News From ACFAS

Yet again Congress failed to specifically include doctors of podiatric medicine as physicians in Title XIX of the Medicaid statutes when the House passed the “healthcare reform bill” on Sunday, March 21. However, the bill — now signed into law — prohibits insurance plans from discriminating against any healthcare providers who act within their state's scope of practice and license.

The issue of Medicare physician reimbursements remains in limbo. Medicare reimbursements will remain unchanged until at least April 30. Pending legislation would extend the physician payment freeze until October 1, and delay the $1,860 hard cap on outpatient physical and occupational therapy services and extend COBRA subsidies until December 31. Senate Majority Leader Harry Reid (D-Nev.) has said that the Medicare reimbursement issue would be addressed immediately after the healthcare reform bill was passed.

While the new healthcare reform law contains no significant medical liability changes, major benefits for physicians include:

• Primary-care doctors and surgeons practicing in underserved areas, such as inner cities and rural communities, will get a 10 percent bonus payment from Medicare from 2011 to 2015.
• Medicaid will pay primary care doctors 100 percent of Medicare rates in 2013 and 2014. Medicaid payment is generally less than 80 percent of Medicare rates.

Foot and ankle surgeons have seen tremendous progress in hospital privileging parity in recent years. However, even board-certified or qualified surgeons may still sometimes encounter difficulties.

This is why the College has numerous online resources to help you. The most recent versions of all ACFAS privileging documents can be found at acfas.org/privileges.

In addition, a new delineation of privileges document is being developed now by the Credentialing and Privileging Task Force appointed by the ACFAS Board of Directors in February 2010. Look for progress updates in This Week and on the ACFAS web site.

The ACFAS Board of Directors met on February 22, 2010, immediately before the Annual Scientific Conference in Las Vegas. Outgoing President Mary E. Crawford, DPM, presided over a full agenda, including these board actions:

• Approval of comments to be submitted to the Council on Podiatric Medical Education on the proposed revisions to podiatric residencies guidelines (CPME Document 320).
• Creation of a new Credentialing and Privileging Task Force to advise the board on relevant issues and the immediate development of a new delineation of privileges document.
• Creation of a new Clinical Practice Guidelines (CPG) Management Council to determine new CPG topics, revisions of existing CPGs and selection of CPG expert panels, and to integrate even more evidence-based medicine and comparative effectiveness data into the documents.
• Preliminary approval of a new position statement on total ankle replacement, to be finalized in April.
• Decision to conduct a survey of charitable medical missions to determine which missions should be posted on the ACFAS web site for member information.
• Prioritization of 10 new initiatives to be implemented as revenues exceed budgeted projections during the year.
• Preliminary approval of a multi-center research proposal on subtalar arthoeresis, following completion of the College’s first multi-center study on 1st MTPJ, as recommended by the EBM/Research Committee.

Foot and Ankle Surgery

Arthritis Drug Shows Promise in Type 2 Diabetes

Early study results suggest that the drug salsalate, used for 40 years to treat arthritis, may have potential as a treatment for preventing type 2 diabetes. Salsalate is also known to have anti-inflammatory properties and chemically resembles aspirin, but it carries a lower chance of stomach problems and has none of the bleeding risks. The study, published in the Annals of Internal Medicine, included 108 adults, ages 45 to 65 years, with uncontrolled diabetes. Glucose levels improved significantly for all patients who took the drug, compared to placebo, although researchers noted that they had hoped for a bigger change. Further research will explore the potential side effect of an increased risk in kidney problems in a few patients. The research was funded by the National Institutes of Health.



The Course of the Superficial Peroneal Nerve in Relation to the Ankle Position

Iatrogenic damage to the peroneal nerve is the most frequently reported complication in anterior ankle arthroscopy. One of the methods to visualize the nerve is combined ankle plantar flexion and inversion. In most cases, the superficial peroneal nerve can be made visible. The portals for anterior ankle arthroscopy are, however, created with the ankle in the neutral or slightly dorsiflexed position and not in combined plantar flexion and inversion. Researchers in this study undertook an anatomical study to the course of the superficial peroneal nerve in different positions of the foot and ankle, hypothesizing that the anatomical localization of the superficial peroneal nerve changes with different foot and ankle positions. In ten fresh frozen ankle specimens, a window, only affecting the skin, was made at the level of the anterolateral portal for anterior ankle arthroscopy in order to directly visualize the superficial peroneal nerve, or if divided, its terminal branches. The researchers found that the nerve consistently moves lateral when the ankle is maneuvered from combined plantar flexion and inversion to the neutral or dorsiflexed position. If visible, they recommended that creation of the anterolateral portal medial from the preoperative marking to prevent iatrogenic damage to the superficial peroneal nerve.



The Two-Pin Arthrodesis Technique for Proximal Interphalangeal Joint Fusion of the Lesser Toes

A commonly performed procedure for correction of the claw toe and hammer toe deformity is arthrodesis of the proximal interphalangeal (PIP) joints of the lesser toes, and multiple fixation methods have been detailed to achieve a solid fusion with variable fusion rates. The standard method has long employed a single intramedullary K-wire, and a group of researchers describes a technique of fusing the PIP joint with two fine K-wires, utilized to prevent rotational displacement and guarantee sound arthrodesis. Thirty-six fusions were performed in 25 patients, and these fusions were evaluated independently using the American College of Foot and Ankle Surgeons score and the Foot Function Scale. A 97 percent fusion rate was achieved with 89 percent of patients reporting satisfaction with the appearance of their toes. Ninety percent of patients reported no pain with normal activities, and the researchers believe that their enhancement to the single wire method yields superior results.

Practice Management

How to Get the Most Out of a Professional Conference

Medical conferences offer many enticing benefits, including interesting topics, enticing locations, and chances to obtain continuing medical education (CME) credits. However, it can be difficult to justify the cost and the time away from a practice needed to attend a conference, meaning should you decide to attend it is important to get the most out of the conference. After balancing the cost against the potential benefits, if you decide to attend the conference, plan ahead to make sure you capitalize as much as possible during your time away from the practice. Determine what you hope to get out of the conference, research the conference schedule in advance, and plan out what events you want to attend.



Informed Administrators Are Key to a Successful Billing Staff

A major mistake billing departments can make is to rebill a claim without first contacting the insurance company to find out why the claim was denied. Rebilling highlights how important it is for practice managers to ensure they have an up-to-date system to monitor billing staff and knowledge of the signs to look for. Practice managers should familiarize themselves with A/R and know the job descriptions of the people in the practice. By familiarizing themselves with such information, practice managers can better assess what each billing person needs to accomplish to meet the practices financial goals. Administrators should be flexible and create a plan that works for their billing group, which could require rearranging job duties.



RAC Audits Now a Potential Risk for Physicians

Earlier this year, two of the four recovery audit contractors (RACs) added medically unlikely edits (MUEs) to their list of CMS-approved issues, giving RACs a new series of issues, including physician services, to audit. HCPro's Peggy S. Blue says that although physician services have not been a primary focus for the RACs, they have been targeted by medical audit consultants, comprehensive error rate testing contractors, and the Office of Inspector General. "The fact that MUEs are approved by CMS for the RACs to review means that this is an issue that can have claims reviewed, and they can go in and do audits on those claims," she notes. Blue says it is likely that RACs will concentrate on physicians sooner or later, and physicians should apply the same preventive measures that facilities take against RACs. Audits should be prevented if physicians work to ensure the billing is clean, the documentation is in order, and that the bill and the documentation match.

Health Policy and Reimbursement

Call to Cap Medical Payments Is Likely

Massachusetts Senate leaders said they will push forward with measures this year to control soaring healthcare costs in the state that probably will include caps on payments to hospitals and doctors. Medical spending on privately insured Massachusetts residents grew more than 15 percent from 2006 to 2008, fueled by outpatient care in expensive hospitals. Last year, a state commission proposed replacing the current fee-for-service system of reimbursement with a per-patient annual fee to cover all of a patient’s medical care.



Employers Plan to Shift More Healthcare Costs to Workers, Survey Reports

The majority of large companies in the United States intend to shift more health care costs to their workers in 2010, according to an annual survey by the National Business Group on Health and Towers Watson. For instance, 28 percent of employers plan to use spousal surcharges in 2010, up from 21 percent in 2009, the survey found. Twelve percent of employers plan to offer only high-deductible coverage in 2010, according to survey, which was conducted from November 2009 to January 2010 and comprised 507 companies with a staff of at least 1,000.



With Medicaid Cuts, Doctors and Patients Drop Out

Medicaid patients are having an increasingly difficult time finding doctors and dentists who will accept their coverage due to a sweeping cuts to Medicaid reimbursements throughout the U.S. states; many are consequently deferring treatment or ending up in hospital emergency rooms. The Urban Institute estimates that two years ago, Medicaid reimbursements averaged less than three-quarters of the rates paid by Medicare, while Michigan had the sixth lowest rate in the country at 63 percent. Following Congress' February health meeting, President Obama sent Capitol Hill a letter in which he wrote that rates might need to climb if Democrats succeed in extending Medicaid eligibility to 15 million uninsured Americans. The cost of Medicaid is shared by the states and the federal government, and the program currently benefits 47 million people, mainly children, pregnant women, handicapped adults, and nursing home residents. Physicians cutting back on Medicaid practices has caused a jump in the number of patients who do not need acute treatment that emergency rooms are seeing.

Technology and Device Trends

Amputees Could Feel Artificial Limb if Put in the Virtual World

University College London computer scientist Anthony Steed will present a study on how virtual environments impact people with artificial limbs at the upcoming Virtual Reality 2010 Conference. In an experiment that had 20 volunteers play games in a virtual world in which an avatar's hands were represented as their own, the participants behaved as if the virtual hand was their own limb. Steed used a monitoring system to record the movements of muscles and nerve-endings firing. The monitoring system enabled him to track the reactions of the volunteers during the virtual game when a lamp on a table toppled onto the avatar's arm. The monitoring system showed that most of the participants made gestures with their arm that suggested an attempt to move it, and the volunteers acknowledged they had reacted as if the virtual hand was their own. When Steed conducted the experiment again, but using an arrow to represent the volunteers' arm, the participants showed no emphatic response to the falling lamp. The research suggests virtual reality can help amputees feel ownership of their prosthetic limb.



Shells Inspire Composite Material

Materials scientists and chemists from the University of Manchester and the University of Leeds have developed a new composite material, drawing inspiration from sea shells, that could lead to crack-resistant bone replacements. The researchers have successfully reinforced calcium carbonate with polystyrene particles. The method could be used to make ceramics with a high resistance to cracking, which in turn could be used in bone replacements. The researchers say that the method allows for the properties of the material to be adjusted by choosing particles of different shapes, sizes, and composition.



Tested: A Reboot for the Immune System

The ability to reprogram the immune system is one of the most desired objectives in medicine, and now researchers are getting increasingly close to succeeding in patients with Type 1 diabetes. For three decades, University of California at San Francisco Immune Tolerance Network and the Diabetes Center Director Jeffrey Bluestone has worked to learn how to keep the immune system from attacking the body itself. Autoimmune diseases, in which the immune cells attack body tissues and organs, can result in one of more than 80 known conditions, including Type 1 diabetes and rheumatoid arthritis. Much of Bluestone's research focuses on an organ-transplant drug called OKT3, which he and other researchers believe could be useful in treating autoimmune diseases. Bluestone was able to alter the drug to stop the progression of Type 1 diabetes in mice, and was able to create a new version that targeted problematic cells in the immune system without disabling the entire system. In human trials, Bluestone's drug has succeeded in not only preventing the loss of the ability to produce insulin, but has managed to increase insulin production in some people with Type 1 diabetes.



Abstract News © Copyright 2010 INFORMATION, INC.

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