News From ACFAS

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The Kansas governor has signed scope of practice legislation that allows podiatrists who have completed a three-year surgical residency to operate on the ankle. The scope expansion legislation was the result of close collaboration between the Kansas Podiatric Medical Association, state medical society, and orthopaedic society. ACFAS worked with College members and KPMA leaders Mark Landry, DPM and Jeffrey Hogge, DPM. More details on this breaking news will appear in the next ACFAS Update newsletter. The ACFAS is working through the Coalition for Patients’ Rights to ensure the realization of the Affordable Care Act’s (ACA) “Non-Discrimination in Health Care” provision, codified at Section 2706(a), of the Public Health Service Act. This provision in the ACA is an important patient-centered health insurance reform aimed at empowering consumers with greater ability to seek care from the provider of their choice and safeguarding patient access to covered health services from the full range of providers licensed and certified to provide such services in their respective states. Specifically, Section 2706(a) states that “a group health plan and a health insurance issuer offering group or individual health insurance coverage shall not discriminate with respect to participation under the plan or coverage against any healthcare provider who is acting within the scope of that provider’s license or certification under applicable State law.”

H.R. 2817, the “Protect Patient Access to Quality Health Professionals Act of 2013”, introduced by Representative Andy Harris, MD (1st-MD) would repeal the non-discrimination clause of the Patient Protection and Affordable Care Act (specifically Section 2706(a), Title XXVII of the Public Health Service Act). The Coalition for Patient’s Rights wrote to House Energy and Commerce Chairman Fred Upton (6th-MI) and Ranking Member Henry Waxman (33rd-CA) urging them and their Congressional colleagues to oppose H.R. 2817.

Further, Representative Kurt Schrader (5th-OR) has written a letter to members of the Democratic Caucus urging them to join him in calling on federal agency officials to ensure the full and fair implementation of ACA’s Section 2706(a). The Coalition of Patients’ Rights, of which the ACFAS is a member, will continue to support the full enactment of this important provision.

For additional information regarding the Coalition’s comments, visit the Patients Right Coalition. Need some guidance on achieving your practice’s financial goals? As a member of ACFAS, you have access to money saving services from our financial Member Benefits Partner, HealthCare Associates Credit Union (HACU). HACU is a not-for-profit, full service financial cooperative serving select employee groups with staff and members sharing a common bond … healthcare.

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Foot and Ankle Surgery

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A new study describes and evaluates an algorithmic method for managing wounds that occur following orthopaedic foot and ankle surgery. The algorithm focuses on pre-operative evaluation by the orthopaedic surgeon and evaluation and treatment of the wound by the plastic surgeon following a referral. The algorithm was evaluated in terms of whether prophylactic or simultaneous soft tissue coverage of the wound affected five wound-healing complications: secondary plastic surgery, malunion, orthopaedic hardware removal, ultimate failure, or additional orthopaedic surgery. The study also evaluated the algorithm with respect to whether post-operative referral for soft tissue management was associated with wound location, size, and orthopaedic procedure. After reviewing the outcomes of 112 patients who underwent elective orthopaedic foot or ankle surgery as well as concomitant plastic surgery to treat their wounds, surgeons found that prophylactic or simultaneous soft tissue coverage did not lead to differences in the frequency of complications compared to post-operative intervention. The study also found that the most common wounds in patients referred post-operatively for soft-tissue management were smaller dorsal ankle wounds, which were most often associated with total ankle arthroplasty. The study concluded that when the algorithm was used, prophylactic or simultaneous soft tissue coverage did not improve the rate of the complications that were examined. However, the algorithm did make it possible to identify skin instability early and allowed soft tissue coverage to be performed before or at the same time as orthopaedic procedures.


A recent study of 377 patients who had undergone surgery for displaced intra-articular calcaneal fractures has found that 40.3 percent had to undergo intraoperative revision following the use of intraoperative 3D imaging. The study also found that the American Orthopaedic Foot & Ankle Society (AOFAS) scores in these patients indicated that post-operative joint surgery congruence had a significant affect on clinical outcome. Joint surface congruence was also found to have had a significant influence on the degree of osteoarthritis in these patients. These findings led researchers to conclude that intraoperative 3D imaging is better than fluoroscopy at identifying intra-articular incongruence and implants. The study also concluded that the resulting options for better joint surface reconstruction may result in an improvement in clinical outcomes, at times requiring repeat reduction, as well as a reduction in post-traumatic osteoarthritis.

Practice Management

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Physicians' practices should not ignore negative information, as such information can be helpful in improving operations, writes Creative Healthcare Solutions Managing Partner Stephen Tramontana. One potential source that practices can mine for potential negative but helpful information is customer service questionnaires. Tramontana notes that while some small- and mid-sized practices have shied away from using these questionnaires, surveying patients about their experiences can provide practices with information they need to deal with any problems and retain their patients. Tramontana also recommends that practices survey their employees about the performance of their management teams, including their physicians. Such surveys can be completed by employees at home and the results can be anonymized so that staffers provide more candid feedback. Information from these surveys can then be used to correct any management problems that may prompt important staff members to resign if otherwise ignored, Tramontana says. Finally, Tramontana recommends that practices ignore what they learned about not criticizing their competition and carry out marketing campaigns that show how they are superior to other practices in their area.


Technology is increasingly allowing documents to be accessed and shared anywhere and at any time, a trend that has impacted doctors' practices and the manner in which they operate. Documents containing patient information that must be protected under the Health Insurance Portability and Accountability Act (HIPAA) can be stored on USB drives, accessed remotely from home computers, stored in the cloud, or downloaded to smartphones, among other things. As a result, practices need to be sure that their HIPAA compliance programs take steps to protect patient information on all of the different locations and devices where patient information is accessed, inputted, or stored, writes healthcare attorney Mary Beth Gettins. This can include policies that govern remote access to patient information, the use of portable devices such as smartphones and USB drives, and the use of cloud storage and document sharing, Gettins says. In addition, Gettins notes that doctors' practices must be sure that they have administrative policies in place for employees and others who are responsible for creating, accessing, storing, and transmitting patient information covered by HIPAA. Finally, Gettins notes that practices should have technical policy safeguards in place as well.


Despite the opposition of thousands of physicians to the American Board of Internal Medicine's (ABIM) new Maintenance of Certification (MOC) rules, enrollment in MOC programs is on the rise. ABIM says that 150,000 doctors have enrolled in the programs since the beginning of the month, which means that the number of physicians enrolled has increased by over 50,000 since the new rules were released in January. More than 20 percent of doctors who have lifetime certifications are enrolled in the programs even though they are not required to do so, ABIM says. ABIM has continued to defend its rule changes, which require doctors to take part in more frequent training and testing by May 1 or risk being reported as not in compliance with MOC requirements, despite a petition signed by nearly 15,000 physicians who consider the rules to be overly burdensome. ABIM says it is taking feedback from doctors into consideration as it considers possible changes to its programs but says it is important for doctors to maintain their certifications in order to assure patients that they have the latest knowledge necessary for the practice of medicine. One of the possible changes ABIM is considering is adding more programs that will provide doctors with MOC credits.

Health Policy and Reimbursement

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Healthcare providers, particularly the hundreds of hospitals that are planning to meet Stage 2 Meaningful Use requirements this year, will need to react quickly to a proposal from the Centers for Medicare and Medicaid Services (CMS) that will give them another year to remain at Stage 1. The proposal calls for healthcare providers to be given an additional year to use 2011 Edition software in their electronic health record (EHR) systems in order to meet Stage 1 Meaningful Use requirements. CMS said it issued the proposal because of the delays some providers are experiencing in adopting and implementing 2014 Edition software in order to successfully attest to meeting Meaningful Use criteria this year. Karen DeSalvo of the Office of the National Coordinator for Health Information Technology says the proposed rule will give "new options" to smaller providers and others who have been unable to obtain 2014 Edition software. Hospitals and other providers that are planning to meet Stage 2 requirement will have only one 90-day attestation period to react to the change, as they are only allowed to begin attestation periods for Stage 2 on the first day of fiscal quarters. However, healthcare providers are generally supportive of CMS' proposed rule.


The Labor and Health and Human Services departments have said that insurance companies and employers can continue to use "reference pricing" to control costs for certain high-cost procedures--a move which some say could undermine provisions in the Affordable Care Act (ACA) that limit consumers' out-of-pocket expenses. The reference pricing strategy involves insurance companies setting caps on what they will pay for some procedures and forces consumers to pay any difference between that cap and the actual cost in addition to any cost-sharing that they would normally incur for the amount covered. The difference between the reference price and the actual cost of a procedure does not count towards a plan's annual limit on out-of-pocket expenses, meaning that the strategy could weaken protections written into ACA that require most plans to pay for 100 percent of costs after consumers reach that annual limit. As a result, there are concerns that the use of reference pricing could result in consumers racking up large medical bills that will not be covered by insurance. Supporters of the strategy, however, say that it helps drive down the cost of the procedures to which it is applied. The Obama administration has said it will work to ensure that the continued use of reference pricing does not weaken financial protections for consumers.


A new report from the Kaiser Family Foundation has found that senior citizens find it difficult to compare the numerous Medicare health and prescription drug plans that are available to them, and consequently keep the same plans even when they do not fully meet their needs. In addition, the report found that many senior citizens choose not to switch plans because they want to avoid what they say is the hassle involved. Judith Stein, the executive director of the consumer advocacy group Center for Medicare Advocacy, says these findings are worrisome because Medicare plans that may seem to be good enough when planholders are healthy may not cover visits to their desired hospital or doctor or the drugs they need when they are sick. The findings also seem to indicate that seniors do not find the federal government's rating system for Medicare plans to be helpful in comparing the plans that are available to them.

Medicine, Drugs and Devices

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A new study suggests that Cumberland ankle Instability Tool (CAIT) score should be less than or equal to 25 for chronic ankle instability rather than previously described 27. They compared subjects with and without chronic instability to come up with this conclusion. A post hoc analysis was utilized to determine the sensitivity and specificity of this new cutoff line. All clinimetric properties showed improvement when using the new cutoff score compared to the original score. However, a high rate of false positives was seen among patients who had a single ankle sprain and no subsequent instability, prompting researchers to advise clinicians to use caution when using the new cutoff score for these patients. Nevertheless, the study concluded that clinicians should use the new score when utilizing the CAIT to maximize test characteristics.


Doctors are experimenting with wearable devices such as Google Glass to assess the technology's potential in treatment settings. For example, Beth Israel Deaconess Medical Center in Boston is testing a modified version of Glass in its emergency department, enabling doctors to quickly access patient information without leaving the scene to use a computer. Doctors use Glass to scan a quick response (QR) code outside the patient's room, which triggers a custom app to retrieve patient records using the hospital's Wi-Fi network. The information is then displayed on a small prism in front of one eye. The custom app limits the amount of information available, and does not enable complex searches or data entry with gesture and voice commands. However, limitations in the Glass interface present opportunities for innovation. One such opportunity, according to New York University computer scientist David Sontag, will be algorithms that can deliver relevant data to doctors at the right time to make wearable technology more effective.


A new study has concluded that chronic plantar fasciopathy patients who are required to stand more than five hours per day at work experience similar benefits from a treatment regimen consisting of a corticosteroid injection and stretching as they do from a physiotherapy-led exercise program. The 56 patients who participated in the study were divided into two groups: one that took part in seven physiotherapy-led exercises on a daily basis for 12 weeks, and another that received a palpitation-guided dexamethasone injection followed by daily calf stretching. Both groups of patients experienced similar, significant improvements in Foot and Ankle Disability Index (FADI) and visual analog scales for pain at work and during daily activities from baseline to weeks six and 12. Neither group experienced significant changes in the thickness of the plantar fascia at weeks six and 12. Finally, significant improvements in the number of cases with focal anechoic areas and the size of these areas were seen at the 12 week point in both groups.