News From ACFAS

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Help shape the future of foot and ankle surgery and ACFAS by volunteering to serve on one of the 11 College committees for the 2014-2015 year. Committee volunteers bring the ACFAS strategic plan to life by taking responsibility for certain tactics outlined in the plan. If you are a leader, a thinker and a dedicated worker and would like to apply to be a volunteer, please visit acfas.org/volunteer for the ACFAS Volunteer Requirements and to complete the 2014 Volunteer Application. The deadline for applications is November 29, 2013. It’s not too late to register for the College’s newest webinar Measuring Practice Success, brought to you by the ACFAS Practice Management Committee. This webinar illustrates specific methods you can use to assess and implement measures to help improve your practice’s success and bottom line. Set for Wednesday, November 20, from 7:30-8:30pm CT, this first-of-its-kind program teaches you and your office staff how to read practice performance indicators and use this new knowledge to keep your practice or department viable for the patients you serve. Registration is $65 for ACFAS Members and their staff, and $100 for non-members and their staff. Visit acfas.org/practicemanagement to register. If you are among the many who became board-qualified by ABPS over the summer, ACFAS would like to welcome you to join the College as an Associate Member. As an Associate Member, you have the opportunity to showcase your new board status by listing the credential “AACFAS” after your name and also be eligible for the many other member benefits offered by the College, including:

• Complimentary membership for the remainder of 2013. Your dues payment will cover your membership from now until the end of 2014. This saves you a total of $187!
• a waived $95 processing fee.
• the opportunity to win an Apple iPad if you return your application by December 31.
• Unlimited access to resources found on acfas.org, such as practice marketing materials, health policy updates, and more.

Join your peers, the 7,000+ select foot and ankle surgeons, in the community of proven leaders and life-long learners making a difference. Fill out the application, and for more information, visit acfas.org/join. If you have questions about membership or the application process, please contact the Membership Department at membership@acafs.org.

Foot and Ankle Surgery

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A recent study by researchers in Italy has found that the long-term presence of conditions such as chondral lesions and previous trauma can affect the long-term results of arthroscopic treatment in patients with anterior ankle bony impingements. The 80 patients who took part in the study had an average age of 37.3 and underwent follow-up after an average of 104.6 months following the arthroscopic treatment. Researchers found that the average American Orthopaedic Foot and Ankle Society (AOFAS) score for these patients increased from 50.9 before the surgery to 70.7 at follow-up. The study also found that the different grades of the van Dijk scale, which was used to document ankle osteoarthritis in patients before they underwent surgery, significantly affected the result. The grade of chondral lesions also significantly affected the outcome. Age, cavus foot morphology, and history of previous ankle fracture had a negative impact on the outcome, while tibial localized spurs had a positive impact. Researchers used these results to create a new classification system for bony impingement syndrome.


A recent study has found that early tensional loading can help improve the mechanical properties of an Achilles tendon as it heals from a rupture. The 35 Achilles tendon rupture patients who were recruited for the study underwent surgery with one suture and received metal markers in the distal and proximal parts of the tendon. Participants were then randomized to one of two groups: one which underwent cast immobilization for seven weeks; and another that underwent tensional loading and wore casts for two weeks followed by removable foam walker boots for five weeks. Patients in the tensional loading group were told to remove the boot twice each day and push a training pedal in order to apply a predetermined, gradually increasing tensional load on the healing tendon. After evaluating both groups of patients at seven, 19 and 52 weeks after the operation, researchers determined that the elastic modulus of the tendon callus was higher in the tensional loading group, just as they theorized it would be. No significant difference was observed in the Achilles tendon Total Rupture Score (ATRS) or the heel-raise index at 52 weeks. However, a significant correlation was seen between the modulus at seven weeks and the heel-raise index at 52 weeks.

Practice Management

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Physicians' practices and other healthcare providers have a number of concerns associated with the growing desire among patients to be able to communicate with their doctors via e-mail, according to a study released by the C.S. Mott Children's Hospital National Poll on Children's Health. The study found that 77 percent of parents want to be able to get advice from their doctors through e-mail, though only 6 percent said that they were actually able to do so. The study noted that doctors have a number of concerns about providing e-mail consultation services, including concerns about the variable nature of reimbursements for such services. Matthew M. Davis, MD, MAPP, one of the study's authors, said that some physicians' practices have successfully addressed such concerns by charging patients who want e-mail consultation services a flat fee that allows them to send as many e-mails as they want whenever they need to. Matt Handley, MD, the associate medical director of quality and informatics at the Seattle-based healthcare system Group Health Cooperative (GHC), says that the use of such a payment structure allows his non-profit organization to remain financially viable while still providing patients with an e-mail consultation service. Some concierge medical practices, meanwhile, are opting to include an e-mail consultation fee in the retainer fees that patients pay when they sign up.


A paper that was recently published in the American Journal of Managed Care found that 31 percent of doctors were exchanging patient clinical summaries with other providers in 2011, though this percentage was higher among physicians who were using an electronic health record (EHR) system. Among doctors with an EHR, 49 percent said they had exchanged patient clinical summaries with another provider, while an additional 61 percent said they had the capability to do so. Many doctors with EHRs also had other types of exchange capabilities, the study found. For example, 78 percent of doctors with EHRs had electronic prescription capabilities, while 87 percent had the ability to view electronic lab results. Conversely, few doctors who lacked an EHR had exchange capabilities such as the ability to exchange clinical summaries with patients or other providers or send lab orders electronically, said lead study author Vaishali Patel. According to Patel, these and other findings are important because they serve as a baseline for showing readiness for Meaningful Use stage 2 and for ensuring that doctors have the capability to exchange data.

Health Policy and Reimbursement

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Sen. Charles E. Grassley (R-Iowa) on Nov. 6 raised concerns about the potential for "serious consequences" arising from a decision by the Department of Health and Human Services (HHS) to define Affordable Care Act (ACA) programs as non-federal health programs. According to HHS Secretary Kathleen Sebelius, who was asked about the issue by Grassley during a Senate Finance Committee hearing, ACA programs--including the health plans that are sold in the online health insurance exchanges--are not considered federal health programs because premiums for these plans are paid to private companies, not the federal government. Sebelius noted that the decision means insurance companies offering plans outside the exchanges will be treated the same as companies that offer plans on the exchanges. But Grassley said the decision raises doubts about whether HHS will have access to enforcement and oversight tools that ban rebates, kickbacks and bribes in order to combat fraud. He added that the decision gives insurers operating on the exchanges a "blanket exemption" from anti-kickback laws and regulations, the Stark law, and other civil and criminal statutes and regulations. Sebelius disputed those claims, saying that HHS can decertify plans from being offered on the exchanges and work with the attorney general to combat fraud.


Health and Human Services Secretary Kathleen Sebelius rejected the growing demands from lawmakers to delay the implementation of some parts of the Affordable Care Act (ACA) during an appearance before the Senate Finance Committee on Nov. 6. The problems with the federal health insurance exchange Healthcare.gov have prompted some lawmakers to propose extending the open enrollment period or delaying the financial penalties associated with the ACA's individual mandate. Sebelius responded by saying that a delay in the implementation of ACA would hurt people who need insurance so they can be treated for diseases or receive routine medical care. Sebelius also addressed the problems with Healthcare.gov, saying there are several hundred fixes that need to be made to the site to ensure it is running smoothly for most users by the end of this month as the administration has promised. Sebelius noted that the work to correct the problems will need to be done on an "aggressive schedule" to ensure all the issues are addressed by Nov. 30. According to Sebelius, most of the work to correct the problems will be done overnight while the site is scheduled to be down for repairs. Sebelius rejected calls from Sen. Max Baucus (D-Mont.) to shut down Healthcare.gov so the problems can be fixed all at once.


Centers for Medicare and Medicaid Services Administrator Marilyn Tavenner testified before a Senate panel on Nov. 5 to provide lawmakers with an update on efforts to correct the problems with Healthcare.gov. Tavenner noted that the round-the-clock repair effort has been successful at correcting a number of issues with the site, including the difficulties that some users have experienced in enrolling for coverage. Users are now able to create an account on Healthcare.gov and can complete the entire application and enrollment process, Tavenner said, adding that CMS can now process almost 17,000 registrants per hour with virtually no errors. Tavenner said that the administration expects there to be a total of 800,000 enrollments in health insurance offered through Healthcare.gov by the end of this month, though she would not tell lawmakers how many enrollments have taken place so far. That information is expected to be made available by the middle of the month, Tavenner said. Tavenner also sought to reassure lawmakers who expressed concern about the security of Healthcare.gov. In one incident, the personal information of a Healthcare.gov user in South Carolina was accidentally given to another man in North Carolina.


The young, healthy individuals that the Obama administration and the health insurance industry had hoped would sign up for health insurance coverage on the nation's online marketplaces do not seem to be doing so at large rates so far, prompting concerns that insurance companies will have to increase their rates. Several insurance companies offering plans through the federal- or state-run exchanges have said that the average age of the individuals who have signed up for coverage so far is older than they had expected. Observers say that this is due in part to the problems with Healthcare.gov, since sicker consumers are more motivated than people who feel that they do not need insurance to try to deal with Web site's flaws and sign up for coverage. Industry experts have said that it remains unclear whether the risk pool will ultimately be made up primarily of older, sicker individuals or if there will be an acceptable balance between such individuals and their healthier, younger counterparts. The Obama administration, meanwhile, has said that it expects most younger individuals to sign up for coverage at the last minute. Some in the insurance industry say that if current trends continue, the health insurance risk pool will consist of an older, sicker group of consumers, which could result in increased prices for everyone.


Sen. Jay Rockefeller (D-W.Va.) says that a bill he introduced in April will help pay for the repeal of the Medicare sustainable growth rate (SGR) formula, though the proposal faces opposition from some in the pharmaceutical industry who claim that it will result in the loss of jobs and other consequences. Under Rockefeller's Medicare Drug Savings Act, on which the Senate has not taken action since it was referred to the Senate Finance Committee last spring, individuals who are eligible for both Medicare and Medicaid will once again be provided with rebate pricing on drugs. The legislation would undo the 2003 move of low-income Medicare patients from the Medicaid drug benefit, which has rebate pricing, to Medicare's drug benefit, which does not. Rockefeller said such a move would generate $141.2 billion over 10 years, which is more than enough to offset the projected 10-year cost of repealing SGR. But Pharmaceutical Research and Manufacturers of America (PhRMA) Senior Vice President Matt Bennett said that Rockefeller's legislation would hurt the biopharmaceutical research sector and could result in job losses. He noted that analysts have predicted that the rebates could hurt new drug research and result in higher premiums and restricted access to medicines for consumers enrolled in Medicare Part D. Rockefeller's proposal is being revisited as Congress is considering bipartisan legislation that would repeal SGR.


The Centers for Medicare and Medicaid Services (CMS) has announced that the annual release of the Medicare physician fee schedule, which typically takes place around Nov. 1, could be delayed until Nov. 27 due to last month's federal government shutdown. CMS also said that there will be a delay in the release of Medicare's End-Stage Renal Disease Prospective Payment System, which includes information on quality incentives, durable equipment, prosthetics and supplies. Two other rules, including the changes to the Hospital Outpatient Prospective and Ambulatory Surgical Center payment systems and the Home Health Prospective Payment System final rule for next year, will be delayed as well. Some in the healthcare industry say that the delayed release of the Medicare physician fee schedule and the three other payment rules could hurt their ability to plan and budget effectively, particularly since it remains unclear whether Congress will pass a fix for the Sustainable Growth Rate (SGR) formula as it has in years past. Such a fix would supersede the payment rates in the Medicare physician fee schedule. Others have said that the delay of the Medicare physician fee schedule will hurt the ability of doctors' practices to plan effectively, since they will be unable to review the policy proposals included in the fee schedule, such as a proposal to pay doctors for non-face-to-face patient care-management activities beginning in 2015.

Medicine, Drugs and Devices

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A new study has found that there are benefits to using cross-sectional imaging to classify Triplane ankle fractures in children. During the study, the radiographic images of epiphyseal fractures in 27 children were blindly evaluated by surgeons who specialized in trauma care as well as younger non-specialized fellows. The images that were evaluated by the observers included X-rays and additional cross-sectional imaging. These observers were then asked to answer questions about the type of fractures as well as their recommendations for treatment. The study found that the use of cross-sectional imaging allowed both the specialized and non-specialized observers to classify fractures more accurately. Specialists were able to correctly classify 48.1 percent of fractures using conventional X-rays and 75.6 percent of fractures using cross-sectional imaging. Non-specialists were able to correctly classify 31.5 percent of fractures using X-rays and 47.3 percent using cross-sectional imaging. The study also found that the use of cross-sectional imaging improved treatment recommendation in specialized surgeons. No such improvement was seen among their non-specialized counterparts.


Researchers have found that there are benefits to using a 3D dynamic foot scanner (DFS) to analyze foot roll over. The study involved ten healthy individuals whose right feet were assessed during gait trials with a DFS system that had been integrated into a walkway. The system created a foot sole picture by vertically projecting points lower than 15 mm from the 3D foot shape. A height value corresponding to the initial vertical coordinates before projection was then determined. Finally, the foot sole picture was divided into anatomical regions of interest (ROIs) to process mean height (average of height data by ROI) and projected surface (area of the projected foot sole by ROI). Researchers found that the use of this method took into account the whole plantar aspect of the foot, unlike plantar pressure data arising from surface contact by the foot. Researchers also said that the use of height data could contribute to a better understanding of plantar arch height and other aspects of foot motion during walking. The study concluded that while DFS is a reliable method for analyzing foot roll over, the DFS measurements need to be validated in a clinical context before the device is used in clinical practice.