News From ACFAS

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Learn the latest techniques in external fixation at the three-day, comprehensive, hands-on surgical course, “Complex Foot & Ankle Applications of Circular External Fixators.” The course, being held in Scottsdale, Ariz., Oct. 28–30, offers discussion, case presentations, lecture and practical instruction in foot and ankle procedures using monolateral and ring fixation techniques, and will reinforce the concepts of pathology correction and frame construction.

Visit the ACFAS website now for the full brochure and immediate registration. The ACFAS Fellowship Committee recently met and recognized three new Foot and Ankle Surgical Fellowship Programs:

• University Hospitals Richmond Medical Center Fellowship, Concord, Ohio.
  Fellowship Director: Jonathan Sharpe, DPM, FACFAS
• Mon Valley Fellowship, Monongahela, Penn.
  Fellowship Director: Mark H. Hofbauer, DPM, FACFAS
• Virginia Mason Foot and Ankle Sports Medicine Fellowship, Seattle, Wash.
  Fellowship Director: Eric J. Heit, DPM, FACFAS

ACFAS highly recommends the continuation of foot and ankle surgical education after residency in the form of a specialized fellowship. Programs meeting minimal requirements are officially recognized by the College, which will in turn provide support for these programs. For a complete listing of programs, support by ACFAS and minimal requirements, please visit acfas.org/fellowshipinitiative. President Obama announced on Sept. 19 his proposal to reduce Medicare spending by $248 billion over 10 years and Medicaid spending $72 billion over the same period. This is part of a $3.2 trillion deficit reduction package that doesn’t include raising Medicare's eligibility age. The proposal is now in the hands of the congressional Joint Select Committee on Deficit Reduction, charged with agreeing on a $1.5 trillion deficit reduction plan due this fall. The administration said 90 percent of the Medicare savings would come from reducing overpayments and those cuts affecting beneficiaries would not begin until 2017. The mantra is reducing waste and boosting the quality of care.

Obama seeks to repeal the current payment system for physicians, a move the American Medical Association is heralding as the plan strengthens the Independent Payment Advisory Board that is making Medicare provider payment recommendations. In addition to cutting reimbursement to physicians and other providers, drug companies, hospitals, nursing homes, durable medical equipment services and home health agencies will see their reimbursement impacted. Bad debt payments to providers would also be reduced. The plan seeks to strengthen healthcare fraud and abuse activities and increase costs for new beneficiaries by imposing higher Part B deductibles and introducing cost-sharing for home health services. More information is available here (178 KB PDF).

Futurescan™

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Healthcare, especially healthcare financing, is changing day by day. To help provide some basic education on current trends in the U.S. healthcare industry, ACFAS is sharing abstracted articles from the American Hospital Association's publication, Futurescan™ 2011: Healthcare Trends and Implications 2011–2016, in this special eight-week section.

For healthcare organizations to successfully lower costs and improve quality, they must facilitate substantial and sustainable process improvement work through concentration on a systematic, data-driven approach to problem solving. Robust process improvement (RPI) will help to remove overuse of health services, waste and risk innate in unnecessarily complex care processes, and preventable complications. RPI tools include Lean Six Sigma, change management processes, and other techniques that have demonstrated effectiveness in other industries. No RPI tool can stand alone in the achievement of truly sustainable improvement, which is where change management tools come into play.

With an upcoming focus on austerity, healthcare organizations will have to do more with less, and RPI offers opportunities to simplify processes and be more efficient. An intelligent focus on quality improvement priorities that also offer the opportunity to lower costs and fortify revenue is a crucial win-win strategy in this environment. Among the steps leaders in healthcare organizations should take to make the switch to RPI are the provision of aggressive staff training to build internal capacity to apply RPI tools and methodologies; incorporation of RPI tools across the organization; empowerment of all employees to lead improvement; and emphasis on leadership's role in embracing and maintaining RPI and a safety culture.

Foot and Ankle Surgery

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Researchers investigated whether changes in dynamic plantar pressure distribution, strength capacity, and postural control after intra-articular calcaneal fracture correlate with clinical and radiological outcome. Sixty patients with unilateral, operatively treated, intra-articular calcaneal fractures were evaluated one year postoperatively.

Clinical examination revealed a reduction in range of motion at the tibiotalar and the subtalar joint on the affected side, plantar flexor peak torque (p<0.001) and postural control. Plantar pressure measurements revealed a pressure reduction at the hindfoot (p=0.0007) and a pressure increase at the midfoot (p=0.0001) and the lateral forefoot (p=0.037).

The AOFAS score was correlated weakly with radiological classifications, moderately with strength and standing duration and strongly with self-selected walking speed.


Researchers hypothesized that in displaced Tillaux and Triplane fractures, the talus would shift laterally along with the distal fibula and the distal tibial epiphyseal fragment increasing the medial joint space. Twenty-two skeletally immature patients (14 displaced Triplane fractures and eight displaced Tillaux fractures) were evaluated for medial joint space widening. Thirteen Triplane and six Tillaux fractures (86 percent) showed medial space widening of 1 mm to 9 mm and equal to the amount of fracture displacement. Reduction of the fracture reduced the medial space to normal. There were no known complications.


Assessing the effectiveness of an augmented method of osteosynthesis in allowing early weightbearing in older patients with AO/OTA 44-B fractures was the objective of a study involving 36 nonconsecutive patients subjected to augmented internal fixation through use of an intramedullary wire, lateral plate, and screw augmentation with polymethylmethacrylate. All patients initiated weightbearing as tolerated in a removable brace at an average of 13.5 days postoperatively, and 30 patients were available for follow-up at a minimum of one year. All the fractures healed with low reduction loss, and the average AOFAS ankle-hindfoot score was 84.9. Ninety percent of patients reverted to prefracture function while two infections were observed.

Practice Management

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Online reputation management is necessary for physicians to prevent negative Web content from tarnishing their reputations and their business, and there are steps they can take to manage this content themselves. Reputation management experts advise physicians to perform Google searches on themselves regularly to see what content exists and stay ahead of a potential crisis. Physicians should establish alerts on Google and Yahoo. Sites that rank high in Google searches may frequently have wrong or outdated contact information and incomplete biographical and educational history; many such sites allow doctors to edit their own profiles, and physicians should take advantage of this to correct errors.

Another reputation management strategy is for doctors to create their own content, which they can do through personal blogs, websites and social media pages. Experts say physicians should embrace constructive criticism, find a handful of rating sites they deem trustworthy, and direct patients to them. Identifying and addressing hot button issues among patients, and publicizing their correction online, also can help doctors' reputations.


It is critical for medical practices to optimize time-of-service collections, with new high-deductible health plans requiring more out-of-pocket contributions from patients. Optimization strategies include having reception staff develop tactful and discreet collection skills quickly. Meanwhile, financial clearance should be performed prior to patients' arrival at the office. Staff should be taught ways to ask for payment that personalizes the interaction and puts the situation in the patient's hands.

In addition to copayments, practices should ensure that reception staff has immediate access to accurate information about the balance due, as this gives them concrete data to supplement their collection. A deposit required at the time of service should be established for uninsured patients, while payment should be requested—or at least expectations set—during appointment scheduling or confirmation calls, or both.

Staff need to be monitored and reported on a weekly basis, while the receipting, recording, and balancing processes must be structured and followed appropriately. A front office staffer who does outstanding collections may be ideal for making collection calls,and a practice should mull a work scheme for the staffer to make such calls once or twice weekly.


U.S. medical patients would be able to get their laboratory test results directly from the labs rather than wait for a copy from their doctors under a new rule proposed by federal health regulators. The proposal from the Centers for Medicare & Medicaid Service, the Department of Health and Human Services' Office for Civil Rights, and the Centers for Disease Control and Prevention would amend the Clinical Laboratory Improvement Amendments of 1988 (CLIA) and HIPAA privacy regulations and is part of a larger effort to strengthen patients' rights to access their own medical records. Under the proposed rule, labs would be authorized to release results to patients or their designated representatives upon request after authenticating that the results belong to the patient.

Health Policy and Reimbursement

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Congress should repeal the Sustainable Growth Rate (SGR) that's poised to cut physician's pay 30 percent starting Jan. 1, the Medicare Payment Advisory Commission said in a draft proposal released Monday. To offset a projected loss in federal revenue of $300 billion, the commission recommends that primary care physicians' pay be frozen for 10 years. Doctors providing more specialized services would endure cuts of 5.9 percent in each of three years. Their pay would then be frozen for the remainder of the 10 years. The remaining shortfall would be covered by other reductions in payments for about 30 other healthcare services and professions, such as reducing payments to clinical labs by 10 percent. More information on the draft proposal can be found here.


Health and Human Services has shut down public access to data on malpractice and disciplinary actions involving doctors. The National Practitioner Data Bank maintains confidential records used to grant licenses or staff privileges to doctors. Although records naming physicians are not available to the public, the data bank provided access to its reports with identifying information removed. On Sept. 1, the data bank removed these files from its website.


The American Academy of Family Physicians wants Medicare to change the makeup of a committee that helps set physician-payment levels, including adding more primary-care representatives to the group. The group also plans to propose different ways for calculating Medicare reimbursement for primary-care services, which it argues are too low compared to payments for specialist services. A study published in Health Affairs found that primary-care physicians earned less than orthopedic surgeons in each of several countries studied, but the differential was largest in the U.S.

Medicine, Drugs and Devices

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WellPoint is planning to use the speed and computing muscle of IBM's Watson supercomputer to help diagnose medical problems and authorize treatments. The WellPoint application will integrate data from a patient's chart and electronic records that a doctor or hospital possesses, the insurance firm's history of medicines and treatments, and Watson's massive archive of textbooks and medical journals. The computer can then mine all this combined data and answer inquiries in moments, supplying several possible diagnoses or treatments, ranked in order of confidence, along with the basis for its answer.


There were 83,466 physician assistants (PAs) practicing in the United States in 2010, double what there was 10 years prior, according to a survey from the American Academy of Physician Assistants. A further breakdown of the data found that nearly 30 percent of PAs practice in single-specialty physician group practices, and 40 percent have been in their current primary specialty for at least six years. Two-thirds of PAs said they were satisfied or mostly satisfied with their career.


The FDA declined to suggest how long women should take bisphosphonates to prevent bone fractures, but agreed the labels should be changed to reflect uncertainty about the risks and benefits of long-term use. The agency had asked two of its advisory panels to recommend whether a "drug holiday" or some time limit was warranted on the drugs, which have been linked to unusual thigh fractures and other side effects. Instead, the advisers voted to make changes to the labeling with many in favor of specifying how often patients need a re-evaluation of whether they need the medicine. Panelists raised concerns that they did not have enough evidence to come up with specific suggestions or conclusions, and some recommended raising awareness of such uncertainties in the label as well. The drugs under review, including Merck's Fosamax and Roche's Boniva, have also been linked to osteonecrosis of the jaw, or jaw bone death, and a possible higher cancer risk.


Total payments to doctors for promoting pharmaceutical companies’ products to their colleagues appear to be falling in Massachusetts, suggesting that new restrictions are leading some physicians to abandon the speaking circuit. Eli Lilly and Co., for example, paid healthcare providers here $866,919 in 2010 for speaking about their drugs, a 46 percent drop from 2009, according to an analysis by the Boston Globe and ProPublica, a nonprofit online investigative journalism organization. The data also show that many Harvard-affiliated doctors have dropped out of company speakers bureaus, a sideline that has allowed many physicians to earn tens of thousands of dollars. Partners HealthCare, the parent organization of Harvard-affiliated Massachusetts General and Brigham and Women’s hospitals, prohibited doctors from participating in promotional drug company speakers bureaus as of January 2010. A similar ban by Harvard Medical School took effect this July. Other academic medical centers in the state have followed suit.