News From ACFAS

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An emergency rule of the Indiana Office of the Secretary of Family and Social Services amends regulations and reduces the Medicaid reimbursement rates paid to podiatrists by 5 percent. The rule is effective March 31, 2011. If you live or work in Indiana, you can contact the Family and Social Services Administration, Office of Medicaid Policy and Planning, at 317-233-4455 with your comments.
On April 12, the U.S. Department of Health and Human Services announced the launch of the Partnership for Patients, a collaborative effort whose two main goals are to lower the number of preventable hospital-acquired conditions by 40 percent, and reduce preventable complications that occur during care transitions by 20 percent by the end of 2013. The CMS Innovation Center will support local projects to improve healthcare quality and medical professionals in their efforts to reduce patient harm. Visit the HHS website for more information.
ACFAS recently participated in the Joint Commission’s Ambulatory Professional and Technical Advisory Committee (PTAC) on field review results of the Primary Care Home (PCH) model. The respondents provided several suggestions for modification, including considerable debate on what constitutes active participation by an M.D. or D.O. ACFAS spoke in favor of an inclusive definition of those providers accountable in the PCH, and did not want to limit any provider’s ability to practice independently.

Keith D. Cook, DPM, FACFAS, is the College’s new PTAC representative, succeeding Adam M. Budny, DPM, AACFAS.
Gain new knowledge whenever you are ready with the online library of foot and ankle health topics in video, podcast, and DVD at ACFAS e-Learning.

The latest free podcast is “Hallux Rigidus,” a comprehensive discussion between experienced foot and ankle surgeons on symptom relief, treatment choices and preferred procedures for the entire progression of this condition, from early to end stage.

New topics are added all the time, so check in often at acfas.org/elearning.
The ACFAS Fellowship Committee is working on new initiatives to provide needed visibility and support for high-caliber podiatric fellowships, furthering the specialized education of foot and ankle surgeons post-residency, and has designated two additional programs as “Recognized Fellowships”:

• Foot and Ankle Fellowship at the Ankle & Foot Care Center, Boardman, Ohio
  Fellowship Director: Lawrence A. DiDomenico, DPM, FACFAS
• Podiatric Medicine and Surgery Research Fellowship at Boston Medical Center, Boston, Mass.
  Fellowship Director: Vickie Driver, DPM, MS, FACFAS

For details on the Recognized Fellowship initiative, including a complete list of recognized programs, ACFAS planned support for programs, and the criteria and application for recognition, visit the ACFAS website.

Foot and Ankle Surgery

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Researchers employed the Achilles Tendon Total Rupture Score (ATRS) to ascertain the level of disability in patients with minimally invasive surgical Achilles tendon rupture repair with a complicated postoperative course. A review of the charts of 340 consecutive patients treated for an acute Achilles tendon rupture by minimally invasive surgical repair was conducted. The average ATRS for the 211 patients who returned a completed questionnaire was 84 points, and the average ATRS for the 135 uncomplicated cases was 89, 71 for the 17 patients with a rerupture, 79 for the 41 patients with a sural nerve injury, and 75 for the 17 patients with another complication; thirteen of those 17 patients suffered a wound-healing complication deemed to be minor, while their average ATRS score was 80 points. In the long term, rerupture substantially raised the risk of quitting or changing sport participation.



Researchers assessed the effectiveness of osteochondral autograft transplantation (OAT) for acute osteochondral fractures of the talar dome (OCFT) affiliated with ankle fractures through the undertaking of the procedure in 16 patients with acute Grade III or IV OCFT. OAT entailed two sequential treatments—harvesting of the osteochondral autograft cylinder from the non-weightbearing surface of the ipsilateral knee, and implantation of the donor graft into the talar defect via a press-fit method; single cylinder transplantation or a mosaicplasty was utilized. Average size of the osteochonral fracture defects was 84.1 square mm, and the average depth was 2.5 mm; the average AOFAS score was 95.4 points postoperatively. Bony integration and articular congruity of the talar dome was indicated in 93.7 percent of the osteochondral grafts based on magnetic resonance imaging of all patients, demonstrating that OAT is an effective procedure with outstanding clinical outcome and imaging evidence of graft integration.




A prospective cohort study was conducted to identify predictors of developing a stress fracture among preadolescent and adolescent girls during a seven-year period, through examination of 6,831 girls aged 9 to 15 years. The subjects' history of stress fracture, including age when fracture took place and site, were reported by their mothers, who are registered nurses, in 2004. Across seven years of follow-up, 267 girls developed a stress fracture, and independent of age, age at menarche, family history of fracture, and hours per week of low- and moderate-impact activity, hours per week of running, basketball, and cheerleading/gymnastics were substantial stress fracture predictors. The researchers concluded that girls who run, play basketball, are cheerleaders, or engage in gymnastics should be encouraged to include varied training in lower-impact activities to reduce the cumulative amount of impact so that they minimize the risk of stress fractures.

Practice Management

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A complex year-old healthcare law is proving to be a windfall for consultants, and much of the activity is centered on a provision encouraging physicians, hospitals, and insurers to collaborate in patient treatment. At first these accountable care organizations (ACOs) will only treat Medicare patients and receive bonuses for supplying better care at reduced cost—but if successful, ACOs will likely proliferate to private patients. "ACOs are worth doing because we need to build systems of care," says consultant Steve Lieberman. "The system is fragmented, doctors are very unhappy and everyone wants to reduce the costs." Among the reasons physicians and hospitals turn to ACO consultants is to wade through the flood of pitches they are inundated with from technology and other vendors selling products they claim will clear a path to becoming an ACO.



For decades, American medicine has been defined by independent doctors who owned their own practices and worked long hours, earning comfortable incomes but often sacrificing family life. However, a growing number of physicians entering the field are choosing not to establish their own practice or join a smaller existing practice in favor of more forgiving hours at a hospital or large organization. Many young doctors are taking salaried jobs, working fewer hours, and even going part time or choosing specialties based on family reasons. Merritt Hawkins, a top doctor recruitment firm, reports that 51 percent of the positions it filled in the past year were for hospitals, up from 14 percent eight years ago.



The Kelsey-Seybold Clinic in Texas, founded in 1985 as a specialty-oriented group, has found that capitation can be the key to financial success, but only if it is structured correctly. When the Texas oil industry fell on hard times, and the practice's target of higher-end patients started to decline, the practice decided to try a guaranteed fee per patient. After difficult negotiations and taking a health plan to court, the practice managed to secure a higher capitation rate from the plan. The practice also had to retrain physicians, shifting away from a fee-for-service culture that focused on doing more because it made more money to a culture of cost-effective, evidence-based practicing. Patrick Carter, medical­ director of care coordination and quality improvement at the practice, says that under a fee-per-service system it can be hard to convince physicians not to perform unnecessary tests and procedures, because it means making less money, but with capitation, physicians aim to provide quality care at the lowest cost because the payment is the same no matter what treatment the patient receives.

Health Policy and Reimbursement

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CMS has released a 429-page guideline on proposed rules for accountable care organizations (ACOs). The deadline for comments on the proposals are due May 31. And the date for qualified ACOs to begin is Jan. 1, 2012. Until then, it would be wise to understand the terminology. Here is a list of 13 terms it would behoove healthcare providers interested in participating in an ACO to refamiliarize themselves with.



There are cases pending in appellate and state supreme courts in at least seven states that target medical liability damages caps. The cases challenge the constitutionality of the caps, and advocates such as Center for Constitutional Litigation president Robert S. Peck note that, in West Virginia's case, the cap discriminates between patients with minor medical injuries and those who have suffered more severe injuries; Peck says that while people with minor injuries can receive full compensation for noneconomic damages determined by a jury, more severely injured patients receive only a fraction. West Virginia State Medical Association executive director Evan Jenkins is worried that the legal battle in his state could be a setback to progress made by reforms. "We are very fearful that we are one decision away from being pushed back into the crisis we saw a decade ago, where physicians were fleeing the state and [we had] an out-balanced liability system," he warns.



Healthcare costs continue to rise, and the U.S. Justice Department plans to increase its efforts to ensure antitrust laws are upheld when it comes to market competition among hospitals and insurers. A recent settlement with a Texas hospital system that requires the system to change how it contracts with private insurers could signal a more aggressive approach by the Justice Department to rein in increasing medical costs as a result of anti-competitive practices. However, even as enforcement efforts increase, antitrust authorities plan to have a more flexible approach toward accountable care organizations authorized under the recently passed healthcare reform law.



The U.S. Senate voted this week to repeal the Form 1099 tax reporting requirement that would have required businesses to file a Form 1099 document with the IRS for purchases of goods and services exceeding $600 a year. It was approved despite misgivings expressed by some Democrats to the way the $22 billion cost to the U.S. Treasury of repealing the tax reporting provision is covered. The bill adjusts the health insurance tax subsidies to be given to middle-income people under the health care law. It would require anyone who receives excessive tax subsidies for health insurance to pay back a greater share than currently required under the law. Critics argued that the payback provision would discourage individuals and small businesses from complying with the law's requirement that they obtain health insurance.

Medicine, Drugs and Devices

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Research to ascertain the validity and reliability of measures acquired using a custom-made device for assessing ankle dorsiflexion motion and stiffness was performed. The Iowa ankle range of motion (IAROM) device was employed to evaluate validity and intertester reliability of dorsiflexion range of motion (ROM) measures at 10, 15, 20, and 25 Nm of passively applied dorsiflexion torque, with both the knee extended and flexed approximately 20 degrees; stiffness values were determined using the angular change acquired between the 15- and 25-Nm torque levels, while convergent validity was assessed via comparison of ankle dorsiflexion angles measured concurrently with the IAROM device and an optoelectronic motion analysis system. Validity testing showed superb agreement, while reliability testing demonstrated good to excellent intertester agreement. The research concludes that the IAROM device supplies valid and reliable measurement of ankle dorsiflexion ROM, and also permits calculation of stiffness by measuring ROM at multiple torque levels, though the reliability of the measurement is not optimal.



Hospitals across the United States, and around the world, are embracing iPads. The reason is simple, according to Dr. John Halamka, chief information officer at Beth Israel Deaconess, who says that iPads are a great fit for doctors. "The secret for the ideal clinical device ... is it has to weigh a pound, it has to last 10 hours, because that’s their shift, you have to be able to disinfect it so there’s no risk of contamination, and you have to be able to drop it 5 feet onto carpet without damage." But what makes iPads ideal, doctors at Beth Israel Deaconess said, is that they combine mobility with interactive touchscreens they can use to share pictures and data with patients.



New antibiotic nanoparticles may be able to eradicate superbugs like MRSA, which killed 19,000 U.S. citizens in 2005, according to IBM Research. The international research team is working on a new nanoparticle material that can be administered topically or through injection and has the potential to kill dangerous bacteria such as MRSA and E-coli. Clinical trials are necessary, but preliminary research shows that nanoparticles are not toxic to human cells. The innovation making these applications possible is a set of nanostructured polymer materials that have a very specific electric charge that essentially tears the cell walls and membranes of the dangerous bacteria apart. Other potential uses for this nanotechnology include controlling the development of bacteria in products like deodorants and mouthwash, and incorporating them into bandages, sutures, and catheters for infection control measures.