News From ACFAS

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Make sure your voice is heard in the 2012 election of your Board of Directors. On Friday, January 13, those eligible who have not yet voted will receive a third and final link to their personal election ballot via email from acfas.ballot@intelliscaninc.net.

Remember, your vote counts and makes a difference in our profession and surgical specialty! Please take a few minutes today to select your candidates.

The election closes on Tuesday, January 17, 2012 at 11:59pm EST.
Do you have an interesting case that proved to be a diagnostic dilemma or presented a management problem?

Looking to present your case in an informal setting to a panel of expert clinicians?

Submit your case for the opportunity to be presented by you or a moderator at the popular session, Curbside Consult, on Friday, March 2, at the 2012 Annual Scientific Conference in San Antonio.

Don't delay; cases are due to Marilyn Wallace at ACFAS by Monday, January 16, 2012. Follow the link below to complete your submission form.

Legal Briefs

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Physicians involved in medical equipment joint ventures can challenge Medicare regulations on reimbursements, according to the federal appeals court judgment in Council for Urological Interests v. Secretary of Health and Human Services Sebelius.

The regulations at issue, 42 C.F.R. §§411.351 , 411.357(b)(4)(ii)(B), bar medical specialists who have a financial interest in an equipment joint venture from referring patients to the venture and prohibit per-procedure leases with physician-owned equipment suppliers. The appeals court noted that the challenged rules were issued under the Stark law, 42 U.S.C. §1395nn. This law addresses the perceived overutilization of services by physicians who stood to profit by referring patients to facilities or entities in which they had a financial interest.

The appeals court said that, in a typical joint venture arrangement, the hospital bills Medicare for the technical fee for each surgical procedure performed and then passes on a prenegotiated portion of that fee to the joint venture on a per-procedure basis. The Secretary of Health and Human Services had approved these arrangements (in compliance with the Stark law), but in 2008 the Secretary reconsidered the issue and issued new regulations prohibiting most of the arrangements. Under the current rules, medical specialists who have a financial interest in a joint venture may no longer refer a patient to the venture for laser services, even if the services are provided under an arrangement with a hospital, the court said.

Foot and Ankle Surgery

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Researchers performed a phantom study to demonstrate the sources of error and necessary controls for accurate quantitative computed tomography of the foot. Foot phantoms were scanned using a 64-slice CT scanner. Energy (in kilovoltage peak) and distance from the isocenter (table height) resulted in relative attenuation changes from −5 percent to 22 percent and −5 percent to 0 percent, respectively, and average bone mineral density (BMD) changes from −0.9 percent to 0.0 percent and −1.1 percent to 0.3 percent, respectively, compared to a baseline 120-kVp scan performed at the isocenter. BMD compared to manufacturer-specified values ranged, on average, from −2.2 percent to 0.9 percent. Phantom size and location of bone-equivalent material inserts resulted in relative attenuation changes of −1.2 percent to 1.4 percent compared to the medium-sized phantom.


Researchers assessed the hypothesis that the postnatal growth of the calcaneus would simulate growth of the foot, and discovered the opposite to be true. They measured 860 normal lateral foot radiographs, 50 for each year of development from one to 18 years, and 10 radiographs from birth till one year, for the length and height of the calcaneus, Bohler angle, the appearance, fusion, and fragmentation of calcaneus apophysis, and the height and width of apophysis. Nonlinear curves were aligned to a growth chart of the calcaneus, and the outcomes were superimposed on the historical growth charts of the foot, stature, and long bones. The ratio of calcaneus length to apophysis height was estimated. The researchers determined that calcaneus growth does not simulate foot growth, which acquires 50 percent of its mature dimension by the age of one year in females and 1.5 years in males. Instead it simulates the growth of the long bones, which attain 50 percent of their mature length after three years of age in females and 4 years in males. Bohler angle stays within normal limits across all ages. When calcaneus length is three times the height of its apophysis, 80 percent of calcaneus growth is complete.


Researchers reported the results of the treatment of talar osteochondral lesions with arthroscopic microfracture method and postoperative intra-articular hyaluronan injection, using 57 patients with such lesions examined between the years 2003 and 2009. The arthroscopic debridement and microfracture technique was administered to the patients. Forty-one patients chosen at random were injected with intra-articular hyaluronan, while 16 did not receive postoperative injection. The average postoperative Freiburg functional and pain scores were significantly higher compared to preoperative functional and pain scores in both the injection group and the non-injection group. The AOFAS functional and pain scores of the patients in the injection group were substantially higher in comparison to preoperative scores. AOFAS scoring of patients in the non-injection group also uncovered significantly higher postoperative functional and pain scores over preoperative scores. The boost in the postoperative scores was determined to be significantly higher in the injection group versus the non-injection group in both Freiburg and AOFAS systems.

Practice Management

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There has been a flurry of consulting activity surrounding accountable care organizations, presenting doctors with the dilemma of being swamped by the accountable care advisory options available to them. Accountable Care Community of Practice co-chair Justin Barnes says physicians should first determine whether an ACO consultant's services are needed in the first place, noting that doctors who think they can commit 5 percent to 10 percent of their time to investigating and developing a practice's accountable care options may not need to hire someone for that job. Barnes also says that do-it-yourself doctors can avail themselves of free resources from the American Medical Association, the Medical Group Management Association, and other organizations that can fulfill the same functions as consultants.


Medical Justice is withdrawing a suite of contracts supplying authority to physicians over online comments posted by patients following a complaint filed with the Federal Trade Commission claiming that the company is engaging in unethical business practices. Though the company recommends that physicians use its eMerit online tool to combat false patient posts, Medical Justice CEO Jeff Segal, MD, said members are "free to do what they want to do," which includes continuing use of the contracts if they see fit. Segal noted that the contracts succeeded in achieving their goal of encouraging patient feedback and showcasing the problem of false online comments, but he said that "we are going to use [the FTC] situation as an opportunity to retire the written doctor-patient agreements."


Experts and studies have found physicians' professional use of social media to be progressing slowly, and one doctor who has adopted social media, Kurt Frederick of Premier Family Physicians, says they are missing a key opportunity to not only attract new patients who will find them online, but also to forge deeper and enduring bonds with patients. Among the obstacles preventing doctors from taking up social media in a professional capacity are worries about breaching patient confidentiality, liability issues, naiveté, and a dearth of time and money. Jonathan Nelson with the Texas Academy of Family Physicians notes that "everybody is going online to search for health information," and that what a doctor like Frederick is doing with social media is "extending the care he is providing beyond the clinic walls."

Health Policy and Reimbursement

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The U.S. Department of Health and Human Services (HHS) has issued an interim final rule with new standards for electronic funds transfers that the department says will reduce provider paperwork and save billions in administrative costs. HHS says the new electronic funds transfer standards will eliminate many of the inefficiencies associated with submitting claims for payment. For instance, the new rule requires the use of a trace number that will automatically link bills from providers with payments from health plans, thereby avoiding "costly manual reconciliation that must currently be done." HHS said its next targets for simplification include unique identifiers for health plans and standards for claims attachments.


Changes to how organizations perform CT scans in California becomes effective, in part, July 1, 2012. Ambulatory care organizations in California that perform CT scans will be required to:

• Record the dose of radiation produced during each CT scan.
• Send each CT study and protocol page listing the technical factors and dose of radiation to an electronic picture archiving and communications system.
• Have the radiation dose produced by the CT imaging equipment verified annually by a medical physicist.


A letter from the Alliance of Specialty Medicine, a coalition of 11 medical societies, to the Centers for Medicare and Medicaid Services (CMS) says the final Medicare physician fee schedule for 2012 lacked transparency during development, lacks uniformity in its payment methodology for patient observation, and has created confusion in an effort to lower payments for diagnostic imaging services. The letter specifically states that the "CMS has not provided adequate justification" for accepting recommendations from advisory panels when developing fees, and has created separate payments for different physicians providing evaluation and management services for patient under observation without providing logical or data-driven reasons for the differentiation.

Medicine, Drugs and Devices

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The American College of Physicians (ACP) has issued a sixth edition of its ethics manual, the first rewrite since 2005. The revised manual offers new guidance on longstanding issues such as physician-industry relations and ethics in medical research. The manual also tackles emerging issues such as the role of social media and its impact on the physician-patient relationship, the growth and impact of the physician-employee model, treating celebrities in the age of Twitter, and physicians' dual role of serving patients' needs while also marshalling scarce or expensive healthcare resources. The manual is published in ACP's flagship Annals of Internal Medicine


Most physicians retain some degree of diversity in their prescribing options in spite of the tremendous investments that drug companies have made in terms of doctor outreach, according to a new study led by the University of Southern California's Schaeffer Center for Health Policy and Economics and published in the American Journal of Managed Care. The report demonstrates that most physicians have habitual favorites when it comes to prescriptions, with one drug, whether brand name or generic, constituting as much as 70 percent of most doctors' new prescriptions in a category. However, with the remaining prescriptions, doctors tried new treatments, prescribing on average two additional drugs in eight of the 10 categories the researchers examined.


The Joint Commission (TJC) will begin pilot testing a new intracycle monitoring process from February through May 2012. Ambulatory organizations and office-based surgery practices are invited to volunteer to be pilot sites. The new process involves touch points, or contacts with customers, that occur twice during an organization’s accreditation cycle, at approximately 12 and 24 months after a survey. The touch points are a way to engage the organization in a performance status update and may include a review of:

• Requirements for Improvement (RFIs) cited during the previous survey
• Program-specific risk areas and related standards and elements of performance
• Focused Standards Assessment tool (replaces the Periodic Performance Review tool in January 2013)
• Selected documents
• Other topics of interest to the organization