and 39 percent respectively.


A study presented 48 patients with complex ankle pathology treated with the Ilizarov technique. Thirty patients exhibited infection and 30 had significant deformity prior to the surgical procedure, and outcome was evaluated clinically with the modified AOFAS (MAOFAS) scale and the Short-Form (SF-36). Arthrodesis was accomplished in 40 patients using the Ilizarov technique and in six more patients with additional surgery, while infection was eliminated in all patients at an average follow-up of 46.6 months. There was a lower likelihood of successful arthrodesis in patients with comorbidities and in tibiocalcaneal fusion compared with tibiotalar fusion. These patients had poor general health scores versus the normal population before the procedure. The average MAOFAS score improved from 24.3 preoperatively to 56.2 postoperatively, but only a modest improvement in general health was observed. The average SF-36 climbed from 44.8 to 50.1. The procedure significantly relieved pain.

Practice Management

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Medical practice mergers can be full of potential risk, and there are a number of common errors that can inhibit an effective merger. Merging more than two practices can be a mistake, as it adds factors that in turn multiply the problems and the associated risks. One such case led to problems because a single manager was selected to serve as administrator to three merged practices. The administrator continued to commit the bulk of his time to management of his own practice while long-term planning and efficiency-bolstering efforts fell by the wayside.

A second mistake is not addressing the turmoil that a merger entails for employees. Examples include physicians who show preference, financial or otherwise, to favorite employees while risking alienating others. Another error is not updating job descriptions after the merger, which complicates matching employees to their skills and creating effective assignments for them. Such missteps can create needless additional and avoidable stress for the merged group.

Furthermore, some physicians become too obsessed with trying to save money on personnel. It has been observed that when practices of similar size were compared to each other, the ones that devoted more money to staff reaped the most profits. This is because recruiting more highly skilled staff such as physician assistants and nurse practitioners generates higher revenues than those stemming from even the most skilled registered nurses and licensed practical nurses.

Practices that create a shared leadership of two or three physicians, typically the heads of the merged practices, are courting trouble. This is because the resulting fuzzy leadership requires decision-making by several physicians that could be more efficiently and effectively executed by a single leader. Meanwhile, many modern practices have installed an electronic health record (EHR) system, and a safe, cost-efficient bet in a merger is to use the larger practice's system, at least at first. This is because simpler EHR systems only focus on medical records, billing and collections, and appointment scheduling. More sophisticated systems provide management information that flags practice weaknesses in need of correction. Larger practices require more data for making solid decisions, and this calls for more more advanced, and thus more expensive, EHR systems than those required by smaller practices.


Practice managers may want to think twice before seeking out alternatives before adding a provider to help deal with an influx of patients. Adding a new provider to a practice can be costly, and it can be far less expensive to simply achieve better control over appointments to properly manage current patients. The best way to do this is to ration appointments that are not critical and can wait, and begin to track the number of emergency appointments made each day. Emergency requests should take the place of less urgent ones, and charting how often these requests are made will help determine how much time should be allotted for them.

In order to streamline appointments, practice managers will need to gather data on their rate of patient visits per hour, the number of no-show patients and cancellations and the number of same-day emergency appointments. Managers can collect the totals at the end of each day, note them on the appointment schedule and, over time, begin to recognize their practice's trend of patient flux. Mondays usually have the highest number of emergency visits, but other days' demand varies depending on the practice. Practice managers should stay abreast of abnormalities that could skew their data collection, including work days after a long weekend, and note any seasonal variation in their data. They can use color-coding on their appointment templates to help themselves and office staff understand which type of patient each slot is reserved for. They can also save the emergency slots for the end of the day.


Impaired or incompetent physicians can pose a safety risk to patients and carry the risk of a potential lawsuit for a practice. Removing such a physician from a practice or disciplining them can be a difficult process, but experts warn that failing to deal with such a physician can lead to lawsuits, high liability insurance rates, ruined reputations for the practice and for everyone else involved and even possible losses of practices and licenses for physicians who knew of the impairment but did not report it.

Practice managers should iron out polices, procedures and expectations for doctors and clarify what will happen should a doctor not meet the expectations of the practice. There should be an operating agreement for doctors on staff and a shareholder's agreement for practice partners. The operating agreement should be written at the beginning of a doctor's employment when every party is healthy and in the right frame of mind. Practices should also have a letter of understanding outlining its expectations for standards of care and the expectations of the community, granting employees the freedom to report any physician deficiencies to supervisors without fearing termination or reprisal and affording the alleged deficient physician the opportunity to file an appeal.

Determining if a physician is indeed impaired or incompetent can be a difficult task that requires analyzing many metrics. Practices should use measures such as board certification and recertification, licensing, maintenance of continuing medical education requirements and the medical staff application process to determine physician competence. Any doctors found unable to continue serving their practice at their expected level of performance can either agree to take a different job at the practice or go into early retirement.

Health Policy and Reimbursement

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The Centers for Medicare and Medicaid Services (CMS) has launched its eHealth effort as a core repository for information on the federal government's digital record-keeping and electronic prescribing programs. The page offers a central location to search the CMS site for details of the major digital health initiatives, including the $22 billion electronic health-record (EHR) incentive program, the hospital inpatient quality reporting system and the e-prescription incentive program. eHealth can be accessed here.


The CMS and the Office of the National Coordinator for Health Information Technology at U.S. Department of Health and Human Services are seeking public input on ways to broaden the reach of health information exchange to providers and patients not currently or only marginally sharing healthcare information electronically. A formal notice and request for information about the extra efforts has been published in the Federal Register.


The nearly 22.3 million Americans who are diagnosed with diabetes cost $245 billion in medical care and lost productivity in 2012, a 41 percent increase from the $174 billion estimate in 2007, according to a study commissioned by the American Diabetes Association. The study reported that 5 million more American adults and children were diagnosed with diabetes in the five years since the last estimate was released. Another 79 million Americans now have pre-diabetes, which puts them at risk for developing Type 2 diabetes. The price tag includes $176 billion in direct medical costs for hospital and emergency care, office visits and medications. The indirect medical costs were estimated at $69 billion to account for absenteeism, reduced productivity, unemployment caused by diabetes-related disability and lost productivity due to early mortality.


The Medicaid and CHIP Payment and Access Commission (MACPAC) has released two recommendations, one to allow states to implement 12-month continuous eligibility for certain enrollees and another to permanently fund a health program that is available to Medicaid enrollees with an increase in earnings. MACPAC's recommendation for 12 months of continuous eligibility would apply to children enrolled in the Children's Health Insurance Program (CHIP) and adults enrolled in Medicaid. Permanently funding the Transitional Medical Assistance program, meanwhile, would help provide certainty to states and families, the commission said.

Medicine, Drugs and Devices

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Researchers have developed a polymer implant that they say helps bone fractures heal faster than autografts, bone transplantation or other conventional treatment methods. The implant is a scaffold made from microporous ammonia methacrylate copolymer type A and a plasticizer that facilitates the adherence of bone stem cells and also prevents scar tissue from forming inside the fracture. A recent study that examined 35 mature dogs and cats with different bone fractures, including delayed healing and non-union conditions, found that the implant helped fractures heal in just eight weeks, compared with the typical five to 12 months. Researchers are now planning to conduct a human clinical trial of the implant.


Researchers at Baylor College of Medicine have performed a study that sheds light on the mechanisms behind the development of osteoarthritis (OA) and could lead to a chondroprotective approach to the treatment of the condition. The study found that intra-articular expression of proteoglycan 4 (Prg4) prevented the development of OA in mice and also had a protective effect in a model of posttraumatic OA created by cruciate ligament transection. Researchers noted that Prg4 expression inhibits the transcriptional programs that promote catabolism and hypertrophy through the up-regulation of hypoxia-inducible factor 3a. Human OA data sets were found to be consistent with this model's predictions.


Researchers at Georgia Regents University are studying techniques that could help mesenchymal stem cells survive transplantation and aging, which in turn could speed up the process of healing broken bones and could lead to treatments for diseases like osteoporosis. The researchers found that mesenchymal stem cells that were genetically engineered to produce 30 times the normal amount of stromal derived factor-1 (SDF-1) were more likely to survive a transplant because apoptosis was decreased and autophagy was increased. The scientists are planning further studies on a drug that could be used to increase SDF-1 in stem cells either before or after transplantation, which could also have a positive effect on existing cells.