News From ACFAS

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After careful review of applicants to serve on the ACFAS Board of Directors, the Nominating Committee recommends these five Fellows for three positions in the upcoming electronic election:

• Randal L. Wraalstad, DPM, FACFAS (Incumbent)
• Gregory D. Catalano, DPM, FACFAS
• Michael J. Cornelison, DPM, FACFAS
• Katherine Dux, DPM, FACFAS
• Meagan M. Jennings, DPM, FACFAS

Two three-year terms and one two-year term will be filled by election. Candidate profiles and position statements will be posted at acfas.org/nominations on December 1. The ballot order and appearance are prescribed in the bylaws. Eligible voters may cast one, two or three votes on their ballot. Regular member classes eligible to vote are Fellows, Associates, Emeritus and Life Members. Individuals who intend to nominate by petition must notify ACFAS by November 7, and petitions are due no later than November 30.

Online voting will be conducted December 15–30. All eligible voters will receive an email with special ID information and a link to the election website in advance. After logging in, members will first see the candidate biographies and position statements, followed by the actual ballot. Eligible voters without an email address will receive paper instructions on how to log in to the election website and vote. There will be no paper ballots.

The 2016 Nominating Committee included Richard Derner, DPM, FACFAS, Chair; Sean T. Grambart, DPM, FACFAS; Tony D.H. Kim, DPM, FACFAS; Javier La Fontaine, DPM, FACFAS; John T. Marcoux, DPM, FACFAS; Harry P. Schneider, DPM, FACFAS; and Monica H. Schweinberger, DPM, FACFAS. If you're a residency director who plans to attend the 75^th Anniversary Scientific Conference set for February 27–March 2 in Las Vegas, come a day early for the third annual Residency Directors Forum, February 26 from 1:30–5:30pm at The Mirage Hotel.

For the first time, residency program codirectors, faculty and administrators are also invited to attend, with up to two attendees per program.

This invitation-only event, cohosted by ACFAS and COTH, will include:

• updates from COTH, AACPM and CPME as well as the Boards (ABFAS and ABPM)
• a presentation by PRR on the new 2.0 version of its database
• discussion on the dos and don’ts of social media for residents
• a session on program assessment tools and improvements to be made
• changes that may be in store for residency programs in the future

Stay tuned for more details on sessions and how to register! Results of the latest poll in This Week @ ACFAS show that surgical coding remains a need-to-know-more topic for readers. A whopping 64 percent of respondents said they would most want to attend an ACFAS practice management seminar on surgical coding.

Rounding out the top three preferred seminar topics were ancillary services (14 percent) and office administration (nine percent). It was a three-way tie for contract review and negotiation, marketing outreach and transitioning to a different practice setting, with each coming in at five percent.

ACFAS will hold a preconference workshop on coding on February 26 (7:30am–5:30pm) at The Mirage in Las Vegas the day before the 75^th Anniversary Scientific Conference officially begins. This is a perfect opportunity to get a feel for ACFAS' coding seminars before we release our 2017 practice management course schedule.

Watch next week's issue of This Week @ ACFAS for our new monthly poll and keep checking acfas.org/vegas for details on how to register for our preconference workshops.

Foot and Ankle Surgery

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A recent study aimed to determine whether initial ankle fracture treatment with close contact casting provides outcomes equivalent to immediate surgery. Participants were 620 adults older than 60 years with acute, overtly unstable ankle fracture. Researchers randomly assigned participants to surgery or casting. At six months, casting resulted in ankle function equivalent to that with surgery. The Olerud-Molander Ankle Score for surgery was 66, compared with 64.5 for casting. Infection and wound breakdown was present in 10 percent of participants who underwent surgery, compared with 1 percent with casts. Radiologic malunion was more common in the casting group (15 percent) compared with the surgery group (three percent). Casting also required a mean of 54 fewer minutes in the operating room than surgery. There were no significant differences in quality of life, pain, ankle motion, mobility and patient satisfaction.


A recent study investigated the prevalence of subclinical ankle involvement in patients with rheumatoid arthritis (RA). Researchers examined 216 patients with RA and 200 healthy controls by ultrasound. For each ankle, researchers assessed the tibio-talar (TT) joint, tibialis anterior (TA) tendon, extensor halux (EH) and extensor common (EC) tendons, tibialis posterior (TP) tendon, flexor common (FC) tendon and flexor hallux (FH) tendon, peroneous brevis (PB) and longus (PL) tendons, Achilles tendon (AT) and plantar fascia (PF). Eighty-seven percent of patients with RA presented ankle abnormalities, compared with 28.5 percent of subjects in the control group. The abnormalities observed in RA patients included TP tenosynovitis (31.9 percent), PL tenosynovitis (26.9 percent), TT synovitis (25 percent), PB tenosynovitis (23.6 percent), AT enthesopathy (19 percent) and AT bursitis (10.2 percent). No significant correlations were found between the ultrasound findings and age, disease duration, body mass index, DAS28, rheumatoid factor, erythrocyte sedimentation rate and C-reactive protein.


Therapy for diabetic claudicants includes supervised exercise programs to improve walking distance. The aim of a recent study was to evaluate whether calf-muscle electrostimulation improves claudication distance. Researchers conducted electrostimulation on 40 participants living with type 2 diabetes mellitus, peripheral artery disease and calf-muscle claudication. Electrostimulation of varying frequencies was applied on both ischaemic limbs for one hour every day for 12 weeks. The group registered a mean baseline absolute claudication distance of 33.71 meters. After an average of 91.68 days of electrostimulation, there was a significant mean increase of 137 meters in the absolute claudication distance.

Practice Management

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One of the most difficult challenges facing medical practices today is protecting the security of patient data and complying with industry regulations. Security risk assessments are required by the Health Insurance Portability and Accountability Act (HIPAA) and federal electronic health records (EHR) incentive programs, but many practices are unable to conduct adequate security assessments on their own. Online risk assessment tools from the Office of the National Coordinator for Health Information Technology (HIMSS) and the Office of the National Coordinator for Health IT (ONC) allow practices to evaluate their existing safeguards and create their own security plan. Practices should also do technical vulnerability assessments to determine the effectiveness of security controls, such as firewalls and antivirus software. All patient data on workstation computers and backup tapes should be encrypted. Assessments should also cover data governance and access; role-based access can be used to limit the access of individuals to the system. Remote access and the use of mobile devices should also be included in a risk assessment. Experts recommend placing mobile device management software on all devices so that data can be wiped remotely if a device is lost or stolen. HIPAA requires practices to sign business associate agreements with any outside parties with which they share protected health information, and it is recommended that practices also assess the security of their business associates. Finally, practices must create an incident response protocol to enable information technology managers to analyze an incident and estimate the potential impact.


The purpose of a practice manager evaluation is to note the areas where performance goals are being met and exceeded and to address performance issues. Managers should be evaluated across the spectrum of their responsibilities, including financial management, personnel management, marketing and practice promotion, self-development and leadership skills. In regards to billing and collections, practices should strive to achieve a net collection of 95 percent and an Accounts Receivable Ratio of 1.5 months based on quarterly or annualized data. Managers should be up-to-date on coding changes and address denials within three days. The practice manager should also recruit and maintain an effective and productive staff while controlling personnel and overtime costs. Marketing and practice promotion duties include developing practice marketing materials and promoting the practice with referring offices and local employers. As a leader, the practice manager must communicate well with physicians and set a positive example for all team members. Self-development of the practice manager is also important; enrolling in management training programs and networking with other practices will enrich the manager as well as the practice.


The successful deployment of a new electronic health record (EHR) system depends on the thoughtful training and guiding of a practice’s physicians. Apart from the initial training received when they are introduced to the new system, physicians should have access to an in-house trainer. This trainer can be a staff member who has either technical experience or the determination to learn new technology. "You're looking for someone who is patient,” says Dan O’Connor, vice president of client relations at Stoltenberg Consulting. “This is a person at your practice who's energetic; many are on the younger side, though we do see some [trainers] who are very seasoned as well.” In addition to being skilled with the new EHR, the trainer should be able to individualize the training physicians receive, as each physician will learn how to use the product in their own way. O'Connor also recommends leveraging physicians who have experience using other EHRs and are able to help train their colleagues.

Health Policy and Reimbursement

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About nine percent more people than last year will sign up for coverage on the Affordable Care Act exchanges during the final open enrollment period of President Barack Obama’s administration. According to the U.S. Department of Health and Human Services, 13.8 million people will have enrolled for coverage for 2017, falling short of the 15 million projected by the Congressional Budget Office. The discrepancy may be the result of fewer people than expected switching from their employers’ plans. In addition, three major insurers have scaled back their participation this year, leaving four states with only one insurer offering plans in their exchange. Premiums are likely to increase this year as insurers adjust to the market. Experts say taxes and other policies could be revised to encourage more people in employer-based plans to shift to the exchange market. There has also been industry support for allowing insurers to charge higher premiums for older enrollees, reducing rates for younger people and persuading more of them to enroll.


State insurance regulators in eight states have approved healthcare premiums that are at least one percentage point higher than requested by insurers. Insurer withdrawals from some markets and rate hikes of more than 50 percent in some areas have prompted concerns of collapsing marketplaces. Carriers that have raised premiums significantly include Blue Cross Blue Shield in New Mexico, which raised premiums by 83 percent, and Crystal Run Health Insurance in New York, which raised premiums by about 80 percent. Pennsylvania, where regulators approved individual plan rate increases eight points higher than requested, has seen two insurers drop out of the Affordable Care Act exchange. Conversely, regulators have signed off on rates that were lower than requested in 12 of the 40 states that have already approved rates. “The business was underpriced in many markets in the first couple years,” says Andy Slavitt, acting administrator for the U.S. Centers for Medicare and Medicaid Services. “In retrospect, life would have been a lot better and easier if things had started 10 percent higher, the rate increases had been higher and it had been just a smooth steady climb.”


A new survey from the Kaiser Family Foundation found most U.S. states in 2017 will tighten controls on spending to combat increasing budgets in the public health insurance program for low-income and disabled Americans. The top cost containment strategies include hiring private managed care companies to deliver services to enrollees, moving more long-term care services from nursing homes to community settings and limiting the use of costly prescription drugs. The campaign to stretch dollars further is a response to next year's reduction in federal aid for states that expanded Medicaid under the Affordable Care Act. Thirty-one states and the District of Columbia have done so and beginning next year they will start paying 5 percent of their expansion costs. State Medicaid spending is expected to climb to 4.4 percent in 2017 versus 2.9 percent in 2016, while total Medicaid spending will grow 4.5 percent in 2017, compared to 5.9 percent last year. Total Medicaid spending was $509 billion in the fiscal year that ended September 30, 2015. The federal portion was 62 percent, and states paid 38 percent. Kaiser determined 39 states use private plans to manage care for Medicaid enrollees, and 28 of them disclosed that at least 75 percent of all enrollees were in a managed care plan, up from 21 states a year ago. Almost all states reported actions to boost the use of home or community-based settings for people requiring long-term care. Meanwhile, 23 states said they have taken or plan actions to contain pharmacy costs in 2017, down from 31 last year.

Medicine, Drugs and Devices

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Some medical devices, such as insulin pumps and pacemakers, may have vulnerabilities that could be exploited by hackers. Earlier this month, Johnson & Johnson alerted 114,000 diabetic patients that hackers could exploit the Animas OneTouch Ping insulin pump, disabling the device or altering the dosage. The OneTouch Ping is eight years old, and the company says newer models with encryption technology are more difficult to hack. Kevin Fu of the University of Michigan’s Archimedes Center for Medical Device Security warns that virtually any electronic device can be breached. "The dirty little secret is that most manufacturers did not anticipate the cybersecurity risks when they were designing them a decade ago, so this is just scratching the surface really,” says Fu. Malware delivered by a USB drive or through a network connection can also cause havoc in hospitals and their connected devices; bedside infusion pumps, defibrillators, patient monitors and radiation therapy machines all could be taken down if a hospital's network is infected. According to security firm Symantec, healthcare providers spend less than six percent of their information technology budget on security. The U.S. Food and Drug Administration this year issued guidance to medical device manufacturers on how to secure their products.


Medical professionals are finding that they are unable to determine who needs nutrients like calcium and vitamin D the most. Currently, it is recommended that doctors follow recommendations established by the Institute of Medicine (IOM) in 2010. However, recent research indicates a lack of evidence for those recommendations. The amount of calcium or vitamin D needed also depends on age, sex, diet and other factors. For its part, IOM does not plan to revise its recommendations based on new data. A. Catharine Ross, PhD, believes those recommendations still help people maintain a healthy level of nutrients in their bodies. However, several pending studies are exploring this matter.


Exoskeletons can be used to ease the movement of people with musculoskeletal disorders, but their design is typically based on data obtained from healthy adults, making the components inadequate for some users, such as children with cerebral palsy (CP). The study aims to custom-size the lower limb exoskeleton actuators based on dynamic modeling for children with CP on the basis of hip, knee and ankle joint kinematics and dynamics of the body during gait. Modeling of the human body of three typically developed children and three children with CP was used. There were significant differences in gait patterns, particularly within the knee and ankle with 0.39 and -0.33 (Nm/kg) maximum torque in typically developed children and children with CP, respectively.