News From ACFAS

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To serve the ACFAS community better, ACFAS has moved its existing Facebook Group to a NEW Facebook Page. A Facebook Page allows more opportunity for interaction among the community, and the best part is that all posts will show up in your News Feed so you won’t miss any of the conversation!

You will not automatically be a part of the new ACFAS page, so you will need to follow this link Facebook.com/AmericanCollegeofFootandAnkleSurgeons and "Like" the new American College of Foot and Ankle Surgeons Page.

We will still post the same great information, news and updates we’ve been posting in the group, but now it will be more convenient for you because you won’t need to actively search for the College whenever you want an update; the updates will come to you!

See you there! Download the free mobile app for the ACFAS 2013 Annual Scientific Conference today, and you’ll be able to follow everything that’s happening in Vegas, even if you couldn’t make it this year. This app allows you to keep track of your pre-selected sessions, review all the conference happenings, find your way around with convenient maps, store contacts, search events and sessions, locate vendors, scan QR codes to find more information, read the latest conference happenings in the Twitter feed, and receive the latest conference alerts. Download the app by typing http://crwd.cc/acfas2013 on your mobile tablet or phone, or just visit the Apple store on your iPad or iPhone, search ACFAS 2013 and hit download. Learn the latest Division activities and happenings in your part of the country at your ACFAS Regional Division meeting being held at ACFAS 2013 in Las Vegas. All Regional Divisions will be meeting during the lunch hours in the Exhibit Hall at the conference, so check your on-site program book or the ACFAS 2013 mobile app to pinpoint your Division’s meeting specific date and time. Bring your lunch and be a part of the meeting with your local peers. All Division members who participate in their meeting at ACFAS 2013 will be entered into a drawing to win an iPad! Not attending the conference? Watch your email for more Division happenings in your area, or visit the Regional Division webpage to find out more about local events and Division support of students, residents and ACFAS members.

Foot and Ankle Surgery

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Researchers evaluated the combined use of liposuction and arthroscopic shaving to facilitate effective lower-limb fasciocutaneous flap contouring in a single session, carrying out the procedure in 10 free fasciocutaneous flaps in nine patients. The median interval between the initial reconstructive procedure and flap debulking was seven months. Two cases of flap superficial epidermal loss and one hematoma were among the observed complications. Five patients said they were very satisfied with the procedure, three were satisfied and one was dissatisfied at an average of 8.6 months follow-up. At the time of follow-up, seven patients were using their original covered footwear.


A study was held to illustrate the relationship that serum concentrations of Matrix Metalloproteinase-9 (MMP-9), MMP-2, TIMP-1 and TIMP-2 have with the healing of diabetic foot ulcers, using a cohort of 94 patients. The four serums were measured at the first clinic visit and at the end of four-week treatment, and were then followed up until 12 weeks had passed. Cases were divided into good and poor healers, based on the decreasing rate of ulcer healing area at the fourth week.

The average level of serum MMP-9 in good healers was lower than poor healers at first visit, and declined approximately fivefold after four weeks of treatment. Meanwhile, the change in MMP-9 concentration did not reach statistical significance in poor healers. MMP-2, TIMP-1 and TIMP-2 showed slight variance in both good and poor healers. The MMP-9/TIMP-1 ratio mirrored healing better than MMP-9 alone before treatment and after four-week therapy. Receiver Operator Curve demonstrated that the cutoff for MMP-9/TIMP-1 ratio at < 0.395 best predicted a reduction in wound area of 82 percent at the end of four-week treatment with a sensitivity of 63.6 percent and a specificity of 58.6 percent.

Practice Management

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Some 14 million newly insured patients will enter the health system as of Jan. 1, 2014, through the Affordable Care Act, and many practices are consequently considering adding physicians, physician assistants or nurse practitioners to accommodate the expected rise in patient traffic. However, practice management consultants warn that if physicians only concentrate on new hires, and not on the attendant marketing and infrastructure changes, then they will become vulnerable to committing serious mistakes.

Consultants say the most frequent error is neglecting to notify the community that the practice has additional capacity or new services, and this information should be sent to local media, area health institutions, the patient population and staff at the practice to lower the chance that patient traffic does not expand at expected levels. One consultant suggests practices use the waiting room to announce expansions and other changes.

The practice also must build its infrastructure to handle the increased patient load and avoid patient dissatisfaction. Providing more restrooms is one such instance of infrastructure build-out. Another example is ensuring that there are ample spaces for patients to park their vehicles on the grounds of the facility. An IT expansion must be considered as well, with consultants noting that paying license fees for an additional electronic health record user can get lost in the shuffle. Any transition will inevitably lead to things being overlooked, so consultants say a practice must identify a problem quickly and remedy it as soon as possible to ensure patient satisfaction without overwhelming physicians and staff.


There are more factors to consider than just cost when it comes to assessing alternatives for acquiring equipment or services for a medical office. To begin with, cost only examines part of what you are giving up, and initial cost makes no contribution to measuring the expected benefits that drive new purchases and other commitments. Furthermore, initial cost does not quantify total cost of ownership, such as consumables and maintenance. There also are many costs that do not entail writing a check or signing a charge slip, and reliability and ease of use can make an immense impact on operating costs.

Practices should take under consideration the goals they aspire to, and weigh such variables about what current equipment or services are unsatisfactory and need replacement or upgrading. Determining what elements of the status quo you want to maintain is important as well. Derived from the statement of what should be achieved is the characterization of important features and functions. The affordability of a piece of equipment or service means nothing if it cannot deliver the objectives. This is a good area to start evaluation of alternatives, as it will screen out products that lack the necessary capabilities.

Products that are good to have, and the business value they provide, are other factors to consider. What must then be weighed is how the alternatives stack up according to value. The practice must consider what it is receiving for its investment of both money and labor, initially and across the life cycle of the acquisition. You must determine which alternative offers the lowest cost/benefit ratio, assuming the cost is reasonable. Although the assessment process can slow down decision making to a certain degree, in general it can help practices avoid substantial time and dollars lost to poor decisions.


A new study from the University of Missouri at Columbia found that the digital tools featured in computerized clinical decision-support systems can sideline physicians from face-to-face sessions, engendering unhappiness among patients about their care. The researchers supplied study participants with various hypothetical physician-patient scenarios, including one where a physician used unaided judgment, one in which a physician used a computerized clinical decision-support system and another in which a physician consulted with an expert colleague.

The most positive ratings were given to physicians who made unaided diagnoses, who were viewed as more thorough, able and professional than their peers who used aids. Physicians seeking help from colleagues also were better rated than those who relied on technology. However, patient satisfaction levels rose when physicians strove to humanize technological tools and included patients in the use of decision-support tools. Physicians "can use the aids as teaching tools to explain their diagnoses using pictures or graphs, which make the patients' experiences much more interactive and educational," says lead study author Victoria Shaffer. The study was published in the journal Medical Decision Making.

Health Policy and Reimbursement

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The Centers for Medicare and Medicaid Services (CMS) has issued a long-postponed final rule for the Physician Payments Sunshine Act, establishing a deployment timeline that is a year past what the healthcare reform law mandated. Beginning Aug. 1, drug and device firms will be required to collect data about payments, gifts and other value transfers given to physicians and teaching hospitals, while manufacturers and group purchasing organizations (GPOs) will have an obligation to disclose physician ownership and investment interests. Under the final rule, manufacturers and GPOs must report the first round of data collection to the CMS by March 31, 2014. The data will then be displayed online by Sept. 30, 2014, one year after what the original law required. The first round of reporting will be restricted to five months of data rather than 12 months.


Evidence is growing that in more markets across the country, private sector health plans and employers are facing “very high price increases year-to-year” in some of the same markets where accountable care organizations have been approved by Medicare, according to Robert Galvin, chief executive officer of Equity Healthcare at Blackstone Group. Galvin said that coordinating healthcare among providers is leading to too much consolidation in some places. Provider consolidation can result in large organizations that have “tremendous pricing power,” which will lead to cost shifting from public sector programs such as Medicare to private payers, such as employers and individual health insurance customers, Galvin explained.


The Centers for Medicare and Medicaid Services (CMS) disclosed new prices for durable medical equipment and supplies under an expanded competitive-bidding program that the agency claims will save billions but that industry experts say could entail hardship for beneficiaries. Those prices are applicable to the second round of the Medicare Durable Medical Equipment, Prosthetics, Orthotics and Supplies competitive-bidding program, which will grow to include 91 major metropolitan areas on July 1 and add new product categories and a mail-order competition for diabetic testing supplies. CMS calculates that Medicare will pay an average 45 percent less than its current fee schedule amounts for product categories that include oxygen equipment, standard wheelchairs, walkers and hospital beds, and overall save the Medicare Part B Trust Fund $25.7 billion and beneficiaries $17.1 billion from 2013-2022. In addition, Medicare will start reimbursing a single payment amount for diabetic testing supplies, whether those supplies are bought through a mail order supplier or a retail supplier. CMS estimates that beneficiaries will save an average of 72 percent on these supplies through a new mail-order competitive-bidding program.

However, Attorney Eric Zimmerman, who represents the Diabetes Access to Care Coalition, says he saw difficulties for beneficiaries in the first round of competitive bidding, and the program's expansion could exacerbate the situation. “We have seen ... beneficiaries unable to get the diabetes test systems that they're familiar with and want," he says. "Quite a good number who purchased their strips from mail order suppliers left mail order to buy their preferred brands from retail suppliers. Now that Congress has extended a single payment amount to retail suppliers, we are concerned retail suppliers will be under the same economic pressure, and beneficiaries will have a very difficult time finding test systems they need.”


The Centers for Medicare and Medicaid Services (CMS) has announced that over 450 healthcare organizations—including nonprofit and for-profit hospitals, academic medical centers, physician-owned facilities and post-acute providers—will participate in the Bundled Payments for Care Improvement initiative, a payment model program created in the healthcare reform law to assess whether bundling payments for services in a single episode of care can enhance quality and reduce costs. The organizations were selected either as awardees for Model 1 beginning in April, or as participants for the first phase of models 2, 3 and 4 that starts with the Jan. 31 announcement.

Awardees in Model 1 agree to furnish a standard discount to Medicare from the typical Part A hospital inpatient payments, and hospitals and providers are able to share any gains that come from their care-redesign approaches. Models 2 and 3 follow a retrospective bundled-payment scheme where expenditures are settled against a target price for an episode of care, while Model 4 entails a prospective bundled-payment scheme where a provider receives a lump sum payment for the entire episode of care. Participants can select up to 48 clinical episodes of care to test in each of these three models. "It is important that physicians in a variety of practice types have opportunities to participate in bundled payment program pilots,” says American Medical Association (AMA) President Jeremy Lazarus. “The AMA urges CMS to provide opportunities for additional practices, which may not have been ready to apply when the program was first announced, to participate. We encourage CMS to offer additional models as the four existing models all involve an inpatient hospital stay.”


A bill to repeal the Independent Payment Advisory Board (IPAB) contained in the Affordable Care Act is supported by the Alliance of Specialty Medicine, a coalition of specialty groups that includes brain surgeons, plastic surgeons and heart physicians. The board would be authorized to make targeted cuts in Medicare payments to physicians if the program's overall costs increase faster than a certain rate. "The process and structure of the IPAB is fraught with potential unintended consequences and the IPAB lacks the clinical expertise and the research capacity to examine the national and regional effects of proposed recommendations to ensure patients are not unduly impacted," the Alliance wrote in a letter to Congress.

The Affordable Care Act requires Congress to adopt the IPAB's recommendations expediently, and lawmakers can only halt the enactment of the board's cuts by passing equivalent cuts elsewhere in the federal budget. "The Alliance strongly opposes the IPAB or any other board resulting in an inappropriate delegation of Congress’ oversight responsibilities," the coalition wrote in its letter. "Significant healthcare decisions must not be made by a group of unelected, unaccountable individuals with little or no clinical expertise or the oversight required to protect access to care for America’s seniors."


The Workgroup for Electronic Data Interchange (WEDI) and the Centers for Medicare and Medicaid Services (CMS) will use an online poll to measure the healthcare industry's level of readiness for the Oct. 1, 2014, compliance deadline for the adoption of the ICD-10 diagnostic and procedural codes. WEDI says it and CMS will use the survey "to evaluate challenges and identify areas in need of additional education and assistance." Health IT Consultant and WEDI ICD-10 work group Chairman Stanley Nachimson says WEDI is re-asking a number of questions from last year's poll, and adding new ones concerning the effects of last year's delay of the ICD-10 deadline on organizations. “My sense is that vendors are moving along and a lot of health plans are moving along and have done considerable work," Nachimson says. “But I think the question is on the providers' side.” Meanwhile, the American Medical Association has made repeated calls for a further postponement of ICD-10 implementation.

Medicine, Drugs and Devices

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A Food and Drug Administration (FDA) panel has proposed new restrictions on hydrocodone drugs. Under the proposal, which would still have to be approved in the FDA's decision-making process before it would take effect, hydrocodone would be reclassified as a schedule II drug. That would mean that patients could only receive one 90-day prescription that could not be written by a nurse or physician assistant.


Researchers say that they may have made a significant advancement in the effort to understand why certain genes are associated with an elevated risk of rheumatoid arthritis and other autoimmune diseases. In a study published in The Journal of Immunology, researchers examined mice and found that a subset of human leukocyte antigen (HLA) genes that contained the shared epitope protein sequence activated osteoclasts and inflammation-causing cells. Researchers said that triggering osteoclasts results in the destruction of joints in people with rheumatoid arthritis. Researchers also said that their findings could lead to the development of drugs used to treat rheumatoid arthritis and other autoimmune disease.


Researchers at the University of California - Santa Barbara have made a discovery that could lead to the development of a new way to detect and monitor osteoarthritis. In a study published in the Proceedings of the National Academy of Sciences, researchers described using a device known as a Surface Forces Apparatus—which consists of an acoustic or electric sensing device and produces a readout similar to an EKG—to examine the type of friction that is occurring between joints. Researchers found that what causes osteoarthritis is not high-friction force but rather stick-slip friction, in which layers of cartilage pull apart and slide across each other, stick together and pull apart again, resulting in jerky movements. The findings suggest new ways to detect stick-slip friction and could eventually lead to new research on the causes of osteoarthritis.