News From ACFAS

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Thursday, December 13, all voting members who haven’t yet voted in the 2012 Board Elections will receive an email with a unique link to the election website. The email will come from acfas.ballot@intelliscaninc.net with the subject line: Vote Now! ACFAS Board of Directors Election.

Please take a few minutes to select members of your Board of Directors who will help lead the College over the next three years. If you have questions accessing the ballot site, please contact our independent election firm at johnarbitell@intelliscaninc.com. Voting ends December 29. Check out our recently lowered hotel rates at Mandalay Bay – only $95 per night; and THE Hotel at Mandalay Bay – $125 per night! If you’ve already booked your hotel room, don’t worry, this new rate will be honored for those attendees who have confirmed reservations. We are in the process of updating the website but onPeak will be sure you receive the lowered rates.

If you haven’t yet done so, register now for the Annual Scientific Conference February 11-14, 2013 in Las Vegas! Visit acfas.org/vegas to view sessions and speakers. Make the best of your time in Vegas and attend one of the pre-conference workshops on February 10.

Visit acfas.org/vegas at any time to register or to find more information. You don’t want to miss these great rates and all ACFAS 2013 has to offer. Have you ever wondered why so many of your medical colleagues in other specialties are becoming employed by health systems? Are you concerned about the future of private practice viability? Do you still buy into the philosophy of volume for revenue generation? If so, you could be missing the trend of physician/health system alignment with physicians that is occurring across the country.

Don’t miss the opportunity to learn more on how to prepare yourself and your practice to capitalize on this emerging trend at the "Perfecting Your Practice" pre-conference seminar during ACFAS 2013 in Las Vegas. During the program, Kevin Lutz, DPM, FACFAS, a senior executive for a Fortune 100 healthcare system, will share his insights on how major health systems are planning to shift from volume to value by partnering with their physicians through employment or other models of alignment.

Register by visiting acfas.org/vegas and clicking "register now." Is your practice looking for a new employee to start the New Year? Recruit the very best candidates with PodiatryCareers.org, the official online job center of ACFAS. PodiatryCareers.org provides direct, targeted access to the 6,800-plus members of ACFAS: the most highly qualified and credentialed foot and ankle surgeon candidates. ACFAS members posting positions receive special pricing starting as low $195 per month plus volume discounts on bulk purchases. Post your jobs today! Call (888) 884-8242 or visit acfas.org for more information and member pricing for job posting.

Foot and Ankle Surgery

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A study was held to determine the effectiveness of microtenotomy coblation using a radiofrequency probe for treating plantar fasciitis, through execution of a prospective non-randomized trial on 48 patients who had failed conservative treatment for plantar fasciitis between 2007 and 2009. The TOPAZ microdebrider device was used to carry out the operation either through an open or a percutaneous technique. Fifty-nine feet were operated on and followed-up for up to 12 months thereafter. Analysis of preoperative, three, six and 12 months postoperative VAS pain, AOFAS hindfoot and SF-36 scores, patient expectation and satisfaction scores was performed. Both groups displayed significant VAS score improvement at one-year follow-up, with the open group having more significant improvement. Although AOFAS hindfoot scores improved substantially for both groups prior to and following the procedure, no significant difference between both groups was observed at the 12-months mark. SF-36 scores exhibited equally significant improvement in both groups one year postoperatively, while expectation and satisfaction scores were equally high in both arms.


A comparison study of 109 subjects with an ankle fracture who underwent surgery with metallic or biodegradable implants was held, with radiographic outcomes evaluated by the criteria of the Klossner classification system and time to bone union. Assessment of clinical results was carried out using the AOFAS ankle-hindfoot scale, Short Musculoskeletal Function Assessment (SMFA) dysfunction index and the SMFA bother index at three, six and 12 months post-surgery. The study was completed by 102 subjects, and there were no differences in reduction quality between the groups at a mean of 19.7 months. The average operative time was 30.2 minutes in the metallic implant group (Group I) and 56.4 minutes in the biodegradable implant group (Group II), while average time to bone union was 15.8 weeks in Group I and 17.6 weeks in Group II. At 12 months after surgery, Group I's mean AOFAS score was 87.5 points and Group II's score was 84.3 points. The average SMFA dysfunction index was 8.7 points in Group I and 10.5 points in Group II at 12 months post-surgery, and the average SMFA bother index was 3.3 points in Group I and 4.6 points in Group II at 12 months. There was no observed difference between the groups with respect to clinical results for subjects with an isolated lateral malleolar fracture.


A review was performed to identify risk factors for wound complications after ankle fracture fixation in hospital and outpatient settings. Four hundred and seventy-eight patients underwent open reduction and internal fixation of an ankle fracture between 2003 and 2010 by a single surgeon at a single institution. Of the patients who were followed, six (1.25 percent) had wounds requiring surgical debridement. Fourteen patients (2.9 percent) required further dressing care or a course of oral antibiotics. There were significant associations between wound complications and a history of diabetes (p < 0.001), peripheral neuropathy (p = 0.003), wound-compromising medications (p = 0.011), open fractures (p = 0.05), and postoperative noncompliance (p = 0.027). There was a significant difference in age between patients with and without wound complications (p = 0.045).

Practice Management

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Many practices found themselves forced to cut back on end of year festivities during the recession, but new data suggests that holiday celebrations in the workplace are back on the rise. "It's really important to take the time to recognize people as people," said MGMA Health Care Consulting Group Principal Kenneth Hertz, who adds, "you can have some fun and do some fun things." The question then, of course, is what to do?

Recognizing and appreciating employees at the end of the year is important, and it's important to do so in a way your employees will most appreciate. There are numerous ways a medical practice can mark the holidays, but the best way to celebrate will vary depending on the practice's employees. End of year parties or holiday dinners are a popular option, but have to be planned and scheduled so that they fit with the practice's employee demographics. Many considerations have to be made, including whether to allow and/or encourage employees to bring spouses and family members, and when best to hold such an event. Employee feedback is especially important for determining this last point, with the holiday season often a scheduling nightmare or overlapping obligations. Charitable giving can also be a fine way to mark the end of the year, either as part of a party or gathering, or as a separate seasonal effort.

Where a party or other end of year event isn't an option, end of year gifts or bonuses, even opportunities for additional time off can suffice. What's important, according to human resource consultants, is finding some way or another to mark the season and makes employees feel that they are appreciated.


Researchers have confirmed two simple cost-effective methods to reduce expensive postoperative complications—communications team training and a surgical checklist. They found that when surgical teams completed communications training and a surgical procedure checklist before, during, and after high-risk operations, patients experienced fewer adverse events such as infections and blood clots. The communications training included three sessions on topics such as differences between introverts and extroverts, effective dialogue among all operating room personnel and how to use a surgical checklist. The checklist was the one-page Association for periOperative Registered Nurses Comprehensive Surgical Checklist, developed in April 2010 with protocols mandated by the World Health Organization, the Joint Commission and the Centers for Medicare & Medicaid Services. The study is published in the December issue of the Journal of the American College of Surgeons. The checklist can be accessed here.


A key topic at the MGMA-ACMPE annual meeting was how medical practices can maintain alignment and integration with hospitals. Numerous education sessions at the meeting focused on how to keep alignment structures from falling apart. Strategies recommended by consultants and medical practice managers included having hospitals and physicians build governance with significant physician involvement, and designing physician compensation plans that line up with payment from insurers. Hospitals and physicians should have ways to address conflict and ramp up communication. Physicians should have input into most of these issues. If they don’t, it may be a sign not to move forward.


Though many practices assume that technology may reduce telephone volume, this is not always the case. Instead, practices may utilize other techniques to reduce volume. For example, when patients wait in a reception area for their appointments, their wait time can be used to have them write down questions for their physician and record their medications. This saves valuable time in the examination room and cuts down on the high call volumes that typically come from patients in the 24 to 48 hours after their visit. Practices should ensure that staff are available to answer telephone calls 30 minutes before the start of office hours, as well as ensuring that lines are being kept open during the lunch hour.

Practices may also adopt the concept of a virtual encounter after every three or four patient visits. This involves allowing a hypothetical encounter to attend to one's inbox and telephone messages. The payoff for conducting this work throughout the day is a clean slate at the end of the day, and it diminishes the volume of repeat calls. More complex calls may also be turned into office visits. For patients that call with long and involved explanations of their symptoms or conditions, telephone schedulers should ask, "Do you want to be seen?" If the answer is "yes," schedule the patient for the first appropriate time slot on the schedule. Coinciding with this, phone lines should be staffed with knowledgeable employees, such that patients can quickly reach staff that have the knowledge and skill to manage their calls in real time, which minimizes message-taking and decreases time spent playing phone tag.

Telephones should also be separated from the work of patient flow, meaning that clinical staff should handle either patient flow and visit support or telephone, not both. Similarly, front office staff should be responsible for checking-in/checking-out duties or telephone work, but not both. Additionally, a secure online patient portal gives patients options other than the telephone to communicate with a practice. Opening the door to secure email messaging and virtual visits allows practices to disengage patient care from the exam room when appropriate and deliver it to patients where they want it, when they want it. Portals should optimize patient access by offering entry routes in addition to the traditional face-to-face, episodic visit or the lengthy telephone call.

Health Policy and Reimbursement

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The Centers for Medicare and Medicaid Services (CMS) has suggested that providers make use of a clearinghouse or billing service to prepare for the transition to ICD-10. Recently, the CMS provided a list of questions providers should ask clearinghouses and billing services as part of the conversation about preparing for the Oct. 1, 2014 compliance date for ICD-10. The questions include asking if the organization is prepared to meet the ICD-10 deadline and if so, how their transition process is progressing. Providers should also ask clearinghouses to verify that their electronic transaction systems are updated to Version 5010. Providers should ask to set up regular check-in meetings and establish a primary contact for issues regarding the ICD-10 transition. Clarify how clients will be involved in testing ICD-10 claims codes and whether the provider can be involved in such tests. Finally, providers should inquire about any training or guidance that the clearinghouse will provide for changing clinical documentation to comply with ICD-10 and, of course, whether all of this will result in any price changes.


The Federal Trade Commission (FTC) has voted to approve a previously announced settlement of a complaint the commission brought against Renown Health alleging that the three-hospital system had likely established an illegal monopoly in heart-care services. Between 2010 and 2011, Renown purchased Sierra Nevada Cardiology Associates and Reno Heart Physicians, whose 31 doctors gave Renown a cardiology market share of more than 88 percent, according to the FTC. Instead of ordering Renown to break up the deals, the FTC voted unanimously to order the health system to let as many as 10 of its cardiologists disregard the language in employment contracts prohibiting them from working for competitors. The 10 cardiologists have already taken advantage of the agreement.


The cost of stopping the 2013 Medicare physician payment reduction has changed, increasing by $7 billion for a one-year pay patch that would preserve rates at 2012 levels, according to the Congressional Budget Office. The estimate will be referenced during negotiations in the lame-duck session of Congress to avoid the Fiscal Cliff. In addition to the 26.5 percent cut mandated by the Medicare statute, Medicare rates are set to be reduced by an additional 2 percent starting in 2013 through a budget sequestration process required by a 2011 deficit reduction law.

Medicine, Drugs and Devices

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In a recent press release, the U.S. Food and Drug Administration (FDA) announced that it was joining a public-private partnership aimed at identifying and funding new evaluation tools and assessment methods for medical devices. The extent of the agency's support for the not-for-profit Medical Device Innovation Consortium (MDIC), which was founded by a number of life science firms and device manufacturers, remains to be seen, but the press release hints that it will likely include contributions to funding efforts and possibly coordination with FDA employees on certain projects. The consortium grew out of a realization in recent years, both within industry and the FDA itself that the agency's medical device approval process was growing increasingly expensive and time consuming. "By sharing and leveraging resources, MDIC may help industry to be better equipped to bring safe and effective medical devices to market more quickly and at a lower cost," said Dr. Jeffrey Shuren, director of the FDA's Center for Devices and Radiological Health.


Insurance companies are increasingly encouraging patients to pursue online or over-the-phone consultations as a way of cutting costs and reducing overall doctor visits. Doctors participating in these telemedicine programs, such as Teladoc or Arizona-based Apogee Doctor on Call which recently began a pilot program in Tennessee, view the programs as a valuable supplement for rural populations without easy access to primary care physicians, and patients looking for after-hours, non-emergency consultations. While programs like Apogee have restrictions on what sort of diagnoses can be made and medications prescribed during remote consultations, some physicians still have concerns

Meharry Medical College professor Mohamad Sidani says he worries about the potential for remote consultations feeding the trend of patients eschewing regular meetings with a primary care physician. Sidani also worries that the very nature of remote consultations, which involve only descriptions of symptoms and perhaps visual inspections in the case of some online services, limits the ability of a physician to make a diagnosis. Sidani notes that symptoms such as a sore throat, headache, and fever can just as easily indicate severe illnesses like bacterial tonsillitis or meningitis, as more common viral infections. "If it's over the phone, I won't be able to see the patient's face," said Sidani, who points out that facial expressions and body language can convey a lot of important information to a physician.


Rates of serious bleeding among patients taking warfarin are much higher than those found in clinical trials of the drug and are even greater during the first month of use, according to a five-year study of 125,195 seniors with atrial fibrillation. Compared with clinical trials for warfarin that found serious hemorrhaging rates of between 1 percent and 3 percent per year, bleeding problems are more common in real-life clinical practice, said the study, which was published in the Canadian Medical Association Journal. In the study, the overall rate of hemorrhaging was 3.8 percent per person annually. However, during the first month of treatment, the annualized hemorrhage rates were 11.8 percent in all patients and 16.7 percent among patients with higher risk of stroke.


Since the 1970s computer researchers have attempted to find ways to use computers to tackle the complex issue of medical diagnosis. Today, the team behind IBM's Watson artificial intelligence program, and Jason Maude, creator of the medical diagnostic software Isabel, are hoping to bring a new level of clarity to diagnosis with vast symptom databases and natural language processing. Maude named his software after his daughter, who has had to endure a series of plastic surgeries after a case of necrotizing fasciitis was misdiagnosed as chickenpox. He says he wants to help combat anchoring bias and make it easier for physicians to spot low-frequency events. However, such efforts have met with limited success and resistance from practitioners.

Henry Lowe, director of Stanford University's Center for Clinical Informatics, has doubts about such systems, noting the difficulties of designing a computer system that can work well with the often incomplete and imprecise information that characterizes reported symptoms. "Most of us don't think we need help at diagnosis, especially with routine cases, which account for the majority of our work," says Dr. Gurpreet Dhaliwal, a renown University of California-San Francisco diagnostician. However, Dhaliwal, who himself uses Maude's Isabel software, says diagnostic computers and software do have a place in diagnosis, agreeing with Maude that they can make spotting rare conditions easier. Dhaliwal cites the example of a recent outbreak of hantavirus at Yosemite National Park as an example of a situation were diagnostic software could have aided a diagnosis. "You might think you're in familiar territory, but the computer is here to remind there are other things."