News From ACFAS

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ACFAS responded this week to the Council on Podiatric Medical Education’s (CPME) proposed changes to Podiatric Medicine and Surgical Residency (PMSR) surgical case requirements. CPME proposed two levels of cases: 300 for forefoot and rearfoot training and 150 for forefoot-only training. “We believe the single, three-year PMSR curriculum was the single greatest step forward in our 75-year march for professional parity,” said ACFAS President Richard Derner, DPM, FACFAS. “So, with this march to parity now virtually inevitable, why would CPME take a huge step backward and propose two levels of surgical cases? The ACFAS Board of Directors unanimously and vehemently oppose this change. The surgical case levels should remain unified and unchanged,” he affirmed.

ACFAS’ complete statement can be read on acfas.org.
ACFAS’ annual poster competition last month in Phoenix featured more than 250 entries—and plenty of unique topics that shed new light on foot and ankle surgery. Visit acfas.org/phoenix to see video presentations of nine posters that challenge us to explore new ways of thinking. Presenters candidly explain their research methodology and future implications of their findings. These posters give you an inside look at this year’s competition and just may inspire you to submit your own poster for ACFAS 2016!
If you haven’t already downloaded the handouts from your favorite ACFAS 2015 sessions, be sure to log in to acfas.org/phoenix today for access. Handouts will be available until June 30, 2015.

Foot and Ankle Surgery

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A study was conducted to quantify bilateral gait biomechanics in patients who underwent ankle realignment surgery by supramalleolar osteotomies, an increasingly popular process. Eight patients, reassessed after at least seven years, were compared against eight healthy controls. Compared to their healthy counterparts, the patients walked more slowly, had a smaller sagittal hindfoot range of motion on their affected leg and had a lower peak ankle dorsiflexion moment (P < .05). Patients and controls showed no difference in quality of life score, although patients reported significantly more pain than the controls. Because of these findings, the study suggests that supramalleolar osteotomies should be viewed as a strong option for patients with asymmetric non-end-stage ankle osteoarthritis.


The propensity for complications in distal tibia and ankle fracture treatments in diabetic patients has prompted a look into a more effective treatment option. An initiative was taken to use a percutaneous technique in which autologous, bone marrow-derived, concentrated cells are injected at the site of non-unions. Eighty-six non-union diabetic patients were treated with the bone marrow concentrate (BMC) method. The results were compared against 86 non-union diabetic patients given standard iliac crest bone graft treatment. Treatment with BMC produced a healing rate of 82.1 percent with few complications. The patients treated with iliac crest bone graft only had a 62.3 percent healing rate and incurred major complications, which included 5 amputations, 11 osteonecroses of the fracture wound edge and 17 infections. The study concluded that the BMC treatment should be viewed as preferable in diabetic patients with ankle non-unions.


A new study was conducted to assess the clinical outcome of simultaneous less-invasive ankle arthroscopy and hindfoot endoscopy for combined anterior ankle impingement syndrome (AAIS) and posterior ankle impingement syndrome (PAIS) in professional athletes. The research involved 12 feet of nine professional athletes with combined AAIS and PAIS undergoing the procedures between October 2009 and October 2011. All patients received radiography, computed tomography and magnetic resonance imaging scans. Ultrasound-guided anesthetic injection was performed for PAIS diagnosis. Active plantar and dorsal flexion angles of the ankle before and after surgery, occurrence of complications and time to return to competitive sports were evaluated. Osteophytes were present in the anterior ankle joint of all feet. Ostrigonum and a large posterior talar process were discovered in eight and four feet, respectively. Combined disorders observed included lateral ankle instability in six feet and an osteochondral lesion of the talus in four feet. Median Japanese Society for Surgery of the Foot ankle/hindfoot scale and visual analogue scale scores improved. Average active plantar and dorsal flexion angles climbed from 40 degrees and 10 degrees pre-operatively to 50 degrees and 15 degrees post-operatively, respectively. Average time to return to competitive sports was 12 weeks.

Practice Management

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There is a common expectation that online marketing is no longer just an option for physician practices, but something they must do to attract new patients and remain competitive. Determining a budget for such an effort best starts with examining what the online marketing program's objectives are and defining them within short-term and long-term situations. Once goals are set, the practice can move forward with ascertaining the costs to realize them. Factors to consider when determining costs include:

1. What online resources the ideal patient typically visits, usually leading to the recommendation that practices should begin with a website and Facebook page.
2. Whether an outside or in-house team should manage the marketing program.
3. The cost of reaching ideal patients. More specific messages may be slightly more or less expensive, depending on the patient characteristics the practice seeks.
4. Staying in touch with patients.

Such costs should be factored into what a single patient is worth to the practice to estimate how much time and money should be invested in online marketing efforts.


Physicians and medical practices are experiencing a shift in operations due to alternative payment models such as bundled payments, pay-for-performance and medical homes. A study of 34 physician practices, sponsored by RAND Corporation and the American Medical Association, found that alternatives are causing practices to partner or merge with each other or with hospital systems, develop team approaches to care management, invest more in data management and provide patients with more options for accessing care. None of the practices in the study reported financial hardship as a result of alternative payment models. Researchers found that delegating less-intense patient encounters to other providers contributed to physician burnout since "lower-intensity patients could be an important source of respite for busy physicians," they write. The study authors suggested that payers explore ways to align and harmonize their alternative payment models, which can free up physician practice resources.


Switching from manual to fully electronic business transactions between healthcare providers and health plans could possibly create significant savings and improve efficiency in the healthcare industry. The 2014 Council for Affordable Quality Healthcare Index report examines data from participating health plans representing 112 million enrollees, almost 45 percent of the privately insured U.S. population, on more than 4 billion transactions. The report found that U.S. healthcare could save $8 billion annually by transitioning six routine business transactions—claim submissions, eligibility and benefit verification, prior authorization, claim status inquiry, claim payment and remittance advice—from manual to electronic transactions.

Health Policy and Reimbursement

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The "doc fix" will have to wait until at least mid-April. The Senate adjourned for spring break on Friday morning without taking up legislation to permanently repeal Medicare's sustainable growth-rate formula for paying doctors. The delay, however, will not necessarily mean that doctors will face a 21.2 percent cut in pay on April 1, when the current patch expires. The Centers for Medicare and Medicaid Services has indicated that it can delay processing claims for a period of time in order to keep the cut from being implemented. "We'll return to it very quickly when we get back," Sen. Mitch McConnell (R-Ky.) told reporters Friday morning. "I think there's every reason to believe it's going to pass the Senate by a very large majority."


The sustainable growth-rate fix that passed the House and will go to the Senate in mid-April will likely simplify quality reporting requirements for healthcare providers. The bill includes a merit-based incentive payment system that would offer bonuses or penalties based on whether physicians score above or below a certain threshold on quality measures, including meeting the requirements for the meaningful use of health information technology. The new program rolls together three existing quality-incentive programs: the electronic health record (EHR) incentive program, the Physician Quality Reporting System and the value-based payment system. The new incentives would range from a 4 percent maximum penalty or bonus in 2019 to a 9 percent maximum penalty or bonus in 2022 and after. The new system would supplant the existing penalties and bonuses under the government's EHR incentive program. Physicians who receive a significant portion of their revenue from alternative payment models, including from private payers, would be exempt from the new system and would see more generous payment increases from Medicare.


House Republicans have expanded recommended budget savings in the government's primary healthcare program for the poor by about $140 billion to offset part of the higher payments to doctors who treat Medicare patients. The change comes as Republicans in both houses struggle with competing priorities, specifically the desire to stabilize the Medicare provider payments system and the 10-year goal of balancing the budget. The Medicare legislation would block a 21 percent cut threatened for April 1 in fees paid to doctors who treat seniors and would replace a 1997 law that has threatened similar reductions for years with a guaranteed modest increase in fee payments. The legislation would also tie fees to a new formula aimed at encouraging physicians to charge based on the quality of care, instead of the quantity.


The Congressional Budget Office reported that a bipartisan House deal to repeal automatic payment cuts to doctors under Medicare would increase the deficit by $141 billion over 10 years. However, it would still cost less than keeping the current payment rates for the same length of time.


An Office of Inspector General report states that federal agencies' failure to implement 25 sets of "significant" recommendations from the Health and Human Services Office of Inspector General has cost U.S. taxpayers and beneficiaries about $24 billion. If implemented, the actions would likely improve quality and patient safety, program integrity, financial and grants management and contractor management, according to the report. For example, a recommendation suggests the Centers for Medicare and Medicaid Services should reduce payments to hospital outpatient departments for surgeries that could be safely provided at "less intensive and less costly" ambulatory surgical centers. This change could provide $15 billion in savings over five years.


As millions of Americans join Medicaid, health experts are conducting experiments to learn how to control healthcare costs, especially those linked to poverty, homelessness, mental illness or addiction. “We had this forehead-smacking realization that poverty has all of these expensive consequences in healthcare,” said Ross Owen, a Hennepin County health official who helps run an experiment in Minneapolis. “We’d pay to amputate a diabetic’s foot, but not for a warm pair of winter boots.” Now health systems around the nation are trying to buy the boots, metaphorically speaking.

Medicine, Drugs and Devices

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A study was conducted to evaluate occupational outcomes and return to running following ankle fracture fixation in a military cohort. The lack of data on the subject necessitated the study, which took results from 72 primary ankle fracture fixation procedures. Of the patients, 88 percent were male and 61 percent were at least 25 years old. The average follow-up was 35.9 months. Among military service members undergoing ankle fracture fixation, 64 percent returned to running. Those with greater occupational demands had a statistical trend to return to running. The study found that 83 percent of service members undergoing ankle fracture fixation remained on active duty or successfully completed their military service. Two-thirds of service members whose jobs required daily running returned to doing so.


A study published in the Journal of Nuclear Medicine determined 18F-fluoride positron emission tomography (PET)/magnetic resonance imaging (MRI) for foot pain without clear cause is technically workable and yields superior image quality to PET/computed tomography (CT). Included in the study were nine men and 13 women with complaints of foot pain of unclear cause who had undergone single-injection dual-imaging protocol with 18F-fluoride PET/CT and PET/MRI. Comparison of imaging results showed image quality was significantly better for PET/MRI. The sensitivity of the PET datasets in PET/MR and PET/CT was equivalent. The same 42 lesions were observed with focal 18F-fluoride uptake. Osteoarthritis, stress fracture and bone marrow edema were the most frequent diagnoses. The researchers also noted patient radiation exposure was lower with the PET/MRI.