News From ACFAS

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ACFAS 2015 attendees, claim your Continuing Medical Education (CME) credits now! Visit acfas.org/phoenix, go to the CME Transcripts link and log in to your record to print a certificate of attendance.

If you have questions, contact the ACFAS Education Department at hjelm@acfas.org or wallace@acfas.org. The handouts from ACFAS 2015 sessions are available for download at acfas.org/phoenix. If you attended the conference in Phoenix and would like a refresher on your favorite sessions, visit acfas.org/phoenix to log in and access all the exclusive handouts.
Congratulations to the 2015 ACFAS Division Scholars! Each student Scholar received a scholarship from their respective ACFAS Regional Division to attend this year's Annual Scientific Conference in Phoenix.

Division 1: Pacific
CSPM: Christopher Sullivan, Class of '17
WesternU: Daniel Spencer, Class of '18

Division 4: Desert States
AzPod: Steven Brantingham, Class of '17

Division 5: Florida
Barry: Jason Spector, Class of '17

Division 6: Midwest
DMU: Chandana Halaharvi, Class of '16
Scholl: Justin Singh, Class of '17

Division 9: Greater New York
NYCPM: Jonathan Srour, Class of '17

Division 12: Tri-State
Temple: Alexandra Spangler, Class of '17

Division 13: Ohio Valley
Kent State: Nickil Nayee, Class of '17

Foot and Ankle Surgery

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A systematic review of electronic bibliographic databases for studies that assessed the ankle-brachial index (ABI) as a screening test for peripheral arterial disease (PAD) in asymptomatic individuals was conducted, featuring random-effects meta-analysis and the reportage of pooled hazard ratios when suitable. Forty individual studies, two systematic reviews and one individual-patient data meta-analysis were included in the study. No studies comparing ABI screening with no screening were found in terms of patient-important outcomes. The yield of PAD screening averaged 17 percent and was 1 to 4 percent in lower risk populations. PAD patients exhibited higher adjusted risk of all-cause mortality and of cardiovascular mortality. Although data on benefits, harms and cost-effectiveness of screening was limited, ABI screening was associated with additional prognostic information and risk stratification for heart disease. The general quality of evidence supporting routine screening was low.


A study was conducted to probe the effect of sensor-based interactive balance training on postural stability and daily physical activity in older diabetic adults. Thirty-nine older adults with diabetic peripheral neuropathy (DPN) were enrolled and randomized to either an intervention (IG) or a control (CG) group. The IG received sensor-based interactive exercise training customized for people with diabetes. The exercises concentrated on shifting weight and crossing virtual obstacles. Body-worn sensors were used to obtain kinematic data and to provide real-time joint visual feedback during training. Outcome measurements included changes in center of mass (CoM) sway, ankle sway and hip joint sway measured during a balance test while the eyes were open and closed at baseline and following the intervention. Daily physical activities were also measured during a 48-hour period at baseline and at follow-up. Versus the CG, the patients in the IG exhibited a significantly reduced CoM sway, ankle sway and hip joint sway during the balance test with open eyes. The ankle sway was also significantly reduced in the same group during measurements while the eyes were closed. The number of steps walked indicated a substantial but non-significant increase in the IG after training.


A study was conducted to investigate the role of negative pressure wound therapy (NPWT) in lowering the rate of wound healing problems following total ankle arthroplasty. The study included consecutive patients receiving total ankle arthroplasty by a single surgeon at a single institution between 2009 and 2013. Incisional negative pressure dressing was administered to 37 patients who underwent total ankle arthroplasty between 2012 and 2013 with a continuous application of -80 mm Hg negative pressure for six days post-operatively. The control group was comprised of 37 patients who underwent total ankle arthroplasty between 2009 and 2012 with a conventional nonadherent gauze dressing. All patients tolerated the incisional NPWT to completion without any dressing failures or skin complications. Both groups exhibited similar distributions in demographics and peri-operative risk factors for wound healing. Nine wound healing problems were observed in the control group, and one was observed in the incisional NPWT group. Incisional NPWT was determined to significantly reduce wound healing problems with an odds ratio of 0.10.

Practice Management

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Practices can lower their risk of being sued for malpractice by following strategies that include:

1) Prioritizing physician-patient communication. Studies show patients are more likely to disclose all of their relevant medical information when they have a strong and trusting relationship with the physician, which also reduces the risk of a diagnostic mistake or misstep that could lead to litigation. When interacting with patients, it is recommended that physicians not dismiss, or appear to dismiss, the patient's concerns; listen carefully; establish realistic expectations; and offer clear answers.

2) Asking staff to interact with patients. Ways to guarantee the staff is not putting the practice at risk for a lawsuit include demanding excellent professional etiquette, ensuring staffers explain delays to patients, providing training on difficult patient encounters and asking staff to observe patient reactions and emotions as they leave the practice and report any problems to physicians and/or the practice manager.

3) Having strong policies and procedures in place, which can ameliorate malpractice risks by preventing occurrence of problems that could lead to a lawsuit and can reduce the probability of a successful lawsuit if litigation is unavoidable. Policies to help ensure this include those related to employee expectations, electronic health record use, scope of practice, care protocols and telephone triage.

4) Having exceptional and rigorous documentation, which can help avoid lawsuits and support the practice's defense in the event of a lawsuit. Documentation areas worth considering include informed consent, prior medical history and patient instructions. The practice also is recommended to regularly conduct random samplings of patient charts to ensure that all tests, referrals and so on are followed up on appropriately.


Physicians could reap significantly more revenue thanks to a new rule from the Centers for Medicare & Medicaid Services (CMS) permitting reimbursement for chronic care management (CCM). Some practices could be enabled to get paid for work they are already doing. Others add services that will boost their revenue and improve patient care. Under the new CCM code 99490, making phone calls, helping patients complete insurance forms, consulting with patients about medication via phone and taking calls from patients during evenings or weekends may all count toward billable activities. "The new CCM code allows payment for helping patients during non-face-to-face visits," notes MidMichigan Health Center's Matt T. Rosenberg. Practices can earn $42.60 per month providing care for each patient eligible for CCM. "The new CMS rule gave us a way to enhance our care and to be able to do more for patients outside of the face-to-face visit," Rosenberg says. However, he cautions implementation of the code will not be easy. It will likely entail adapting current practice workflow to provide and capture billable CCM.

For clinicians to take advantage of the new rule, beneficiaries must be Medicare patients who have been diagnosed with two or more chronic conditions that are expected to last at least a year, or until death, and create risk for death or decline for the patient. Rosenberg says the attraction is that many services the practice provides for patients are not reimbursed, but now the practice can get paid for much of the time spent on these activities. The new CCM code's stipulations include the beneficiary's written consent, five specified capabilities and at least 20 minutes per month of non-face-to-face care management services. The five capabilities providers must fulfill to bill for CCM include use of a certified electronic health record for specified purposes; maintenance of an electronic care plan; guaranteed beneficiary access to care; facilitation of transitions to care; and care coordination. "Everything you do for this code needs to be documented for the insurance companies," Rosenberg says.


When being sued for malpractice, it is crucial to immediately report a malpractice claim to your professional liability insurance carrier and secure the services of an attorney specializing in defense of medical malpractice cases. The physician must work closely with the attorney to defend the claim and leverage the best opportunity to obtain favorable outcomes. To help ensure the physician-attorney relationship is most favorable, it is recommended the physician meet with the attorney early on. Meeting early means the attorney will be able to explain the litigation process to the client. It also gives the client an opportunity to explain to the attorney the medical care that was provided to the patient. The patient's record can be reviewed, and the physician can communicate information that may not be contained in the record. All information about the patient and his or her family, the care rendered by the physician and other defendants, if any, is vital.

Preparing for the deposition is also important. The process has two key elements: the first is that the physician review in detail all records, including any hospital records where he or she participated in the patient's treatment; next, the physician should meet with an attorney for extensive discussion of the medico-legal issues. It also is suggested the physician attend depositions, as there is no more forceful motivation for the witness to be truthful than having the physician in the room and being in a position to immediately notify the attorney when the physician believes the plaintiff's responses are inaccurate or false. The physician's insight can also be helpful in the witness selection process, and the defendant should request status reports on what is happening.

Health Policy and Reimbursement

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The U.S. House Ways and Means Committee passed the federal Electronic Health Fairness Act by voice vote on Feb. 26. The bill would exempt encounters in surgical centers from meaningful use until the Office of the National Coordinator for Health Information Technology develops standards for electronic health record (EHR) certification. Eligible professionals must show that at least half of their outpatient encounters are at practices and locations equipped with certified EHR technology to qualify for meaningful use incentives. Ambulatory surgical center encounters would otherwise put physicians at a disadvantage when attempting to meet meaningful use requirements.


The Office of the National Coordinator for Health IT (ONC) may not have authority over health exchange governance, according to U.S. Rep. Morgan Griffith, who is on the House Energy and Commerce Subcommittee on Health. The HITECH Act established ONC in law and provided the Department of Health and Human Services with the authority to establish programs to improve healthcare quality, safety and efficiency through the promotion of health IT, including electronic health records and private and secure electronic health information exchange. However, at a Feb. 26 subcommittee hearing on the Health and Human Services fiscal 2016 budget proposal, Griffith took the opportunity to call out HHS Secretary Sylvia Burwell on ONC’s authority and its request for $92 million to fund accelerated improvements in health IT interoperability, including strategic investments to support development and testing of interoperability standards and the agency’s new draft Interoperability Roadmap.


It is all but certain that Congress will not pass a permanent repeal of Medicare's sustainable growth rate (SGR) formula by March 31. U.S. Rep. Tom Price, chair of the House Budget Committee, recently told an advocacy meeting of the American Medical Association that there is not enough time to complete a full repeal before the deadline, and the most likely solution is a four-to-six-month patch. Price says he thinks a full repeal of the physician payment system is likely by the end of the fiscal year, Sept. 30, and it will be tied to extending funding for the Children's Health Insurance Program (CHIP). While a permanent repeal is unlikely, this does not mean lobbyists are still pushing for one. Tom Barber, chair of the advocacy council of the American Academy of Orthopedic Surgeons, says a permanent fix "could happen in one day" if Congress wants, but that he feels like no one in Congress is in much of a hurry. Congress has passed 17 different patches to the SGR, and if the current patch expires Medicare payments to doctors could be cut by 21 percent. Lawmakers might run into problems if they try to link CHIP to the SGR because separate political battles are associated with CHIP.

Medicine, Drugs and Devices

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The overall median price for high-spend hospital products fell 1.5 percent between 2013 and 2014, from $144,278 to $142,072, according to the ECRI Institute. This trend is largely due to hospitals negotiating better deals with suppliers and cutting spending on physician-preference items. "Overall, there is more focus on reducing costs," said Timothy Browne, director of ECRI's PriceGuide service. "The mindset that physicians can get what they want and have no interaction with the supply chain no longer sits well."


A new study published in the journal Cell Metabolism suggests the accumulation of salt in the skin of mice and humans helps prevent infections. Use of a magnetic resonance imaging method to measure salt accumulation in and around skin infections in six patients uncovered high concentrations of salt in the skin of patients' infected legs, while uninfected legs had no discernible concentrations. Following antibiotic treatment, both the salt accumulations and the infections vanished. A follow-up test was conducted on mice battling infections on their footpads, which were fed a high-salt diet that enabled an increased concentration of salt at the source of infection and allowed the animals to get rid of the infection faster than those that did not receive the diet.


A mere decade after the pharmaceutical industry worried that it would not have enough drugs in the pipeline to maintain the costly research-driven business, the industry is enjoying a rush of expensive breakthrough medicines. However, the result has left the drug industry at odds with those picking up the tab for medical science’s advances. The conflict threatens to slow the pace of future discoveries and patients’ access to the drugs. Many pharmacy benefit managers (PBMs) have decided to favor cheaper drugs over expensive ones. "The costs are just so staggering, the healthcare system cannot sustain it," says Steven Avey, vice president for specialty programs at MedImpact Healthcare Systems, a PBM.