News From ACFAS

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The best opportunity in a decade to fix the Medicaid Act by specifically including podiatrists as providers, just as the Medicare Act does, warrants every DPM to act now and support the bipartisan HR1761 and S1318 bills.

Also known as the “HELLPP” (Helping Ensure Life- and Limb-Saving Access to Podiatric Physicians (HELLPP) Act, this legislation, sponsored by Representatives Lee Terry (R-NE) and Diana DeGette (D-CO) and Senators Charles Schumer (D-NY) and Chuck Grassley (R-IA), would remove patient access barriers to podiatric physicians and surgeons, enhance patient choices, improve health quality outcomes and reduce health spending.

Even though foot and ankle care is a covered benefit under current law Medicaid, medical and surgical foot and ankle care provided by a podiatrist is considered an optional benefit and is not covered by all state plans, thus limiting Medicaid patient access to specialized foot and ankle medical and surgical care.

The HELLPP Act would remedy this access barrier by recognizing podiatrists as physicians and would bring the Medicaid program in line with the Medicare program which has recognized doctors of podiatric medicine as physicians since 1967. Additionally, clarifications to Medicare’s Therapeutic Shoe Program for persons with diabetes in the HELLPP Act would improve coordination of care for patients and result in fewer Medicare office visits.

Also supporting the HELLPP legislation is APMA, National Hispanic Medical Association, American Public Health Association, and Society for Vascular Surgery.

ACFAS is strongly supporting this legislation and encourages all members to write your federal legislations a.s.a.p. in support. Visit apma.org/eAdvocacy, login, and quickly send e-mails to U.S. representatives and senators today. Official ACFAS hotels are still available for the 2014 Annual Scientific Conference in Orlando February 27-March 2, but book now before our exclusive rates expire on February 6.

With less than one month before ACFAS 2014, our housing partner OnPeak is still making it easy for attendees to book their hotels in Orlando. Each hotel in the ACFAS official hotel block is conveniently located to ACFAS 2014 and includes hotel extras and exclusive low rates.

Remember, to receive your exclusive ACFAS hotel rates and be a part of the official room block, you must make your hotel reservations through OnPeak and ACFAS by visiting, acfas.org/Orlando. Don't miss out on the complimentary membership webinar, Maximizing your ACFAS Membership scheduled for tomorrow, Thursday, January 30, 2014 at 8pm CST.

Get answers to your questions on your new membership in ACFAS when you join Russell Carlson, DPM, AACFAS, member of the ACFAS Membership Committee, and Michelle Butterworth, DPM, FACFAS, ACFAS Past President, as they walk you through all that ACFAS has to offer. After the webinar, there will also be time for Q&A.

To register for the free 30-minute webinar, visit http://eo2.commpartners.com/users/acfas/.

Foot and Ankle Surgery

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A recent study retrospectively evaluated the outcome of immediate reimplantation of the talus in nine patients with complete talar extrusion without associated fractures. In all nine patients, the dislocated talus was reduced and held in place with two Steinmann pins placed from the inferior aspect of the calcaneus, through the talus and into the inferior aspect of the tibia. The limb was stabilized using an external fixator. Researchers found that six patients did not experience any complications. The average American Orthopaedic Foot & Ankle Society (AOFAS) Ankle-Hindfoot Scale scores of the six patients who were evaluated with this metric at final follow-up was 82.5. Two patients had an infection, one had avascular necrosis of the talus, and one displayed signs of subtalar joint arthritis. Two patients needed to undergo arthrodesis. The study concluded that reimplantation of the talus should be attempted since a good final outcome is likely. In addition, the study concluded that reimplantation of the talus will ensure adequate bone stock for future surgical procedures, even when a patient has experienced a catastrophic complication.


The use of an internal implant provides acceptable alignment, pain reduction, and improved function in patients who undergo hammertoe correction, a new study has found. Doctors treated 29 patients and a total of 53 toes with a hammertoe deformity with resection arthroplasty of the proximal interphalangeal joint (PIP) joint and fixation with an implant. However, doctors were only able to follow up with 24 patients (42 toes), all of whom returned for a final clinical and radiographic evaluation after an average of 12 months. All of the patients reported being satisfied with the results of the procedure at final follow up. Average American Orthopaedic Foot & Ankle Society (AOFAS) scores increased from 52 before the operation to 71 afterward, while average Visual Analog Pain Scale (VAS) scores improved from five to one. No recurrent deformities or transverse plane deformities were seen, though a minor digital rotational deformity was seen in one toe at final follow up. All of the PIP joints displayed good alignment, and bony union was seen in 81 percent of these joints.

Practice Management

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Healthcare industry consultants say there are a number of factors that doctors need to take into consideration when deciding whether or not to sell their practices to hospitals. For example, doctors should determine the nature of the hospital's long-term strategic plan, including any health reform initiatives that are being planned, the way the hospital defines quality patient care, and whether it plans to purchase other local practices, says Pinnacle Healthcare Consulting principal Bill Cherry. The goal here is for doctors to determine whether they will be comfortable aligning with the hospital's goals. Jennifer Snider, the vice president of operations at The Halley Consulting Group, says that doctors should also be sure they aware of any expectations a hospital may have for their practices before selling. Doctors need to consider whether these expectations are realistic, Snider says, as well as whether the hospital provided them with the chance to share their input and feedback on these expectations. Snider also notes that doctors should ensure that hospitals have a strategic vision for their practices, and that a purchase is not being motivated simply by a desire to buy the practice before a competitor is able to.


There are a number of steps that doctors' practices can take to ensure that their physicians are engaged throughout their careers. Ensuring physician engagement begins during the recruitment process when prospective doctors are being interviewed. The individuals conducting these interviews should be sure that candidates are a good fit for the practice's culture by asking them questions about conflict management, teamwork, and communication. Once doctors have been hired, medical practices should objectively assess the behaviors and attitudes they want in their employees and provide incentives to those who display these characteristics in order to create the type of workplace culture they want. Another step that medical practices should follow is to create a year-long onboarding program centered around physicians. One key to making onboarding programs a success is to provide new physicians with clear expectations, milestones, and benchmarks for the development of their practices. By ensuring that physicians are engaged, medical practices can increase the likelihood of hiring and keeping good doctors.

Health Policy and Reimbursement

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Patient safety advocates are concerned that a recent settlement between the Justice Department and the healthcare supplier CareFusion over allegations of conflict of interest could damage the public's trust in the patient safety field. CareFusion had been accused of paying millions of dollars to Dr. Charles Denham, the chairman of the Leapfrog Group's safe practices committee, to influence the committee's national quality-of-care standards. Leapfrog Group's safe practices committee, which is a high-profile component of the National Quality Forum (NQF), ultimately recommended the use of CareFusion's skin-sterilization product ChloraPrep in its draft recommendations. In addition, Denham's Texas Medical Institute of Technology allegedly awarded grants to NQF to develop the quality-of-care guidelines and to identify some of the "safe practices" considered by the Leapfrog Group committee. Dr. Peter Pronovost, the senior vice president for patient safety and quality at Johns Hopkins Medicine, says the allegations are troubling because the patient safety field's image could be distorted in the public's mind if it starts to seem as if quality and safety efforts are being guided by people with financial interests instead of science. Experts say this problem can be mitigated by following several steps, including asking members of studies and guideline committees to provide detailed information about any conflicts of interest. Experts also say that members of these committee who have potentially conflicting financial relationships surrounding certain issues should limit their participation when discussing or voting on these issues.


The Center for American Progress (CAP) released a report on Jan. 24 in which it criticized the Patient-Centered Outcomes Research Institute (PCORI) for not doing enough to fund research on the best healthcare outcomes. The report noted that PCORI, which was created by the Affordable Care Act (ACA) as part of an effort to reduce healthcare costs and improve the quality of care, has devoted less than 40 percent of its funding to comparative effectiveness research (CER) in the past four years. CAP Vice President for Health Policy Topher Spiro says PCORI should invest at least 80 percent of its funding in CER by fiscal 2016 so that it can enact a "bold research agenda" aimed at reducing healthcare costs. The report also criticized PCORI for not conducting any CER studies of medical devices and for only carrying out a handful of CER drug studies. PCORI Executive Director Joe Selby responded to the report by saying that a pragmatic studies initiative his organization plans to launch on Feb. 8 will address the concerns raised by CAP in its report. PCORI plans to use the initiative to provide as much as $15 million in funding for six to nine studies twice a year. Among the topics these studies will focus on is the Institute of medicine's 100 initial priority topics for CER.


Target has joined the growing list of major U.S. retailers that have decided to no longer provide health insurance coverage for their part-time employees in order to save on healthcare costs. Target says the move is necessary in order to compensate for the changes being brought about by the Affordable Care Act. Target and several other companies that have opted to end health insurance coverage for part-timers, including Home Depot and Trader Joes, all say that affected employees will be able to obtain insurance coverage and subsidies through the nation's health insurance exchanges. Some employees may even be able to pay less for health insurance coverage offered through the exchanges compared to plans formerly offered by their employer, one analysis found. Meanwhile, there have been a number of reports that the majority of consumers signing up for health insurance coverage through the exchanges already had insurance. This finding could be cause for insurance companies who need a wider customer base, as well as an optimal balance of consumers, in order to maintain market stability and keep premiums down. But both insurance industry experts and Obama administration officials say that there are still three months to go in the current open enrollment period, and that it is still too soon to determine how the enrollments so far will impact market stability and premiums.


A survey of a random sample of 9,145 adults across the U.S. has found that the percentage of uninsured consumers dropped just as many provisions of the Affordable Care Act took effect. The Gallup-Healthways Well-Being Index found that the percentage of uninsured consumers stood at 16.1 percent in January, which was down 1.2 percentage points from the index's last reading. The biggest declines in rates of uninsured consumers took place among two groups who are far more likely to not have insurance than the general population: the unemployed, who experienced a 6.7 percentage point decline in uninsured rates; and non-whites, who saw a 2.6 percentage point decline. However, there were no significant changes in the rates of insurance coverage among adults aged 18-34. Gallup Editor-in-Chief Frank Newport says the most reasonable explanation for the overall decline in the number of uninsured consumers is the implementation of the ACA's major provisions on Jan. 1, though he said it would take three months to determine whether the decline is part of a trend towards greater insurance coverage caused by the healthcare reform law. He added that a stronger economy and other factors could have played a part in bringing down the number of consumers without insurance.


High on the American Hospital Association's (AHA's) lobbying agenda for this year is the effort to delay the implementation of the Centers for Medicare and Medicaid Services' (CMS) two-midnight rule. AHA says it supports a bill being considered by the House that would delay the implementation of the rule--which calls for Medicare contractors to assume hospital admissions are reasonable and necessary for patients who stay in a hospital for two midnights and to presume that shorter stays are legitimate if they are designated as outpatient observation--until Oct. 1. The bipartisan bill also calls for CMS to adopt a new payment policy for short inpatient stays that occur next year. Meanwhile, a number of AHA members have asked CMS' Provider Reimbursement Review Board to grant an expedited judicial review of their claim that a 0.2 percent cut to the standard hospital payment rate that is being made as a result of the two-midnight rule is illegal. AHA is also planning to focus on the issues surrounding the lapse of a short-term fix for Medicare physician payments on March 31 and the sustainable growth-rate formula. AHA says that Congress should not cause financial harm to hospitals in order to offset the cost of dealing with these issues.


The Centers for Disease Control and Prevention's National Center for Health Statistics (NCHS) recently released the results of a survey performed last year that examined doctors' readiness for Stage 2 Meaningful Use. NCHS surveyed more than 10,300 doctors, and found that just 13 percent of office-based physicians planned to participate in the electronic health records (EHR) incentive program and were using a system that met 14 of the 17 Stage 2 core objectives. NCHS said that finding may overestimate the percentage of doctors who are ready for Stage 2 Meaningful Use, since doctors with EHR systems that support the 14 core objectives may not be able to meet the remaining requirements to receive an incentive payment from Medicare and Medicaid. The survey also found that 56 percent of all physicians planned to participate in the EHR incentive program but did not meet the core objectives NCHS asked about. Karen DeSalvo, MD, MPH, the Department of Health and Human Services' national coordinator for Health Information Technology, said the finding is understandable since the survey was performed before 2014 certified products were available. She added that early EHR adopters will not have to begin attesting Stage 2 Meaningful Use until October, while later EHR adopters have even longer to attest Stage 2 Meaningful Use.

Medicine, Drugs and Devices

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A recent systematic review has found that four tumor necrosis factor (TNF)-alpha inhibitors are more cost effective than placebo in treating progressive psoriatic arthritis (PsA) in patients who have not displayed an adequate response to standard treatment. The review focused on recent studies that examined the cost effectiveness of the TNF-alpha inhibitors adalimumab, etanercept, golimumab, and infliximab. Researchers performed a Bayesian network meta-analysis to estimate the relative efficacy of these TNF-alpha inhibitors in terms of Psoriatic Arthritis Response Criteria (PsARC), Health Assessment Questionnaire (HAQ) scores, and Psoriasis Area and Severity Index (PASI). The results of the meta-analysis and current cost data were used to update an existing economic model, which in turn was adapted to delineate patients by PASI 50 percent, 75 percent, and 90 percent response rates to differentiate between psoriasis outcomes. An analysis using 1,000 model simulations found that etanercept was the most cost-effective treatment on average. Adalimumab, etanercept, and infliximab were also found to be significantly more effective than placebo at improving HAQ scores in patients who had achieved PsARC response and in improving these scores in PsARC non-responders.


A recent study concluded that a positive effect of a fluoroscopically-guided anesthetic injection in a foot-ankle joint is not an indication that future arthrodesis will be successful. The study involved 74 patients, all of whom underwent fluoroscopically-guided and contrast-confirmed anesthetic joint injections to confirm the localization of pain in their foot-ankle joints. The effect of the injection as well as several clinical factors were used to decide whether to recommend conservative treatment or arthrodesis. Patients were then assigned to four groups based on the result of the injection and the occurrence of surgery. The study found that surgery was related to improvements in Visual Analogue Scale (VAS) and Foot Function Index (FFI), regardless of whether pain was reduced following the injection. In addition, VAS and FFI scores were consistently lower in patients who underwent conservative treatment, even when previous injections showed improvements in VAS scores.


A recent study examined the in vitro compatibility of an injectable atelocollagen matrix when used as part of the autologous collagen-induced chondrogenesis technique (ACIC). Researchers made the matrix by seeding human bone marrow mesenchymal stem cells and human chrondrocytes on pre-solid and solid atelocollagen scaffolds. Cell-scaffold constructs were then cultured for one week and prepared for histological analyses. Five patients affected by chondral lesions of the talus underwent arthroscopic ACIC and were followed up with six months after the surgery. In vitro results showed that the bone marrow mesenchymal stem cells and the chondrocytes efficiently colonized the pre-solid atelocollagen scaffold from the surface to the core, though they were not able to do so on the solid form of the scaffold. Researchers also observed no adverse events in patients treated with ACIC as well as significant improvements between pre- and post-operative Visual Analog Scale (VAS) and American Orthopaedic Foot & Ankle Society (AOFAS) scores. The study concluded that injectable atelocollagen, particularly the pre-solid form, is a feasible scaffold for cartilage repair treatment. In addition, the study concluded that ACIC leads to good clinical results in patients treated with chondral lesions of the talus. However, researchers said longer follow-up and more patients are needed to confirm their findings.