News From ACFAS

---

The ACFAS Board of Directors has submitted a second warning to the accreditors of podiatric CME that significant reform is needed, despite a similar call one year ago to the Council of Podiatric Medical Education (CPME). The College’s call for reform was in response to a second round of public comments to proposed revisions of CPME’s CME standards, otherwise known as Documents 720 and 730.

“ACFAS believes that CPME’s CME standards must be equivalent or more stringent than allopathic CME requirements if podiatry is serious about professional parity,” said newly installed ACFAS President Thomas S. Roukis, DPM, PhD, FACFAS. “A few of our 2013 comments were included in the revised CPME 720 and 730 documents, but the first round of revisions are grossly inadequate to meet the challenges facing this profession.”

ACFAS members can view the College’s cover letter and 19-page analysis at acfas.org/CMEreform. Publicize to your patients and community that you’ve advanced your education by attending the ACFAS 2014 Annual Scientific Conference in Orlando with ACFAS’ Fill-in-the-Blanks Press Release. This free marketing tool, customized just for ACFAS 2014 attendees, is available online at acfas.org/marketing (login is required). Just open the release template, fill in the blanks with your professional contact information, add your logo and send off to your local media, put in your newsletter or on your website and even share in your social media pages-- it’s that easy.

While on the ACFAS Member Marketing Toolbox page, you’ll also find other great practice promotional items available free to members, including other Fill-in-the-Blanks Press Releases, FootNotes newsletter templates and ACFAS member logo files.
If you attended the ACFAS 2014 Annual Scientific Conference, you're eligible to download the session handouts that will be available next week at acfas.org/orlando (Login is required). Also, watch for the poster links and video presentations of seven unusual research topics presented at the ACFAS 2014 in Orlando. Jeffery Carlson, DPM, AACFAS, from Sidney, OH attended his ACFAS Division 13: Ohio Valley Membership Meeting, and Qeena Woodard, DPM, FACFAS, from Chicago attended her ACFAS Division 6: Midwest Membership Meeting – and along with learning about ACFAS happenings in their parts of the country, they also each won an Apple iPad Mini! Congratulations, Drs. Carlson and Woodard!

For all ACFAS members who attended the conference and sat in on their Division’s Membership Meetings, thanks for taking part in the ACFAS Division Presidents Council’s iPad Mini raffles. Please watch your email to learn about your ACFAS Division’s activities happening soon, or you can visit the Division webpages for more information.

Foot and Ankle Surgery

---

A recent study has concluded that excision of the os peroneum, tendon debridement, and tenodesis of the longus to brevis is an effective surgical technique for treating tears of the distal peroneus longus tendon. The technique was used in 12 patients, all of whom were suffering from peroneus longus tendon tears with associated pathology of the os peroneum. Eight of the patients had a tear that was associated with a fractured os peroneum, while the remaining four had an enlarged and entrapped os peroneum that prevented movement at the cuboid tunnel. Nine patients experienced partial tears of the peroneus brevis that were treated with debridement and suture repair. Patients underwent follow up at an average of 63.3 months after surgery. American Orthopaedic Foot & Ankle Society hindfoot scores increased from an average of 61 before surgery to an average of 91.7 at follow up. Average Short Form-36 (SF-36) Physical Component Scores, meanwhile, increased from 36 before surgery to 52 after the operation. Mean Visual Analog Scale (VAS) scores dropped from 6.3 before surgery to 1.0 afterward. However, two patients suffered sural neuritis and three others experienced superficial delayed wound healing, though the latter were successfully treated without additional surgeries.


A new study has found that tibiotalocalcaneal arthrodesis using an osseous compressing arthrodesis nail system is an effective technique for treating concomitant tibiotalar and subtalar arthritis and correcting any associated deformities. Thirty limbs that were operated on using this procedure were studied, 13 of which had a preoperative coronal plane deformity of more than 15 degrees. Patients were followed-up with at an average of 26 months, at which point 76 percent of limbs had a coronal deformity of less than 5 degrees. Union was achieved in 96.6 percent of patients. Average Visual Analog Scale (VAS) scores dropped from 6.5 before surgery to 3.1 at follow up, while average American Orthopaedic Foot & Ankle Society (AOFAS) Ankle/Hindfoot scores rose from 29.7 to 74.3. Average total Short Form-36 (SF-36) scores rose as well, from 85.6 before surgery to 98.8 at follow up. However, tibial stress reaction, transient plantar nerve irritation, and wound infection were seen in three cases each.

Practice Management

---

Doctors need to be aware of the existence of so-called apology laws, which prevent patients who file malpractice suits from using apologies made by physicians as evidence of wrongdoing. Physicians in 37 states are protected by apology laws, while those in New York, Illinois, and 11 others are not. However, there is variation in the types of apology laws that have been enacted by these states. Most of the states have enacted partial apology laws, which prevent patients from using statements of compassion, commiseration, condolence, or sympathy from being used as evidence against a doctor in a malpractice suit. The full apology laws that have been enacted in Connecticut, Colorado, and Georgia, among others, prevent patients from using any statement of fault, error, liability, or mistakes from being construed as an admission of guilt for the purpose of a malpractice claim. Doctors should be sure which type of apology law, if any, is in effect in the state in which they practice. Regardless of whether such a law is in place, doctors should be sure to make themselves available to patients after treatment so that they can learn why patients may not be satisfied in order to provide an explanation if necessary. This will help improve relationships with patients while shielding the practice from malpractice suits.


A recent survey of nearly 1,000 doctors found that 29 percent of physician practices spent more than $200,000 implementing electronic health record (EHR) systems. That includes spending on hardware, software, training, and consultation. An additional 22 percent said they spent anywhere from $10,000 to $50,000 on EHR implementation, while 18 percent said they spent between $50,000 and $100,000. Fifteen percent said they spent less than $10,000 on their efforts to implement EHRs, the survey found.

Health Policy and Reimbursement

---

President Obama's fiscal 2015 budget calls for almost $1 trillion in spending for the Department of Health and Human Services' (HHS) health programs, though it also includes a number of cuts to Medicare and premium increases that are being criticized by some healthcare provider groups. The legislation specifically calls for HHS to be given $1.8 billion to allow it to fully implement the Affordable Care Act in the next fiscal year. Medicare Part D and Part B premiums for higher-income beneficiaries would be raised under the bill, while reimbursement rates for Part D drugs would fall from 106 percent of average sales price to 103 percent. In addition, Medicare's drug payment policies for low-income beneficiaries would be altered so that they are the same as similar policies used by Medicaid. Another proposal calls for lowering the target rate for triggering the Medicare recommendations the Independent Payment Advisory Board provides to Congress. Future disproportionate share hospital allotments would also be rebased after 2023 under the budget proposal. The American Hospital Association has criticized the president's budget, saying that it would hurt efforts to improve the nation's healthcare system and would make it more difficult for patients to obtain access to care.


The Congressional Budget Office (CBO) estimates that the cost of permanently repealing the Medicare Sustainable Growth Rate (SGR) formula will be $138 billion over the next 10 years. That amount includes the 0.5 percent annual increases in Medicare physician payment rates that the repeal bill provides for, but does not include the cost of extending funding for additional health programs that are related to Medicare. Congress has to find a way to offset the cost of repealing SGR because the repeal bill must comply with pay-as-you go rules that are written into the law. Some say that could be difficult to do because lawmakers from both parties are hesitant to upset their constituencies in an election year. As a result, there could be another SGR patch that will prevent the 24 percent cut to Medicare physician rates from occurring on March 31 as scheduled. A Senate Finance Committee aide said there is no talk of a new SGR patch, though at least one healthcare industry observer says there is a great deal of discussion about a nine- or 12-month extension of current payment rates.


Centers for Medicare and Medicaid Services (CMS) chief Marilyn Tavenner says the conversion to ICD-10 codes will take place on Oct. 1 as planned. Tavenner said that the implementation of ICD-10 has already been delayed several times and that it is time to move forward with the use of the new diagnostic and procedural codes. American Medical Association (AMA) President Ardis Dee Hoven criticized Tavenner for not offering an additional delay, saying that a large number of doctors may be unable to adequately test the software updates they need for the conversion because they have yet to receive these updates from vendors. Dee Hoven warned that any problems with this software that remain unresolved after Oct. 1 could result in a massive backlog of medical claims that negatively impacts doctors' practices and the ability of patients to obtain healthcare, since there is no plan for dealing with disruptions in Medicare claims processing. Meanwhile, the American Hospital Association (AHA) criticized Tavenner for saying that she will not push back the April 1 and July 1 deadlines for eligible hospitals to begin 90 consecutive days of meeting Stage 2 meaningful use criteria. AHA says that as many as 40 percent of hospitals may miss the deadline for meeting meaningful use requirements and adopting certified electronic health records. However, Tavenner said CMS could provide hardship exemptions for Stage 2 meaningful use requirements to some providers on a case-by-case basis.


The U.S. Supreme Court announced March 3 that it will take up a case in its next term involving a dispute over the North Carolina Board of Dental Examiners' use of state action immunity as a defense against allegations brought by the Federal Trade Commission (FTC). The board is appealing a ruling by the U.S. Court of Appeals for the Fourth Circuit that found that it could not use state action protections as a defense for charges that it conspired to eliminate competition for teeth-whitening services offered by non-dentists in North Carolina. Such actions constitute a violation of the Sherman Act, the FTC argues. The appeals court said the board was not entitled to use those protections because it is a private body. The FTC says it agrees with the appeals court's ruling. The outcome of the case could have several important ramifications. For instance, the High Court's ruling could provide greater clarity about the extent to which a state medical board can use state action immunity to defend itself from charges of anti-competitive conduct brought by the FTC. Legal observers also say that the case could have an impact on FTC enforcement, particularly since it is being heard at a time when the regulation of medical professionals by state boards is becoming more contentious.


Incoming Senate Finance Committee Chairman Ron Wyden (D-Ore.) is calling on Congress to pass legislation that would permanently repeal Medicare's Sustainable Growth Rate (SGR) formula. Speaking to attendees at the Federation of American Hospitals' recent annual conference, Wyden said that legislation that would repeal SGR would be beneficial because it would help move the healthcare system away from fee-for-service medicine by incentivizing healthcare providers to use coordinated care delivery models. Those incentives would be provided beginning in 2017. However, Wyden did not say how Congress should pay for the repeal of SGR, which is expected to cost roughly $126 billion over 10 years. If lawmakers are unable to find a way to offset the cost of repealing SGR, they may not be able to pass a permanent repeal of the formula this year. Congress has until March 31, when the current SGR fix expires. If Congress fails to find a way to pay for the repeal of SGR by then, it could have to pass another temporary patch. Wyden would not say whether he thought Congress would have to take such a step or not.


The Centers for Medicare and Medicaid Services (CMS) has announced that it will re-review all Medicare in patient claims that have been denied under the two-midnights rule since Oct. 1. CMS says the re-reviews are necessary because Medicare auditors may have denied claims for reasons that are no longer supported under the updates that were made to the policy on Sept. 5, 2013 and Jan. 30. The re-reviews of the denied claims will be performed apart from the normal appeals process. Hospitals whose Medicare claims were denied under the two-midnights rule before the Jan. 30 update was issued will not have to have to wait the standard 120 days before filing an appeal, CMS says. The agency also says that hospitals should work with their local Medicare contractors to ensure that denials of claims under the two-midnights rule have undergone the re-review process before the formal Medicare appeals process is used. It is unclear how many Medicare claims will be re-reviewed by CMS, as the agency has not said how many claims have been denied under the two-midnights rule. That policy states that hospitals are to be reimbursed under Medicare in-patient rates only if patients are in hospital beds for two nights; if not, hospitals are to be reimbursed under the lower outpatient observation rates.


Estimates about the size of the 2015 payment rate cut to Medicare Advantage vary widely, though officially the Centers for Medicaid and Medicare Services (CMS) says that the cut will be at least 1.9 percent. But some healthcare industry groups and analysts doubt that. America's Health Insurance Plans (AHIP) estimated that the cut for fiscal 2015 will be at least 4 percent. However, AHIP noted in a statement issued Feb. 24 that some industry analysts believe the cut could be as large as 9.3 percent. AHIP added that a cut of at least 4 percent, coupled with the more than 6 percent cut that was made in fiscal 2014, would cause "further disruption" to senior citizens enrolled in Medicare Advantage. The organization also noted that additional changes to Medicare Advantage payment rates could push the cut "much higher" than 4 percent in fiscal 2015. A CMS spokesman would not speculate about any such additional changes, and pointed out that the proposed cut of at least 1.9 percent is smaller than the reduction in payment rates that was made in the current fiscal year. The spokesman added that premiums for Medicare Advantage beneficiaries have fallen as a result of efforts to reduce overpayments for healthcare services. Federal regulators will issue a final figure of the size of the payment reductions within the next several weeks.


Doctors' practices may be at risk of not being reimbursed by insurance companies after treating patients who have enrolled in insurance plans offered through the new health insurance exchanges but have yet to pay their premiums, due to a provision of the Affordable Care Act. The statute gives patients who have purchased coverage through the exchanges but have not yet paid their premiums a grace period of up to 90 days, during which they can technically use their new plans to obtain care. Insurance companies are required to pay any claims made by such patients during the first 30 days of the grace period, though during the next 60 days insurers are allowed to wait to pay doctors until the patient pays his premium. Insurers are also allowed to refuse to pay these pending claims or recover any payments made to doctors if patients still have not paid their premiums by the end of the 90-day grace period. As a result, some physicians' practices say they are verifying that patients have paid their premiums by calling their insurance companies before providing care. But at least one practice reports that hold times for insurance company representatives have been lengthy, and that spending a large amount of time on the phone has hurt the practice's productivity. At least one insurer says it is trying to rectify such problems by adding more call center employees and extending business hours.


President Obama said Feb. 25 that roughly 4 million people have signed up for health insurance coverage through the exchanges established by the Affordable Care Act (ACA), and added that millions of other people are benefiting from the statute's expansion of Medicaid and a provision that allows young people to stay on their parents' plans until they are 26 years old. The number of enrollees is well short of the 7 million people the Obama administration had hoped would sign up for insurance coverage by the end of the open enrollment period on March 31. The president said the low enrollment figure is the result of problems with Healthcare.gov last fall as well as intense political opposition to ACA. However, the administration is planning a public relations campaign to encourage uninsured consumers to take advantage of the exchanges and sign up for coverage. The president himself, as well as the first lady and Vice President Joe Biden, have already made appearances on a number of radio and TV programs encouraging such consumers to do so. Consumers who have not signed up for coverage by the end of the open enrollment period face the possibility of federal fines.

Medicine, Drugs and Devices

---

A new technology called low-level laser therapy (LLLT) holds promise in treating patients with chronic plantar fasciitis, a new study has found. The 30 patients who participated in the study were treated with LLLT twice a week for three weeks and underwent 12 months of follow up. At the conclusion of the follow-up period, average heel pain Visual Analog Scale (VAS) scores had dropped to 6.9 from 67.8 at baseline. Total Foot Function Index (FFI) scores improved as well, falling from an average of 106.2 at baseline to 32.3 at final follow up. Although the doctors who performed the study said the results are promising, they added that more research into the effectiveness of LLLT is needed.


A new study has found that hybrid ankle foot orthosis (AFO) that use polypropylene covered with canvas fabric can be recommended for controlling ankle motion in chronic hemiparetic stroke patients. The study involved 17 chronic hemiparetic stroke patients who had used either a hybrid AFO or a plastic AFO. Participants were asked about their level of satisfaction with the devices and also underwent gait analysis to determine the effects of the two types of AFOs on walking speed, mean and peak ankle dorsiflexion angles, and ankle dorsiflexion angles at heel strike and toe off. Patients who wore hybrid AFOs reported greater levels of satisfaction than did patients who wore plastic AFOs. However, the use of plastic AFOs resulted in higher ankle dorsiflexion angles at heel strike than did hybrid AFOs. No significant differences were observed between the plastic AFO and hybrid AFO groups in terms of the other metrics examined in the gait analysis.