News From ACFAS

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At its November meeting, the Board of Directors reviewed and approved two updated position statements revised by the Practice Management Committee and the Professional Relations Committee, respectively. The ACFAS Position Statements on Practice Management Core Competencies and The Education, Training and Certification of ACFAS Podiatric Foot and Ankle Surgeons can be found in the Physician section of the website under the Health Policy and Advocacy tab. You can help shape the advancement of the profession, the future of the College and, ultimately, the care of patients by volunteering for 2012–13 ACFAS committees. For information on becoming a committee volunteer, please visit acfas.org/volunteer. The deadline for applications is Dec. 23, 2011. The ACFAS Board of Directors has approved a donation to the California Podiatric Medical Association’s P&S Fund to help their work with that state’s medical and orthopaedic associations in working toward a common state physician and surgeon certificate for DPMs, MDs, and DOs.

“While we will continue to assist our members in any state scope debate, the California initiative is a unique and historic opportunity,” said ACFAS President-Elect Michelle Butterworth, DPM. “This is a licensure initiative, not a scope issue; and, if successful, could ‘trump’ scope issues since a common physician and surgeon certificate would be issued. This is the first time all three organizations have mutually agreed to work toward an agreement with no legislation or court suit pending. Also, CPMA and the California Medical Association have enjoyed a unique and mutually beneficial relationship in the past. If this is successful, the ‘California model’ could spread and solve scope battles from coast to coast, forever. For these reasons, ACFAS wants to support this initiative.”

Note: ACFAS President Glenn Weinraub, DPM, recused himself from discussing and voting on this matter due to his conflict of interest as a California practitioner.
It's not too late, there's still time to help contribute to the research at ACFAS through its new multicenter study. While, two sites have joined the study, the College is still recruiting additional investigative sites for the retrospective study on predictive variables associated with successful and unsuccessful outcomes when performing subtalar joint arthroereisis in adults and children. Subjects and sites will be compensated for their time. If you’d like to participate, please complete and return the application on the ACFAS website.

Criteria for site selection include:

• Required one-year contractual commitment by the investigative site.
  
• Primary investigator at each site in good standing with ACFAS.
  
• Volume and variety of patients treated for symptomatic non-neuromuscular flatfoot with subtalar arthroereisis during the past 10 years.
  
• Past participation in multi-center studies.
  
• Professional reputation for scholarly activity.
  

Foot and Ankle Surgery

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Researchers assessed the excision of an avulsed bone fragment of the proximal fifth metatarsal in symptomatic nonunion management, observing the operation in six male high-performance athletes, while the remaining bone edge was contoured and smoothed. None of the patients had an eventful operation or recovery, and they returned to competitive play at an average of 11.7 weeks. Activity-related pain and discomfort abated following excision and rehabilitation, and there were no surgical complications observed.


Researchers determined the overall risk of deep vein thrombosis (DVT) and pulmonary embolism (PE) after an Achilles tendon rupture and identified potential risk factors including surgery through the review of 1,172 patients with ruptures, none of whom received anticoagulation. The patients were separated into surgical versus nonsurgical group, age older than 40 years, history of congestive heart failure, previous history of DVT or PE, and a body-mass index higher than 30. A patient was deemed to have symptomatic DVT or PE related to the Achilles tendon rupture if diagnosed within three months from the injury or surgery. The general rates for DVT and PE following Achilles tendon ruptures were 0.43 percent and 0.34 percent, respectively. The incidence of DVT or PE was not predicted by age older than 40 years, congestive heart failure, history of DVT or PE, obesity, and whether a patient had surgery.


A study was held to assess the bone rotation of each joint in the hindfoot and compare the load response in healthy feet with that in flatfeet by analyzing the reconstructive three-dimensional (3D) computed tomographic (CT) image data during weightbearing. The study involved the administration of CT scans to 21 healthy feet and 21 flatfeet, in non-load condition followed by full-body weightbearing load condition. The hindfoot bone images were reconstructed into 3D models, and the volume merge technique in three planes was used to calculate the position of the talus relative to the tibia in the tibiotalar joint, the navicular relative to the talus in talonavicular joint, and the calcaneus relative to the talus in the talocalcaneal joint. The talar position difference to the load response relative to the tibia in the tibiotalar joint in a flatfoot was 1.7 degrees more plantarflexed compared to that in a healthy foot, while the navicular position difference to the load response relative to the talus in the talonavicular joint was 2.3 degrees more everted. The calcaneal position difference to the load response relative to the talus in the talocalcaneal joint was 1.1 degrees more dorsiflexed and 1.7 degrees more everted.

Practice Management

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Two separate but related announcements—that the American Medical Association would oppose ICD-10 deployment and that the Centers for Medicare and Medicaid Services would postpone enforcement of its rule requiring use of the Version 5010 data standards—has shaken the healthcare industry overall and its information technology sector specifically. American Hospital Association vice president of policy Don May reports that while 5010 increases the efficiency of the billing process, "we're concerned about how this delay of enforcement might work." May also says ICD-9 is outdated and the transition to a new system is necessary, but he concedes that "hospitals are dealing with ICD-10, meaningful use, accounting for disclosures, bundled payments for accountable care organizations—there are a lot of overlapping burdens put on that same IT department."


Independent physician practices are slowly fading away, as doctors are being pushed to employment in hospitals or by hospitals. While some may like the safety, the regular hours, and the freedom to practice medicine rather than worrying about small business concerns that an employment contract offers, others are expressing dissatisfaction with the trend. According to the physician component of the 2011 HealthLeaders Media Industry Survey, 58 percent of doctors say that healthcare reform has weakened their organization's financial position, and 60 percent say healthcare reform has weakened morale, while only 67 percent would encourage their child to enter healthcare.


Doctors might not be aware that they risk legal action against a practice if they fail to address complaints about patients who harass staffers, and the legal system could designate a chronic, unresolved problem of this type as a hostile work environment. Experts advise practices to draft written policies and provide employee training; policies should include how to mitigate or defuse potentially uncomfortable situations. The policy can be similar to addressing harassment among personnel, and it should have means for reporting problems with anyone who does not work at the practice, including patients and outside vendors; the policy also should indicate that staff will not be subject to retaliation for reporting, and any report should be investigated, with information collected from all witnesses. The policy also may be articulated to patients and others who come into the practice, while practices need to devise response strategies in the event a complaint has been filed and harassment has been established.

Health Policy and Reimbursement

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For the healthcare industry, the collapse of the deficit-cutting supercommittee marks the beginning, not the end, of efforts to defend its interests in the federal Medicare and Medicaid programs. Under the negotiations that created the supercommittee, its failure to reach an agreement means automatic budget cuts worth $1.2 trillion, including a 2 percent reduction every year from 2013 to 2021 in the payments received by healthcare providers for treating Medicare beneficiaries. If this happened, Medicare beneficiaries would not see their premiums or co-pays go up, as they might have under some deficit-reduction proposals. But the reduction in payments to healthcare providers could mean that Medicare beneficiaries find it more difficult to find providers willing to accept them as patients.


The Centers for Medicare and Medicaid Services has announced that it will roll out a number of demonstration programs starting next January to target some of the most common factors that result in improper payments, and the issues that have the most dramatic effect on providers are the launch of a recovery audit prepayment review program and a Part B rebilling effort. In the first program, recovery auditors in 11 states will be permitted to review claims prior to payment to make sure that the provider adhered to all Medicare payment rules, with a particular focus on certain types of claims that historically lead to high rates of erroneous payments.


The National Committee for Quality Assurance has announced a three-tiered accreditation program for healthcare providers to confirm and score their claims that they are accountable care organizations (ACOs). The committee is introducing seven criteria that ACOs will be expected to master, and they will verify their ability to supply that quality of care on onsite polls beginning in March. The criteria include having infrastructure to coordinate providers and collaborating with stakeholders to improve quality of care, patient experience, and manage financial resources; possessing sufficient numbers and types of practitioners to provide timely access and monitoring its effectiveness in meeting patient needs and preferences; supplying patients access to patient-centered medical homes and assessing the ability of primary care practices to deliver that care; respecting patients' rights and privacy, limiting data access, and having a method for patients to submit complaints; and collecting, integrating, and using data for care management and performance disclosure, focusing on the capture of information in electronic systems and making sure that practitioners can access it.

Medicine, Drugs and Devices

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The use of computerized medical-information tools in hospitals to help doctors make decisions at the point of care results in better patient outcomes, according to the results of a study from researchers at Harvard University. The study, published in the Journal of Hospital Medicine, examined data for Medicare beneficiaries at 1,017 hospitals using a clinical-information system called UpToDate between 2004 and 2006. The researchers compared that data to data from 2,305 hospitals that did not use such a system, and found that the use of the systems was an independent predictor of reduced mortality, shorter hospital length of stay, and better performance on widely used hospital quality metrics.


The American Board of Medical Specialties (ABMS) intends to make information about whether individual physicians are meeting maintenance-of-certification (MOC) requirements publicly available, which coincides with initiatives to make healthcare more transparent. Beginning in 2012, patients, insurers, credentialing organizations, and others will be able to access a doctor's MOC status on an ABMS website, with ABMS CEO Kevin B. Weiss, MD, noting that "now that physicians are engaged in maintenance of certification, it is a very natural next step for that information to be made available to the public." Seven member boards, including the American Board of Surgery, are expected to make the MOC information publicly accessible by next August. Weiss says the ABMS site will supply explanations for those doctors whose boards do not mandate that they participate in MOC.


Orthopedic surgeons often use models of a patient's bones to prepare for surgery to ensure the operation is properly planned. These models are regularly used to practice the surgery, but making the models is expensive, with individual bone models costing thousands of dollars and significant time to make. To reduce costs and enable shorter wait times for surgery, RSHC Glasgow (Scotland) orthopedic surgeon Mark Frame used 3D printing to create bone models. Using open source software and the 3D printing company Shapeways, Frame was able to convert CT scans into images and upload the files onto Shapeways account. The bone models were ready in a week, and matched the CT scans. Frame reported that the models were made of "a great material to machine and use our normal orthopaedic drills and saws and screws on to practice the operation." The cost of the 3D printed models was only about $120, which is just 10 percent of the cost his team spent on another model that was both truncated and unusable for planning surgery.