News From ACFAS

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All Fellow and Associate members should have received their 2014 ACFAS dues reminders in the mail. Don't let your membership in your professional organization slip; renew your membership today by visiting acfas.org/paymydues or via mail or fax to ensure your member benefits will continue. Renew by December 31 to avoid a late fee.

As always, your College membership connects you to the best and brightest foot and ankle surgeons in the world. Start the new year off right by continuing your relationship with the professional organization comprised of the best and brightest foot and ankle surgeons — ACFAS.
Looking for a way to keep a regular open communication with your patients? Need new material for your social media outlets to attract new patients? The latest edition of FootNotes, your free, customizable patient education newsletter is ready for downloading.

Stories for this issue include:

• Tasty Holiday Meals Can Trigger Painful Toes
• What You Can't See This Winter Can Hurt You
• Don't Let the Cold Nip at Your Toes

The marketing opportunities are endless with FootNotes -- put them in your waiting room, mail to your patients in their statements, use on your website or hand out at health fairs or speaking engagements. Plus, don't forget to also take advantage of other valuable marketing tools to promote your practice from ACFAS on our website in the ACFAS Marketing Toolbox.
After a record number of clinical and scientific grant proposals submitted, the ACFAS Research Committee is pleased to announce the funding of five 2013 Clinical and Scientific Research Grant proposals. Congratulations to the following:

• The Association Between Hemoglobin A1C and Surgical Morbidity in Elective Foot and Ankle Surgery
  Katherine Dux, DPM, FACFAS; Michael Pinzur, MD; Natalie Domek, DPM; Frances Weaver, PhD
• Charcot Pathogenesis: A Study of RANKL and OPG Gene Expression
  Georgeanne Botek, DPM, FACFAS; James Connors, DPM; PGY-2; Mark Hardy, DPM, FACFAS; Lauren Kishman, DPM, PGY-3
• Do Biopsychosocial Patient Attributes Influence our Outcomes in Hallux Valgus Surgery?
  Erin E Klein, DPM, MS, AACFAS; Craig Wirt, PhD; Rachel Greenley, PhD; Lowell Weil, Sr., DPM, FACFAS; Lowell Weil, Jr., DPM, MBA, FACFAS; Adam Fleischer, DPM, MPH, FACFAS
• Comparative Analysis of Weil Metatarsal Osteotomy vs. Weil Metatarsal Osteotomy in Conjunction with Plantar Plate Repair for Forefoot Metatarsalgia
  Lowell Weil, Jr., DPM, MBA, FACFAS; Lowell Weil, Sr., DPM, FACFAS; Daniel Hare, DPM; Erin Klein, DPM, MS, AACFAS; Michael Bowen, DPM, AACFAS; Nathan Kramer, DPM; Adam Fleischer, DPM, MPH, FACFAS
• Phalangeal Osteotomy Versus Resectional Arthroplasty for the Correction of Flexible Hammertoe Deformity
  Lowell Weil, Sr. DPM, FACFAS; Lowell Weil, Jr., DPM, MBA, FACFAS; Nathan Kramer, DPM; Daniel Hare, DPM; Michael Bowen, DPM, AACFAS; Erin Klein, DPM, MS, AACFAS; Adam Fleischer, DPM, MPH, FACFAS

The ACFAS Clinical and Scientific Research Grant program provides financial assistance to members conducting research in foot and ankle surgery. The program seeks to educate members in the implementation of evidence-based medicine for the advancement of clinical practice in areas related to the betterment of foot and ankle surgery for the patients served. The research must be clinical or laboratory based, with clearly defined research goals meeting all the criteria for grant submissions.

The ACFAS research grant program is in its eighth year of supporting research conducted by members of the College, and is proud to have the ability to award up to $40,000 in grant money.

For a full listing of past award recipients, visit acfas.org/grant. With 2013 almost behind us, ACFAS would like to thank each and every member for their dedication to the profession and for the countless hours volunteered to help the College continue to make a difference. It’s been quite a year for ACFAS and our members and here’s a quick look at some of the highlights of 2013.

• ACFAS Breaks Membership Record: We are now 7,000 members strong!
• ACFAS.org undergoes a complete re-vamp of the site for members’ ease of use.
• JFAS is now available in an iPad app!
• ACFAS breaks attendance records at 2013 Annual Scientific Conference.
• The new ACFAS Marketing Toolbox rolled out.
• New Informational Videos on the education and training of foot and ankle surgeons launched.
• JFAS online subscriptions expand to include students and international affiliates.
• ACFAS expands its social media outreach to include YouTube and Google+ outlets.
• ACFAS releases The Foot and Ankle Surgeon brochure for members to help educate patients and the community on the profession.
• ACFAS’ Foot Health Facts Facebook Page reaches record number of followers.
• ACFAS Recognizes three additional Fellowship Programs and develops a conditional status for 2013.
• Post-Graduate Affairs Committee Established
• Released a new Position Statement on Total Ankle Replacement (TAR)
• Revised the Truth in Advertising, Board Certification of Residency Directors, Complementary and Alternative Medicine and Cosmetic Surgery Position Statements
• Approved revisions to the Principles of Professional Conduct.

Foot and Ankle Surgery

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A new study has found that there are a number of benefits associated with the use of fibular centralization during ankle fusion following distal tibia bone tumor resection. The study involved four osteosarcoma patients, two Ewing's sarcoma patients, two patients with giant cell tumors, and one chondrosarcoma patient. All nine patients underwent wide resection of their distal tibial tumors and ankle arthrodesis with centralization of the fibula. After following up with patients at an average of 37 months, researchers found that the mean Musculoskeletal Tumor Society (MSTS) score--which was used to estimate final outcome--was 22.75. Researchers also found that one of the osteosarcoma patients had a recurrence a year after limb salvage surgery and subsequently died a year and a half later due to the spread of the tumor. One patient also developed leg length discrepancy. However, researchers concluded that fibular centralization is a durable reconstruction tool for correcting defects of the distal tibial metaphysis. They also found that the procedure has an acceptable functional outcome, carries a low rate of complications, and produces reproducible results.

Practice Management

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Consumers and clinicians alike are increasingly using mobile medical applications that allow them to communicate with one another and to better manage health issues. A recent survey by Manhattan Research found that roughly 95 million Americans used their mobile phones as healthcare tools or to find health information this year, a number that is 27 percent higher than it was in 2012. A separate survey by Modern Healthcare found that Epocrates was the top clinician-oriented mobile app, followed by Medscape, Micromedex, and WebMD. The survey also found that the drug reference was the most popular mobile medical app function, followed by general medical reference and personal fitness. According to IMS Institute for Healthcare Informatics Executive Director Murray Aitken, the use of mobile medical apps will be mainstream within the next five years. He noted that more and more patients will be instructed to download a mobile healthcare app after a doctors visit or after being discharged from the hospital in order to maintain an open line of communication with a healthcare provider. Using mobile medical apps in this way will lead to better care and lower costs, Aitken said. However, experts say there are a number of obstacles that are preventing healthcare providers from realizing the full potential of mobile medical apps, including the fact that there are not a large number of apps that are fully integrated into a comprehensive healthcare and wellness information system.


A recent study by the healthcare management consulting firm Press Ganey found that medical practices that want to maintain patient loyalty should primarily focus on ensuring patients have confidence in their abilities and providing high-quality care coordination. The study, which analyzed patient records and the reasons given for leaving a practice, also found that the concern providers show in responding to patients' questions and worries is another important variable that affects patient loyalty. The ability of providers to listen and the courtesy they show to their patients are important as well, the study found. In addition to identifying the variables that affect patient loyalty, the study also included a "decision tree" analysis that identified groups of patients at high or low risks of leaving a practice. The analysis found that patients who had a high level of confidence in their provider were at a 1.9 percent risk of leaving the practice, while patients with a low level of confidence were at a 74.6 percent risk. Patients who had a high amount of confidence in their provider and also believed there was good care coordination among providers were at a 1 percent risk of leaving the practice, compared to an 11 percent risk for patients who were unimpressed with the quality of care coordination.

Health Policy and Reimbursement

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The Obama administration announced Dec. 19 that some people over the age of 30 will in some circumstances be allowed to use health insurance exchanges to purchase catastrophic plans, which had previously been limited to consumers under 30. The Department of Health and Human Services said that consumers facing one of 13 types of "hardships" will be allowed to apply for an exemption from the Affordable Care Act's requirement that their insurance plans include certain types of coverage, which will effectively allow them to buy catastrophic plans. The exemptions will be available to consumers in certain income levels as well as those who believe they cannot afford to purchase a plan on the health insurance marketplace to replace a cancelled individual plan. America's Health Insurance Plans President and Chief Executive Officer Karen Ignagni criticized the announcement, saying it amounted to a "change" in the Affordable Care Act that could result in "significant instability in the marketplace and lead to further confusion and disruption for consumers." A White House spokeswoman, however, said the announcement was not a rule change and that the move is allowed under the Affordable Care Act.


Centers for Medicare & Medicaid Services Communications Director Julie Bataille said Dec. 23 that her agency has taken steps to ensure that anyone who selects a health insurance plan through Healthcare.gov by the end of the day on Dec. 24 will be covered beginning Jan. 1, 2014. The deadline for obtaining health insurance coverage that begins in the new year had been Dec. 23. But Bataille said the deadline needed to be pushed back by one day because many people were making final decisions about the plans they wanted on Dec. 23. High demand for coverage offered through Healthcare.gov as well as the fact that consumers were signing up from a number of different time zones also prompted CMS to push back the deadline, Bataille said.


Congress has passed a two-year budget agreement that temporarily fixes the Medicare Sustainable Growth Rate (SGR) formula by extending current physician payment levels through March. The move means that doctors will not face a 23.7 percent cut in Medicare payments on Jan. 1, 2014. The bill calls for offsetting the cost of temporarily fixing SGR by changing the payment system for long-term acute-care hospitals. In addition, the bill extends the 2 percent sequestration cut to Medicare by an additional two years. Despite the passage of the budget agreement, Congress will still need to pass appropriations bills--including one for the Department of Health and Human Services (HHS)--before the current budget resolution that funds the federal government expires on Jan. 15, 2014. The HHS appropriations bill includes a number of issues lawmakers will need to address, including spending levels for the Centers for Medicare and Medicaid Services. Another spending issue on the horizon is the imminent need to raise the nation's debt ceiling. Paul Van de Water, a senior fellow at the left-leaning Center on Budget and Policy Priorities, predicted that "Medicare will be one of the hostages" if Republicans use the debt ceiling fight to force spending cuts or other policy changes.


The American Medical Association (AMA) and the American College of Physicians are expressing concern about a provision in the Senate's Sustainable Growth Rate (SGR) repeal bill that would create a database containing information about all Medicare payments made to physicians. Sen. Chuck Grassley (R-Iowa), who supports the creation of the database, said that making Medicare claims information available to the public online would be beneficial because it would result in greater scrutiny of Medicare policy and spending. AMA President Ardis Dee Hoven, MD, says that her organization supports expanding physician access to Medicare claims data from Qualified Entities (QEs) and qualified clinical data registries in order to advance quality improvement efforts. But she added that AMA is concerned that the bill would allow raw Medicare physician claims data to be released without similar safeguards that are currently applied to QEs, including appropriate attribution and risk adjustment, timely correction of errors with appeal rights, and explanatory information that will allow patients to be well informed. The bill does allow healthcare providers to correct payment information before it is posted online. The American College of Physicians says it shares AMA's concerns. The transparency provisions would take effect on July 1, 2015 for physicians and July 1, 2016 for other healthcare professionals, assuming language about the database is not removed.


The Senate's version of the Sustainable Growth Rate (SGR) repeal bill includes two amendments approved by the Senate Finance Committee on Dec. 19 that would increase Medicare coverage for telehealth services. One of the amendments would give greater flexibility to providers who use telehealth services with an alternative payment model starting in 2017. The second amendment would create a pilot program for incentivizing home health and other long-term care agencies to closely monitor Medicare patients in order to prevent any unnecessary admissions. The American Telemedicine Association says it supports both amendments, because the long-term benefits they bring will be particularly helpful in the transition towards more value-based, all-inclusive Medicare payment methods.


A software glitch has caused Healthcare.gov to make incorrect eligibility determinations for thousands of people who have signed up for either Medicaid or private insurance coverage through the site. The flawed software uses a set of roughly 200 rules that take into consideration factors such as immigration status to filter enrollees into Medicaid or the insurance marketplaces. But errors in the software have resulted in some consumers being enrolled in state Medicaid programs even though they make too much money, while others have been prevented from enrolling in coverage through insurance marketplaces even though they are eligible to do so. Insurance companies are warning that the errors could result in some of the affected patients being unable to use their new coverage next year. The Department of Health and Human Services (HHS) has said that the problems are only affecting a limited number of people, and that it is taking steps to correct errors in the eligibility determination software that have yet to be fixed. HHS and the rest of the Obama administration are also taking steps to prevent any widespread confusion when newly-insured consumers begin seeking care in the new year, including urging consumers to verify their enrollment in private insurance plans, verify their eligibility for Medicaid, and appeal incorrect eligibility determinations.


The Medicare Payment Advisory Commission is reportedly considering a set of draft recommendations that would reduce or eliminate the substantial differences in payments given to hospital outpatient departments and doctors' offices for certain procedures beginning in 2015. Current Medicare reimbursement rates call for hospital outpatient departments to be paid 80 percent more than freestanding physician clinics for routine evaluations and management office visits. The draft recommendations also call for increasing hospital inpatient and outpatient prospective payment rates by 3.2 percent in 2015. In addition, the draft recommendations freeze Medicare payments to doctors in 2015 in place of the sustainable growth rate (SGR) formula. By comparison, the latest proposed SGR patch delays the implementation of a 24 percent cut in Medicare payments for physicians through March 2014. Other proposed changes include reducing long-term care hospital reimbursement rates so that they are the same as those for general acute-care hospitals for patients who do not have a chronic critical illness. The money saved by cutting reimbursement rates for long-term care hospitals will be used to create a new outlier pool for patients with chronic critical illnesses who are treated in hospitals that are reimbursed using the inpatient prospective payment system.


Reps. Henry Waxman (D-Calif.), the House Energy and Commerce Committee's ranking member, and Diana DeGette (D-Colo.) issued a statement on Dec. 13 in which they said that there have been no successful cyberattacks against Healthcare.gov since it was launched on Oct. 1. The statement was based on testimony given by a number of government officials, including Department of Health and Human Services Chief Information Security Officer Dr. Kevin Charest, during a classified hearing on Dec. 11. Waxman and DeGette also reported that no individual or group has maliciously accessed the personal information of Healthcare.gov's users since the site was launched. However, the two House Democrats noted that there have been 32 security "incidents" at Healthcare.gov since Oct. 1. More than a dozen of those incidents involved an individual who was given someone else's information by mistake. Waxman and DeGette also said that none of the 32 incidents involved significant breaches of personal information. In addition, they said the glitches that caused these incidents have since been corrected.

Medicine, Drugs and Devices

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GlaxoSmithKline's announcement that it plans to end its practice of paying doctors for promoting its products in their speeches and for attending medical conferences could prompt other drugmakers to follow suit. One reason why other drugmakers could follow GSK's lead in this matter is because they are now required under the Sunshine Act to report payments and gifts worth $10 or more that are given to doctors and medical schools--payments that drug companies and doctors alike may be embarrassed by if they are made public, one expert says. In addition, speakers' bureaus--in which doctors are paid to promote a company's products--as well as the gifts and free meals that are sometimes given to doctors, are generally seen as being unethical. Drug companies that fail to stop paying doctors for promoting their products could face increased scrutiny from Congress, said Rep. Elijah Cummings (D-Md.).