News From ACFAS

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Take advantage of the free patient newsletter, FootNotes, to start a conversation with your patients and the community.

The latest edition is now available for download at acfas.org/footnotes or at the web link below (member log in required). Topics this issue include:

• Are You a Candidate for Ankle Replacement Surgery?
• High Ankle vs. Lateral Ankle Sprains: What's the Difference?
• Spring Walking Checklist

Your input is important to the ACFAS Research-EBM Committee's survey on DVT Prophylaxis--please take a few minutes to participate in the 15-multiple-choice question survey.

The survey is open to all licensed DPMs and is available through the web link below or here at ACFAS DVT Survey.

Foot and Ankle Surgery

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Researchers used the Doppler spectrum of the first dorsal metatarsal artery to assess the safe timing of weight-bearing or reconstructive surgery in patients with Charcot arthropathy of the foot and ankle. Fifteen patients with acute diabetic Charcot arthropathy of the foot and ankle were immobilized in a non-weight-bearing cast. They were followed at two-week intervals and bilateral Doppler spectra of the first dorsal metatarsal arteries were obtained using a 10 MHz linear ultrasound probe. The patients were allowed to start weight-bearing or undergo surgery after the Doppler spectrum had returned to normal pattern. The Doppler spectra in the unaffected limbs were triphasic in pattern, whereas those in limbs with active Charcot arthropathy showed monophasic forward flow. They returned to normal after a mean of 13.6 weeks of immobilization. Three patients underwent pan-talar arthrodesis to correct gross instability and deformity.


Researchers evaluated the short-term efficacy and safety of platelet-rich plasma (PRP) compared with hyaluronic acid (HA) in reducing pain and disability caused by osteochondral lesions (OCLs) of the ankle. Thirty-two patients were allocated to a treatment by intra-articular injections of either HA (group 1) or PRP (plasma rich in growth factors [PRGF] technique, group 2) for OCLs of the talus. Thirty OCLs, 15 per arm, received three consecutive intra-articular therapeutic injections and were followed for 28 weeks. The Ankle-Hindfoot Scale score improved from 66 and 68 to 78 and 92 in groups 1 and 2, respectively, from baseline to week 28 (P < .0001), favoring PRP (P < .05). Mean visual analog scale scores (1 = asymptomatic, 10 = severe symptoms) decreased for pain (group 1: 5.6 to 3.1; group 2: 4.1 to 0.9), stiffness (group 1: 5.1 to 2.9; group 2: 5.0 to 0.8), and function (group 1: 5.8 to 3.5; group 2: 4.7 to 0.8) from baseline to week 28 (P < .0001), favoring PRP (P < .05 for stiffness, P < .01 for function, P > .05 for pain). Subjective global function scores, reported on a scale from 0 to 100 (with 100 representing healthy, preinjury function) improved from 56 and 58 at baseline to 73 and 91 by week 28 for groups 1 and 2, respectively (P < .01 in favor of PRP).


Researchers retrospectively reviewed 18 patients (19 feet) with relapsed clubfeet who underwent correction by soft tissue distraction using an Ilizarov ring fixator. The mean age of the patients was 8 ± 2 years. K wire fixation for the midfoot joints combined with a below-knee cast were used during the consolidation stage. The mean followup was 4.5 years. The average duration of frame application was 5 weeks; the mean duration of treatment was 11 weeks. At last followup, 16 of 19 feet were painless and plantigrade and only three of 19 feet had recurrence. The mean preoperative clinical AOFAS score had increased at last followup from 57 to 81. The values of the AP talocalcaneal, AP talo-first metatarsal, and lateral calcaneo-first metatarsal angles improved after treatment. The three recurrent clubfeet were treated by corrective osteotomies and Ilizarov frame application.

Practice Management

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Despite doing all of the correct things for a practice, such as electronic health records, regular contact with patients, and coordinating with other specialists and hospitals, some physicians are finding that they are having trouble keeping their practice going. One reason is that many modern enhancements are not reimbursed under traditional insurance contracts that pay primarily for face-to-face visits. Additionally, many practices have to cut back on patients while undergoing system upgrades. Such problems may become more common as practices around the country start transitioning to new ways of paying for healthcare.

Insurers are increasingly targeting traditional systems that paid for services provided instead of better results. In recent months, UnitedHealth, WellPoint, and Aetna have announced plans to pay practices more if they make efforts like more face-to-face visits and the adoption of new technologies. New reimbursement designs can also provide doctors with significant financial rewards if they reach quality goals and cut costs. However, such changes often require a financial commitment from physicians, including buying new equipment, hiring staff, adding support staff, and getting special training for outreach and patient coordination. "You're asking a practice that may be only marginally viable as a business to invest in significant infrastructure," says American Academy of Family Physicians President Glen Stream.

Some physicians are being proactive and going to work for hospitals, which have greater financial resources and better leverage with insurers. The consulting firm Accenture projects that by 2013 only about a third of doctors in all specialties will own their own practices, down from about 43 percent in 2009.

Physicians can reduce costs by encouraging staff to serve multiple roles, like having a health coach who works with patients on diet and exercise plans also compile and track patient data. Physicians can also find new revenue by selling things, provided they feel the products are backed by medical evidence.


A physician's time is of utmost importance to the productivity and profitability of a practice, which means systems must be as efficient as possible in order to see the necessary number of patients to make a decent living. George Ellis, who practices internal medicine in Youngstown, Ohio, and is a clinical assistant professor of medicine at the Northeast Ohio Medical University, Rootstown, has instituted a seven-step process that has improved his productivity by approximately 25 percent, aided primarily by the use of an electronic health record system. The system is equally effective in a primary care practice or emergency setting. It has seven steps: registration; verification of patient-supplied information; obtaining of vitals; data entry, including patient's chief complaint, history of present illness and his or her past medical history; assessment or examination by the physician; discharge; and follow-up.


Long-term cost management is among the greatest challenges for out-of-network ASCs, so Toni Rambeau, the administrator of an out-of-network surgery center that performs more than 300 cases per month in a one-room OR, has developed several necessary cost management strategies that sustain long-term profitability. She specifically notes five essential strategies for eliminating unnecessary costs, securing reimbursements and educating center staff on the importance of cost containment in an out-of-network center. First, encourage physicians to test less expensive surgical tools, an effective cost-cutting strategy for the long term. Next, reprocess single use items by using a consistent medical supply reprocessing company, which can save surgery centers around 50 percent per item. Third, train other employees to be cost-conscious, which in turn creates a cost-conscious culture. Fourth, work with a device management company to recover implant costs, particularly when an insurance company will not reimburse. Finally, ensure staff member are cross-trained and able to work flexible hours.


Florida gastroenterologists Domingo Ngo and his son Benjamin worked out a way for Benjamin to join his father in practice even though he did not wish to be a solo-practice physician once Domingo retired. Their solution was for Domingo to contact a local hospital, Martin Health System, to inquire whether it would purchase the practice and employ both him and Benjamin. "We have an aging physician work force, and, from our perspective, this was succession planning," says Steven Myrick with the Martin Medical Group. Experts' advice for doctors with solo or small practices who are considering similar acquisition deals includes approaching local players in the health system, basing expectations realistically, and expecting some loss of autonomy.

Health Policy and Reimbursement

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The Centers for Medicare & Medicaid Services (CMS) will not begin enforcing the mandated move to Version 5010 transaction standards for an additional three months. The deadline for the switch to the 5010 standards was Jan. 1. In November, the CMS announced that although it was not changing the actual deadline for complying with the standards, it would not initiate enforcement action until March 31. On Thursday, CMS' Office of E-Health Standards and Services said no action will be taken against noncompliant medical practices, hospitals and other healthcare entities through June 30. The Office "is aware that there are still a number of outstanding issues and challenges impeding full implementation," according to the announcement. CMS went on to say that it is urging industry collaboration to resolve remaining problems and that it will partner with industry groups to expand technical assistance.



In its annual March report to Congress, the Medicare Payment Advisory Commission (MedPAC) reiterated its position from last fall that federal lawmakers should repeal Medicare's sustainable growth-rate formula and replace it with 10 years of statutory fee-schedule updates. This would include a freeze in current payment levels for primary care, and, for all other services, reductions of 5.9 percent for three years, followed by a freeze. The report presents to Congress suggestions on Medicare payment policy that MedPAC’s commissioners agreed to in January, such as a 1 percent payment increase in payment rates to the inpatient and outpatient prospective payments systems for 2013. Other recommendations for 2013 include a payment update of 0.5 percent for ambulatory surgery centers.


The Supreme Court of Pennsylvania is going to weigh whether healthcare providers and their records-reproducing proxies are required to report their "actual and reasonable" costs of generating charts and records. Petitioners Wayne M. Chiurazzi Law and David A. Neely want to file a class-action lawsuit against the UPMC health system, accusing UPMC and the private company that handles its medical records requests, MRO, of charging excessively. The petitioners requested the court's consideration that the Medical Records Act requires "medical records reproducers to disclose their estimated actual and reasonable expenses of reproducing the charts or records, and to limit their copying charges to these amounts or the statutory ceiling rates, whichever is less." In August, the state Superior Court majority of Judges Jack A. Panella and Jacqueline O. Shogan determined that the calculation of estimated actual and reasonable expenses for paper copies is not mandated by the Medical Records Act, and that the statutory schedule creates safe harbor rates for the estimated actual and reasonable expenses of producing such paper copies; dissenting Senior Judge Robert E. Colville said the law's plain language sets a cap on the amounts that patients can be charged.

Medicine, Drugs and Devices

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The Centers for Medicare & Medicaid Services has launched phase one of its Electronic Submission of Medical Documentation (esMD) program, during which healthcare providers will still get medical documentation requests through paper mail, while having the option of electronically sending their documentation to the requesting review contractor. Pace Healthcare Consulting's Amanda Berglund says the deployment of esMD may help decrease providers' administrative load and enhance submission tracking when it comes to record requests. Pace Healthcare CEO Elizabeth Lamkin says the program's probable overarching goal is to make the medical documentation submission process completely web-based, and it could go a long way toward protecting providers from a HIPAA perspective. "It will reduce paperwork and costs, but also, with everyone being mandated to go to an EHR system, this is the logical next step," she notes. "Also, with the Office of Civil Rights all over HIPAA, this definitely makes sense from a security standpoint."


A study was conducted to determine the existence of biomechanical differences between appropriately sized conventional partially threaded screws and tapered variable pitch screws under physiologic cyclic loading conditions with regard to Jones fracture fixation. Simulated Jones fractures were produced in 23 matched pairs of fresh-frozen fifth metatarsals. A single bone from each pair was stabilized with a conventional partially threaded screw and the contralateral bone with a tapered variable pitch screw, and initial compression and fracture site compression, angulation, and bending stiffness were compared between groups across 1,000 physiologic cyclic loads. Conventional partially threaded screws acquired substantially greater initial compression in comparison with tapered variable pitch screws. Significantly greater compression was maintained across cyclic loading with conventional screw fixation versus tapered variable pitch screws. Fracture site angulation was significantly greater with the employment of tapered variable pitch screws from the tenth load cycle through completion of cyclic loading. In spite of a trend toward greater fracture site bending stiffness when using conventional screws, no difference in fixation stiffness was evident between the two types of screw.


Medical device suppliers are hoping that the FDA will incorporate Universal Device Identifiers (UDIs) into electronic health record certification and standard regulations. The FDA is currently evaluating UDIs and has held discussions on including UDI in stage 3 of the Meaningful Use Program with the Office of the National Coordinator of Health IT. UDI could have many benefits, including helping investigators track device data, inform doctors what devices a patient is using, ensure proper charging for devices and supply information for inventory and supply chain purposed. The FDA has been asked to chose the GS1 product information standard as the official UDI, and while the market seems to be leaning in that direction, the FDA will approve either the GS1 or its competing HBCC standard, if they comply with the FDA's UDI requirements.