News From ACFAS

ACFAS Past President. Former JFAS Editor-in-Chief. Educator. Internationally-respected lecturer. Author. Innovator. Leader. Mentor.

An unfathomable magnitude of change has taken place in the almost 45 years since Lowell S. Weil, Sr. received his DPM from Illinois College of Podiatric Medicine. Physician practices, medicine, products, and the use of technology have been transformed.

In "Dialog with Lowell S. Weil, Sr., DPM," this podiatric "legend" presents a big-picture view of how far the profession has come since his 6-month residency at Detroit's Kern Hospital.

Log-on to this new ACFAS e-Learning Podcast for an eye-opening, entertaining, insightful hour of conversation moderated by Barry I. Rosenblum, DPM. We promise: it's never dull!

When planning your schedule for the March 4-8 Annual Scientific Conference in Washington, D.C., be sure to include Saturday night’s special event at the International Spy Museum and dinner at the famous Gordon Biersch microbrewery-restaurant.

The Spy Museum is DC’s hottest tourist ticket and we’ll have private access to 200 fascinating exhibits on spy gadgets, weapons, bugs, cameras, and history from spy agencies like the OSS, CIA, and KGB. Afterward, walk across the street to Gordon Biersch for micro-brews, good food, and great conversation. Then, either roam the DC Entertainment District or hop on our bus for a nightlights tour of DC’s monuments.

Tickets may be purchased with your online conference registration or on-site at the ACFAS Conference Registration Desk. Don’t miss this unforgettable event!

Also, don't forget the Honors and Awards Ceremony and Annual Business Meeting will be held Friday, March 6 at 12 Noon.

The privacy of your patients’ health records is protected under the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule. In this age of electronic health information exchange and personal health records (PHRs), the requirements of the Privacy Rule may present unique challenges to providers. The United States Department of Health and Human Services, Office for Civil Rights (OCR) has issued new guidance to assist practitioners in remaining compliant with the Privacy Rule.

Two particular resources are available to help you develop policies behind electronic health information exchange in a networked environment: (i) The Nationwide Privacy and Security Framework for Electronic Exchange of Individually Identifiable Health Information (the “Framework”) and (ii) the Health IT Privacy and Security Toolkit (the “Toolkit”).

The OCR has also developed a new FAQ about the application of the Privacy Rule on family medical histories, another area that can raise difficult questions when patients are developing PHRs.

For more information and links to various Department of Health and Human Service documents, use the Web link below.


Last Friday a bill was introduced in the South Carolina Senate (S356) that would expand the scope of podiatry practice to expressly include the ankle “and the related soft tissue structures to the level of the anterior tibial tubercle” as well as amputation of the toes and other parts of the foot (excluding amputation of the entire foot).

In addition to expanding the scope of practice, the bill requires health facilities to allow podiatric foot and ankle surgeons to pursue and practice full clinical and surgical privileges within this scope of practice. Health facilities would also be required to make privileging decisions without regard to whether the applicant is an M.D., D.O., or D.P.M.

If you would like more information, contact the ACFAS Health Policy Department at (773) 693-9300.

Foot and Ankle Surgery

A Prospective Study of Autologous Chondrocyte Implantation in Patients With Failed Prior Treatment for Articular Cartilage Defect of the Knee

Researchers led by Kenneth R. Zaslav, MD, of the Department of Orthopedic Surgery at the Advanced Orthopedic Centers at Virginia Commonwealth University sought to gauge the effectiveness of autologous chondrocyte implantation in patients who experienced failure in prior treatments for articular cartilage defects of the knee. In a clinical study, 154 patients with failed treatment for articular cartilage defects of the knee received autologous chondrocyte implantation. Eighty-two percent, or 126, of the patients completed the four-year study. Seventy-six percent were treatment successes at the study end, with outcomes based on change from baseline in knee function, knee pain, quality of life, and overall health. The researchers concluded that patients with moderate to large chondral lesions with failed prior cartilage treatments can expect sustained and clinically meaningful improvement in pain and function after implantation.



Bilateral Heel Panniculitis Presenting as Calcaneal Osteomyelitis

The histopathological findings related to panniculitis can make diagnosis difficult, write Meir Marmor, MD; Amir Haim, MD; Michael Drexler, MD; and Tamir Pritsch, MD, of the Department of Orthopedic Surgery at Sourasky Medical Center in Tel Aviv, who present an example of bilateral heel panniculitis that was initially misdiagnosed as calcaneal osteomyelitis. The 66-year-old female patient did not see improvement in her right heel condition after an incision and drainage operation, and her left side began to see similar phenomena, leading to the new diagnosis of panniculitis and to corticosteroid treatment that improved her condition quickly. The initial diagnosis was influenced by the patient's history of a foreign body penetration, but this was later found to be a distraction from the real cause of the problem, which likely was erythema induratum. Some of the problems associated with diagnosing panniculitis include the varying names that have been used for the same disorder and the changes to existing terms, such as cases that once would have been called Weber-Christian disease being categorized now as a1-antitrypsin deficiency panniculitis, lupus panniculitis, or pancreatic panniculitis. Many forms of panniculitis resemble one another, presenting as tender erythematous subcutaneous nodules, although they can have diverse etiologies and represents various different disease processes. Panniculitides are classified by histopathological appearance and etiology, requiring excisional biopsy for a precise diagnosis.



U.S. Outpatient Surgeries on the Rise

A new report from the National Center of Health Statistics at the Centers for Disease Control and Prevention shows that outpatient surgery visits now make up nearly two-thirds of all surgery visits. The increase in outpatient surgery visits in the last decade is due to medical technology and changes in payment arrangements, according to the report, titled "Ambulatory Surgery in the United States, 2006." The report found 34.7 million outpatient surgery visits in 2006. Average operating-room time per visit varied from about 43 minutes at freestanding centers to close to 62 minutes at hospital-based centers, with the type of diagnosis having a large impact on average total length of time. The principal source of payment was private insurance.

Practice Management

Considering Your Staffing Options

Many medical practices find it difficult to retain part-time billing workers, which reduces productivity. Practice administrators need to first determine if the workload warrants a full-time employee. Hiring a full time employee may be necessary for proactively resolving front end issues. This professional could also work with affiliated facilities to improve the data that comes into the practice. Full time employees are also more likely to have a personal stake in the success of the practice compared to a part-time worker. It is also important to see if existing employees are working at full capacity and efficiently. For example, an employee might be making the same mistake repeatedly, which wastes significant amounts of time. Another option is to outsource billing to a revenue cycle management (RCM) vendor or a professional employer organization. Some RCM vendors charge a flat fee while others charge according to a percentage scale based on performance. Practices can also create a formal job-sharing arrangement with former part-time employees in which those who are more regularly available can get a higher wage.



Contracting: Beyond the Basics

Negotiating changes in an insurance carrier's routine physician contract is not a simple task, but it is something that physicians and private practice managers are increasingly having to do. If a contract is unacceptable, the physician can decline it, change it, or create an addendum, though declining will mean patients will have to pay a larger copayment or deductible--which may affect the practice's collections. Much simpler is to create an addendum to the contract, particularly if there are problems in the areas of the definition of usual and customary, down-coding protections, fee change procedures, special bundling procedures, rules and regulations clause, look-back provisions, clean claim definitions, timely payouts, most favored nation, full fee disclosure schedule, dispute resolution, common credentialing, and automatic addition of new members to the practice. Contract review and negotiation should be an ongoing process, and physicians should train their office manager or administrator to monitor these issues and address them with carriers so that they do not take up too much of the physician's time.

Health Policy and Reimbursement

U.S. Stimulus Plan Would Pour Billions Into Health

The U.S. stimulus plan pending in Congress would put at least $100 billion into healthcare proposals, underscoring the idea that improving the healthcare system would stimulate the economy. The Senate version of the bill includes an $87 billion increase in the federal share of Medicaid and a $25 billion 10-year injection to COBRA, with a proposal that the government pay 65 percent of COBRA premiums for people who lost their jobs since September. Other proposals include $17.9 billion for health information technology, including a bonus of 85 percent of costs for doctors whose patient list is at least 30 percent Medicaid patients, as well as a yet-to-be-determined bonus for hospitals with at least 10 percent Medicaid clients. In addition, $1.1 billion is proposed for comparing the effectiveness of medical tests and treatments via the Agency for Healthcare Research and Quality and the National Institutes of Health, and $1.3 billion is proposed for Transitional Medical Assistance for people about to move off Medicaid.



UnitedHealth Settlement Big for Docs

The UnitedHealth settlement newly unveiled by New York Attorney General Andrew Cuomo holds the promise of much more empowerment for physicians as it sheds more light onto the processes insurers use in deciding how much to pay. As part of the settlement, UnitedHealth will have to shut down the benchmarking databases administered by its Ingenix subsidiary and pay $50 million toward creating an independent, nonprofit replacement for them. Aetna has also agreed to put $20 million toward this new effort and to use the resource when it becomes available. Providers have complained that the system gives patients the incorrect impression that insurers will pay some percentage of the patient's actual bill for out-of-network services, whereas in reality the insurers pay a percentage of what is seen as the prevailing rate in the geographic area in question. "I think it's a very substantial benefit to consumers," says Paul Ginsburg, president of the Center for Health System Change. "Everything in price transparency so far has really only applied to in-network providers." Cuomo noted that the Ingenix data encouraged doctors to report numbers that would support low insurer payouts. "It's hard to explain why it's gone on so long without this kind of attention," says William Van Slyke of the Healthcare Association of New York State. "It puts the hospital in this terrible position of eating the cost themselves or going after the patient, who in our estimation is being poorly treated by the payer."



Senate Passes Children's Health Insurance Bill

The Senate has approved legislation to expand health insurance for children under SCHIP. The measure mirrors one approved in the House two weeks ago and would provide coverage for an additional 4 million children, but the vote in the Senate, 66 to 32, highlights partisanship and could bode ill for future efforts to reform the healthcare system in the United States by the Obama administration. In the past, SCHIP has enjoyed bipartisan support, though there have been dissenting views over the income threshold for qualification in the program. In 2007, SCHIP legislation developed by senior Republican and Democratic lawmakers won approval from 45 Republicans in the House and 18 in the Senate; Thursday's vote, by contrast, won the backing of just 9 senators. The vote signaled Republican rebellion against Democratic efforts to expand the federal government's role in providing health insurance as well as anger over the insertion of a provision in the bill that would expand health insurance for the children of legal immigrants. An earlier bipartisan compromise limited such aid to children who have been in the country for more than five years. Yet experts doubt Republicans will be able to derail efforts to reform the U.S. healthcare system given the determination of the Obama administration and Democratic support in Congress. "At the end of the day, it may be that healthcare reform will be passed with only a small number of Republicans," says Chip Kahn, a former Republican staffer who heads the Federation of American Hospitals.



California's High Court Bans Balance Billing

The California Supreme Court recently ruled unanimously that state law does not allow out-of-network emergency physicians to turn to patients for outstanding bills that health plans will not cover, but doctors say this does not resolve the root issue of HMOs routinely underpaying physicians. According to the court ruling, reimbursement disputes "must be resolved solely between the emergency room doctors, who are entitled to a reasonable payment for their services, and the HMO, which is obligated to make that payment," and patients "may not be interjected into the dispute." Physicians have expressed concern that the court did not remedy reimbursement discrepancies and that this will add to the stress on the emergency care system. While physicians are sympathetic to patients, says California Medical Association (CMA) President Dev GnanaDev, MD, "you can't just give a blank check to HMOs. ... There's no way a little trauma surgeon like me can go after any HMO. My resources are minimal. It's like David versus Goliath." CMA reports that California's emergency departments were underpaid by more than $1 billion in 2007 and that more than 70 emergency departments have had to close in the past few years because of financial problems. Meanwhile, the court's ruling reaffirms recent regulations saying that balance billing for out-of-network emergency care is an unfair billing pattern, according to Department of Managed Health Care (DMHC) Director Cindy Ehnes. Some measures provided under state laws and regulations to protect out-of-network emergency doctors include requiring HMOs for emergency services, prohibiting them from engaging in unfair payment practices, requiring them to have internal dispute resolution mechanisms, and allowing emergency doctors to sue HMOs over reimbursement issues. However, doctors argue that these have done little to make HMOs accountable. DMHC has backed an independent dispute resolution process also supported by CMA, but doctors have been less interested due to the cost of participation.

Technology and Device Trends

UT to Develop Fracture Putty for Traumatic Leg Injuries

Development of a bio-compatible compound or "fracture putty" to treat serious leg fractures is the goal of a multi-institution initiative led by biomedical engineers at the University of Texas Health Science Center in Houston. The U.S. Department of Defense has provided $5.2 million in initial funding in hopes of developing a compound that could regenerate bones shattered by explosive devices—a non-union fracture that can be difficult to heal. A successful fracture putty could enable injured soldiers to get full use of their legs back much more quickly than they can now. "Success on even a small part of the project has the potential to revolutionize orthopedic medicine. It could give people with serious leg injuries an opportunity to regain full use of limbs that now require amputations or the use of permanent implants," says principal investigator Mauro Ferrari, Ph.D. "We're creating a living material that can be applied to crushed bones. The putty will solidify inside the body and provide support while the new bone grows." The putty is to include a material known as nanoporous silicon, developed in Ferrari's lab, to make the putty strong enough to support the weight of the patient as new bone tissue is being regenerated. "The fracture putty will serve as a bioactive scaffold and will be able to substitute for the damaged bone," said Ennio Tasciotti, Ph.D., a research assistant professor in the lab. "At the same time, the putty will facilitate the formation of natural bone and self-healing in the surrounding soft tissue through the attraction of the patient's own stem cells."



US Approves 1st Stem Cell Study for Spinal Injury

In yet another indication of President Barack Obama's intention of reversing many of his predecessor's policies, a U.S. biotechnology company has won federal approval to proceed with the world's fist study of a treatment based on human embryonic stem cells. Menlo Park, Calif.-based Geron will inject up to 10 paraplegics with cells derived from embryonic cells in a bid to test the safety of the procedure as well as its efficacy. "It's a milestone and it's a breakthrough for the field," says Ed Baetge, chief scientific officer of Novocell, which hopes to begin a similar human study for treating diabetes in a few years. The Geron study will involve injections made at the site of damage in the spine. Animal studies suggest that the stem cells will mature and repair what is basically a lack of insulation around damaged nerves while "pumping" out substances that nerves need to function and grow. Patients will receive anti-rejection drugs for about two months; after that, the injections should not be needed. Dr. Thomas Okarma, president and CEO of Geron, says that if successful, the therapy will be "remarkably affordable ... in the context of the value it provides."



Foot Segment Kinematics During Normal Walking Using a Multisegment Model of the Foot and Ankle Complex

Gait analysis using optical tracking gear is a clinically practical tool for measuring three-dimensional kinematics and kinetics of the human body, although the motions of the joints of the foot cannot be measured in current practice because the foot is treated as a single rigid segment that articulates with the lower leg. A multisegment kinematic model of the foot sectioned into hindfoot, talus, midfoot and medial and lateral forefoot segments was devised to be used in a gait analysis laboratory. Half a dozen functional joints—ankle and subtalar joints, frontal and transverse plane motions of the hindfoot relative to midfoot, supination-pronation twist of the forefoot relative to midfoot, and medial longitudinal arch height-to-length ratio—were defined. A dozen asymptomatic subjects were tested walking barefoot with an optical stereometric system and passive markers clustered in triads, and coefficients of multiple correlation were used to test repeatability of reported motions. Measurement of motion within the foot is essential to maintain the relevance of gait analysis in orthopedic and rehabilitative therapy of the foot and ankle.



Abstract News © Copyright 2009 INFORMATION, INC.

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