News From ACFAS

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Since May 2010, ACFAS has worked in collaboration with the Joint Commission and directly with the Centers for Medicare and Medicaid Services (CMS), through letters, e-mails and phone calls, to encourage CMS to make changes in the hospital conditions of participation to allow podiatric physicians and surgeons to head medical staff. As a result, the College is now pleased to announce the promulgation of a draft regulation, “Medicare and Medicaid Programs; Reform of Hospital and Critical Access Hospital” (CMS-3244-P).

This rule solidifies CMS’ recognition that on many medical staffs across the country, the education, training and experience of credentialed and privileged podiatric surgeons is equivalent to their MD and DO partners on the healthcare team. ACFAS will submit formal comments to this draft proposal that will hopefully clear the way for ACFAS members to showcase their medical staff leadership very soon.

For more information on the proposed rule, visit the CMS website. Have you recently changed your work, home or e-mail address, or phone or fax number? Does your practice have a website? Do you want to change your “preferred address” for receiving the Journal of Foot & Ankle Surgery and other ACFAS mailings? We want to stay in touch with you! Update your contact information at acfas.org/profile (member login required).

Your contact information can be listed in the College’s online membership directory so your colleagues can find you, and you can also be listed in the “Find an ACFAS Physician” search tool on ACFAS’ consumer website, FootHealthFacts.org. After completing your professional profile with website, hours, and up to three locations, scroll down to “ACFAS Website Listing” and check “Yes” for “Consumer Physician Search” and “Members-Only Directory.”

Keep yourself available to your peers, potential patients and the College! Update your profile today. At this time of year, you may be looking at requirements for continued licensure or privileging. But did you know that members of the College are eligible for free continuing education contact hours with selected materials at ACFAS e-Learning? All it takes is successful review of the material and completion of an associated exam.

The latest addition is the scientific session video, “Infection.” View experienced surgeons discussing aspects of this treatment challenge, including limb-threatening soft tissue infections, septic fusions, final options before BKA, and related developments in antibiotic therapy and imaging.

Find this and many other topics for extra CME any time at ACFAS e-Learning!

Legal Briefs

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A federal appeals court has ruled that a Puerto Rico physician licensing restriction does not violate due process or equal protection rights of general practitioners, confirming the authority of state medical boards to impose reasonable restrictions on physicians in practice specialties. In Gonzalez-Droz v. Gonzalez-Colon, the U.S. Court of Appeals for the First Circuit ruled that Puerto Rico regulations that prohibit physicians from performing cosmetic surgery if they are not trained in that specialty do not violate the U.S. Constitution. The court said the regulations satisfied the constitutional test that they reflect a “rational basis” for creating a regulatory distinction between different classes of physicians—those who are trained to perform cosmetic surgery and those who are not. The court also found the application of those regulations to a specific physician, Dr. Efrain Gonzalez-Droz, did not violate his civil rights.

In upholding the regulations, the court found Puerto Rico reasonably determined that a general license to practice medicine was insufficient to ensure patients were not injured and that the regulations were needed to guide and protect patients. Using board certification in dermatology or cosmetic surgery was a reasonable surrogate for classifying those authorized to provide those services, the court said, noting that it is well-established that states have authority to regulate the practice of medicine as part of their responsibility to protect public health. Additionally, a requirement that a cosmetic surgeon be board certified in dermatology or plastic surgery to perform cosmetic surgery and advertise those services is not unreasonable, the court found.

Foot and Ankle Surgery

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A 14-year comparative prospective longitudinal study was held to directly evaluate the differences in outcomes between the traditional stretch and strap technique for managing idiopathic clubfoot and the Ponseti method. The study period witnessed 52,514 births in the local population and all newborns with clubfoot were referred directly to the pediatric orthopedic surgeon. A radical subtalar release (RSR) was undertaken if conservative treatment failed to correct the deformity adequately. Sixty-four out of 114 feet in 80 patients were treated via the traditional technique while 50 feet were treated with the Ponseti method. The presence of idiopathic clubfoot was established in 76.25 percent of patients. Average time to RSR was 33.3 weeks and 44.1 weeks for the traditional and Ponseti groups, respectively. RSR surgery was performed on 65.6 percent (CI: 53.4 to 76.1 percent) of feet in the traditional group, versus 25.5 percent (CI: 15.8 to 38.3 percent) in the Ponseti group. When idiopathic clubfoot was solely analyzed, these rates fell to 56.5 percent (CI: 42.3 to 69.8 percent) and 15.8 percent (CI: 7.4 to 30.4 percent), respectively. The Relative Risk of requiring RSR in traditional compared to Ponseti groups was 2.58 (CI: 1.59 to 4.19) for all patients and 3.58 (CI: 1.65 to 7.78) for idiopathic clubfoot.


Research was conducted to evaluate how patients with soft tissue impingement of the ankle responded to arthroscopic debridement, using a series of 41 arthroscopies performed for soft tissue impingement between April 2007 and April 2009. The subjects included 26 men and 15 women with a mean age of 30.1 years, and arthroscopy was executed on an average of 21 months post-injury. The Visual-Analogue-Scale Foot and Ankle (VASFA) score and Meislin's criteria were employed to assess response to treatment. The average pre-operative VASFA score was 44.5, which climbed to 78.3 postoperatively. Thirty-four results were good or excellent, five were fair, and two were poor, according to Meislin's criteria. Pre-operative magnetic resonance imaging was useful in identifying tears of the anterior talofibular ligament and excluding osteochondral defects, but synovitis and soft tissue impingement was under-reported.


A study was to held critically assess clinical, radiographic, and functional results of traditional open reduction techniques with limited internal fixation and external fixation (EF) methods following high-energy fractures of the tibial plafond. Sixty-two patients diagnosed with 63 Type 43C pilon fractures were treated surgically by a single surgeon and retrospectively reviewed between 2000 and 2006. Twenty-seven patients were treated with a hinged bridging external fixator with supplemental limited internal fixation and 35 were treated with open reduction and internal fixation (ORIF) utilizing traditional small fragment plates and screws. Forty-six of the 62 patients were available for review. Seventy-four percent of both the EF patients and ORIF patients were available for followup with an average of 18 and 22 months, respectively. No differences between the cohorts with respect to mechanism of injury, presence of an open wound, and age were observed. Functional outcomes were similar between the two groups based on the AOFAS score and the "function" index of the Short Musculoskeletal Function Assessment. General complication and union rates were similar between the two groups.

Practice Management

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Eight Nashville-area medical specialty practice groups have launched a new entity to collaborate, measure and improve quality, standardize procedures and trim costs of care. Health Innovation includes doctors in anesthesiology, general surgery, neurosurgery, obstetrics and gynecology, and orthopedics. Each doctor is contributing seed money to the effort.

Initially, the group plans to gather data from insurers or large employers on services provided and develop ways to monitor quality of entire episodes of care. Tennessee Orthopaedic Alliance, one of the participants, hopes to prove through data crunching the cost effectiveness of its procedures. Health Innovation allows its members to pool their resources, which saves money on collecting and analyzing data for improving quality. As Health Innovation evolves, the entity could participate in bundled payments, shared savings and other pay-for-quality arrangements emerging under healthcare reform.


When a medical practice partnership breaks up, there are strategies that can keep the drama to a minimum, according to experts. To make a split no more painful than necessary, the practice should complete the paperwork establishing the practice and keep it current; experts advise reviewing and possibly amending shareholder contracts and other practice documents annually at best, but at least every five years. Practice partners should attempt to address every contingency when contemplating a breakup or when agreeing to severance, and questions they should discuss include whether electronic patient records are protected; how patients should be notified of the breakup; and how physicians should divvy up equipment. American Medical Association policy mandates that doctors must give patients adequate notice of a split or closure and forward patient records, if necessary, to wherever the patient wishes to transfer; physicians also are required to maintain patient records and ensure patients have access to those records, even if the practice closes.


Doctors are generally barred from personally profiting from the Medicare business that they refer to clinical laboratories, according to an advisory opinion by federal regulators. Lewis Morris, chief counsel in the HHS inspector general's office, reports that a proposed scheme in which physicians jointly own a limited-liability corporation (LLC) that would contract with an existing clinical pathology lab to execute services for patients referred by the owners would almost certainly trigger sanctions under the Anti-Kickback Statute.

Health Policy and Reimbursement

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Medicare should pay doctors for handing telephone calls after they see a patient, educating and training patients on self-managing their health, improving management of anticoagulation drugs, and coordinating team-based care when the patient is not present because such services can help limit more expensive patient care down the line, according to the American Medical Association (AMA). In a recent letter to the Centers for Medicare & Medicaid Services, AMA said incentivizing chronic care coordination with dedicated effort would help improve quality of care, especially for patients with multiple co-morbidities. AMA says the recommendations are of "immediate urgency" because the 2012 Medicare Physician Payment Schedule will be finalized in November, setting payment policies starting Jan. 1, 2012.


Speakers at a recent American Bar Association conference addressed, among other things, the issue of how Congress would act to block a 30 percent cut in payments to doctors, set to take effect Jan. 1, under Medicare's Sustainable Growth Rate (SGR) formula. "It's too early to tell at this point," said a GOP aide. Whether or not Congress opts for a one-year doctor payment fix costing some $20 billion to $25 billion over 10 years, or a permanent overhaul of the doctor payment formula costing some $300 billion, negotiators will be moving further and further from their deficit reduction target if they include the "doc fix" in their legislative package, the aide said. "You need some sweeteners in there to attract some sort of base of support for a bill. So there's a window of opportunity for SGR to be considered."

A House Democratic aide said he expects the scheduled cuts to be blocked. "We think the SGR needs to be fixed," the aide said. "I think it will be fixed." The Democratic staff member suggested that projections of spending on the war in Afghanistan by the Congressional Budget Office could easily be lowered, more than covering the cost of a permanent overhaul of the formula. "We could easily reduce that by a trillion dollars and more than pay for SGR," he said.

Medicine, Drugs and Devices

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The medicine Colchicine, which has been used to treat gout and other inflammatory conditions for thousands of years, has recently skyrocketed in costs. URL Pharma recently decided it would test the drug as part of an FDA program to either approve some of the approximately 1,000 medications that have never been approved by the FDA. In return for performing the research necessary to clarify safety and dosing information, the FDA granted URL exclusive rights to sell the medication. Drug benefits manager Prime Therapeutics reports that the cost of an average 23-day prescription, including pharmacy charges, has jumped from under $6.72 to $185.53. Adding up the number of Colchicine prescriptions nationwide shows that the cost of URL's price hike could exceed a half-billion dollars in just one year. URL says by studying and getting FDA approval for the drug it has drastically reduced adverse reactions due to Colchicine. URL's exclusive right to Colchicine for its most common use, gout, expires next July, but there are about 1,000 other unapproved medications currently available, and because the FDA does not control drug prices such a scenario could happen again.


The Food and Drug Administration (FDA) and the Centers for Medicare & Medicaid Services (CMS) have launched a parallel review pilot program that allows medical devices to be reviewed for approval by the FDA and CMS simultaneously. The pilot is expected to run for two years, though it could be terminated early or extended. It is voluntary and does not change existing FDA or CMS review standards, and it is open only to qualifying new medical device technologies.

According to the notice in the Federal Register, appropriate candidates will be using using new technologies which have had sufficient pre-investigational device exemption (IDE) interaction with the FDA or an approved IDE application, for which an original or supplemental application for premarket approval or petition for de novo review would be required, and that are within the scope of a Part A or Part B Medicare benefit category and are not subject to a national coverage determination.


A randomized, controlled, double-blind, clinical trial was performed to assess the impact of topical phenytoin on healing in diabetic foot ulcers. Individuals 18 years or older with peripheral neuropathy, an ankle brachial pressure index greater than 0.5, and a diabetic foot ulcer of four weeks' duration or longer were independently randomized to the phenytoin group for a total of 31 participants, or the control group for a total of 34 participants. Participants with renal disease, ankle brachial pressure index of less than 0.5, necrosis, or osteomyelitis were not included. Standard wound care and dressing was applied to the subjects, while survival analysis was used to calculate primary endpoint analysis to determine whether or not the diabetic foot ulcer healed at 16 weeks. The 65 participants, 52 of whom had Type 2 diabetes, were treated for no more than 16 weeks. Healing was observed in 60 percent of ulcers (18 in the phenytoin group, 20 in the control group) with no statistically significant disparities in complete healing or in diabetic foot ulcer area over time between the two groups. At 24 weeks follow-up, recurrence of one diabetic foot ulcer was seen.