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This Week's Headlines

News From ACFAS
Foot and Ankle Surgery
Practice Management
Health Policy and Reimbursement
Technology and Device Trends

News From ACFAS

Make Money, Even in a Tough Economy

Don't leave money on the table. Maximize your reimbursements with timely advice on correct coding and practice strategies.

Come to Charleston May 15-16 for the ACFAS Coding and Practice Management Seminar and listen to experts' tips from speakers Douglas Stoker, DPM, Karen Zupko and others.

Online registration is also open for October's Flatfoot Surgical Skills Course in Denver and the November Complex Reconstruction Surgical Skills Course in Las Vegas.

Click on the Web link below for details.

Reach Patients with Spring FOOTNOTES

Fill your waiting room...first with copies of Spring FOOTNOTES, the ACFAS patient newsletter, and then with the patients it attracts.

FOOTNOTES educates prospective patients about all the things you can do for them, and it's free as a member benefit. Many foot and ankle surgeons place it in their waiting rooms, send it out with their billing, distribute it at community health fairs and post it on their Web sites.

The Spring issue tells patients how you can help them with heel pain, Morton's neuroma and children's athletic injuries.

Click on the Web link below, download FOOTNOTES, add your contact information on the back and print out copies.
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This Week @ ACFAS goes beyond traditional “society news” to bring you abstracts of stories selected from thousands of periodicals and internet resources, with news especially relevant to the practicing podiatric foot and ankle surgeon.

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This Week @ ACFAS is a work in progress, and only by hearing from our readers will we know what changes to make. Let us hear from you at

An archive of past issues may be accessed via the web link below.

Foot and Ankle Surgery

B.C. Program Lets Hospital Fast Track Surgeries and Slash Wait Lists

Surgeries for people stuck on wait lists with painful foot, ankle, hand or wrist conditions are being fast-tracked through a new project at a Vancouver hospital. British Columbia foot and ankle surgeon Dr. Murray Penner says St. Paul's Hospital's Distal Extremities Surgical Project includes a clinic where family physicians evaluate patients to see if they require specialized surgery, and he notes that "the backlog of referrals gets enormous. There's really no capacity to deal with that so some type of screening mechanism needs to be put in place." Penner says thousands of patients have been taken off the wait lists by the screening process since the project's inception six months ago. Referrals to specialists can now take place days after the patient is seen in the clinic, rather than several months, and Penner says an operation is scheduled within a few weeks. In addition, there is less waiting for the surgery itself because a pair of new "swing operating rooms" at St. Paul's let doctors move from one surgery to another without delay because while one patient is in surgery, another is being anesthetized. Patients are given local anesthetic for surgeries of less than 90 minutes, which makes for a faster recovery and saves the health care system money that would otherwise be spent on sending patients to post-operative recovery rooms staffed by specialized nurses. The hospital gets paid according to the number of surgeries carried out, according to Dr. Thomas Goetz, who heads St. Paul's Orthopedic Surgery Division. "If the government allows the hospitals to get funded per patient they're going to want to have more patients so I can get the work down, whereas under the previous model the effort is to not let work get done," he notes.

From the article of the same title
Canadian Press (03/25/09)

Taking Vitamin D Supplements Helps Seniors Avoid Bone Fractures, but Dosage Matters

Taking a sufficient daily dose of vitamin D supplements may make people 65 and older less likely to suffer bone fractures, according to a research review published in the Archives of Internal Medicine. Seniors whose daily dosage exceeded 400 international units (IU) were 18 percent less likely to have hip fractures and 20 percent less likely to have nonvertebral bone fractures. The review is based on a dozen trials of vitamin D focusing on nonvertebral bone fractures and eight trials involving hip fractures. Patients took up to 770 IU daily, but the precise optimal concentration of vitamin D was not determined by the study. The body can absorb calcium with the help of vitamin D, and J. Edward Puzas, PhD, of the University of Rochester School of Medicine and Dentistry says that bone cells possess vitamin D receptors. He says those bone cells "do respond to vitamin D by stimulating their activity and generally increasing overall bone health," and adds that "bone density is higher [and] fractures are lower in patients with adequate amounts of vitamin D." Exposure to enough sunlight causes the body to produce vitamin D, but this process becomes harder as people get older; dark-skinned people and people who reside in northern latitudes also have a more difficult time generating vitamin D. Current Institute of Medicine (IOM) standards have established adequate daily vitamin intake of 200 IU for children up to age 13 and people aged 14 to 50, 400 IU for people aged 51 to 70, and 600 IU for people aged 71 and up. However, many experts say those levels are not high enough, and in October 2008 the American Academy of Pediatrics doubled its recommended daily intake of vitamin D for children and adolescents to 400 IU per day. The IOM's current standards place the upper limit for vitamin D at 2,000 IU per day.

From the article of the same title
WebMD (03/24/09) Hitti, Miranda

Anatomical Reconstruction for Chronic Lateral Ankle Instability in the High-Demand Athlete

Researchers tested a theory that the functionality of high-demand athletes who suffer chronic lateral ankle instability can be restored through anatomical reconstruction of the lateral ankle ligaments, and they determined that this can indeed be accomplished using a variant of the Gould-modified Bröstrom procedure with suture anchors. The test involved 62 patients with grade III ankle sprain that failed at least a six-month course of supervised conservative management with a preinjury Tegner score of 6 or higher. Each patient underwent the Gould-modified Bröstrom procedure with suture anchors for lateral ankle instability, and was then given the Tegner and Karlsson questionnaire at the six-month, one-year, and two-year time points. Range of motion of the operative ankle was also evaluated, and the mean age was 19.6 years. The mean follow-up was 29 months in all but 10 patients who were lost to follow-up, and mean Tegner scores at the one- and two-year time points were 8.2 and 8.6, respectively. Mean Karlsson scores were 92 plus or minus 5.2 at the one-year time point and 95 plus or minus 3.1 at the two-year time point. All but three patients at the two-year follow-up exhibited a range of motion equal to the contralateral ankle, and three re-ruptures were included in a 6 percent major complication rate.

From the article of the same title
American Journal of Sports Medicine (03/01/09) Vol. 37, No. 3, P. 488; Li, Xinning; Killie, Heather; Guerrero, Patrick

Practice Management

Challenging Your Rating: You Don't Have to Accept What the Health Plan Says

Health plan ratings can be a very contentious subject for physicians, who have the option of challenging the ratings. The biggest health plans have pledged to grade fairly, and organized medicine is striving to guarantee that the plans deliver on their promise. Some doctors are being aided by practice management experts and organized medicine in their efforts to dispute assessments, and these experts say there are legitimate reasons to pursue such challenges. Major plans doing business in New York agreed with the state attorney general's office in late 2007 to use more than cost as a basis for their physician ratings, and to instill transparency in their ratings platform. The plans concurred that doctors would have the opportunity to appeal their ratings or designations. When it appears that plans have not come through on their promise of transparency and fairness, the first step for physicians to consider is whether an appeal is worth their time, and Bruce Bagley, MD, with the American Academy of Family Physicians says appeals are not worthwhile if co-pays are not affected and the doctor's designation is only listed online. Marilyn Rissmiller of the Colorado Medical Society adds that doctors who feel strongly enough to challenge a rating should first request the records associated with their rating, while Elaine Kirshenbaum with the Massachusetts Medical Society says they should ask for the "drill-down" data that identifies individual patients. Rissmiller says that once those records have been obtained, it might save time to learn if a designation would be changed by improving a specific measure. Doctors with information that would change their grade should ask for a meeting with someone who can discuss their rating and is empowered to amend it. The American Medical Association advises physicians to notify patients when they challenge a rating, irrespective of whether they are satisfied or unsatisfied with the rating.

From the article of the same title
American Medical News (03/23/09) Berry, Emily

When Patients Declare Bankruptcy: What Happens to Unpaid Bills?

When patients file bankruptcy, physicians must immediately cease collection activities, though they can seek amounts owed by the patient's insurer or demand payment for debt incurred after the bankruptcy filing date. For patients who have filed bankruptcy, practices might consider payment plans, then proceed under the practice's non-payer policies if bills still are not paid. However, to avoid legal or ethical troubles, physicians should not fire a patient without completing treatment plans initiated prior to bankruptcy and planning for the patient's future care. In some instances, attorneys say doctors can request that patients sign reaffirmation agreements to continue being seen by the practice; these agreements state that the debtor promises to pay his/her bills no matter what the bankruptcy court decides. However, University of North Carolina at Chapel Hill law professor Melissa Jacoby says not all patients who have filed bankruptcy should be classified as high risk. According to Jacoby, "Just because a person files bankruptcy once doesn't mean they will be a problem payer in the future. From a doctor's perspective, this patient will now focus on more important things—like medical care and housing."

From the article of the same title (03/09/09) Caffarini, Karen

Health Policy and Reimbursement

AMA Announces Physician Class Action Against WellPoint

The American Medical Association (AMA) and several other medical societies have filed a class action lawsuit against WellPoint, the largest health insurer in the United States, in a bid to reform reimbursement policies. The suit, filed in a Los Angeles federal court, alleges that WellPoint colluded with others to underpay physicians for out-of-network medical services, resulting in excessive charges for patients. AMA filed similar class action lawsuits last month against Aetna Health and CIGNA. "Physicians will not tolerate an apparent conspiracy that allows health insurers to play by their own rules without regard to patients, or the legitimate costs required to care for them," says AMA President Nancy H. Nielsen, MD. All three AMA lawsuits claim that the insurance companies conspired with Ingenix, a unit of United Health Group, on a price fixing scheme linked to a database run by Ingenix that set artificially low reimbursement rates for out-of-network care. An investigation by New York Attorney General Andrew Cuomo confirmed that the Ingenix database was purposefully designed to allow insurers to shortchange reimbursements. "Now that the underlying scheme has been exposed, health insurers are doing the right thing by cutting their ties with the flawed Ingenix database. However, serious damages resulting from prior use of the Ingenix database still need to be addressed," says Nielsen. The lawsuits are also seeking relief for physicians adversely impacted by the use of the database. Joining AMA in the WellPoint lawsuit are the California Medical Association, Connecticut State Medical Society, Medical Association of Georgia, and North Carolina Medical Society.

From the article of the same title
Fox Business (03/25/09)

Health Insurers Offer Shift on Premiums

America's Health Insurance Plans and the Blue Cross Blue Shield Association offered to stop charging sick customers higher premiums, which comes as congressional lawmakers discuss the creation of a government-run insurance program. However, the insurers stressed in a letter to senior senators that all Americans must first purchase health insurance to enlarge the risk pool. "By enacting an effective, enforceable requirement that all Americans assume responsibility to obtain and maintain health insurance, we believe we could guarantee issue coverage with no pre-existing condition exclusions and phase out the practice of varying premiums based on health status in the individual market," the insurers wrote. They added that insurers would still have to vary rates according to geography, age and family size, and they requested permission to offer discounts for people who practice healthier behaviors such as following treatment programs for chronic diseases and quitting smoking. America's Health Insurance Plans Director Karen Ignagni would not say whether revenue lost by leveling premiums between ill and healthy customers could be recovered by insurers in a larger market in which all Americans have to buy insurance. It is also not clear whether the insurers' proposal will stem demands for a government-run insurance program, which would compete directly with private insurers. A new study from the Robert Wood Johnson Foundation found that nearly one in five working adults is uninsured, while the United States' uninsured population has risen by almost 9 million since 1994 to 45.7 million. Ignagni and Blue Cross Blue Shield Association President Scott P. Serota warned in their letter that a government-run insurance program "would thwart the ability of the health care sector to implement meaningful delivery system reforms, exacerbate the cost shifting from public programs to consumers in the private market, and destabilize the employer-based system."

From the article of the same title
Los Angeles Times (03/25/09) Levey, Noam N.; Girion, Lisa

Is Cash-Only Medicine the Next Big Thing?

Some physicians are responding to decreases in reimbursements by opting out of managed-care contracts and launching cash-only practices. These practices are gaining popularity among patients without health insurance, as they generally charge less, and some experts believe cash-only practices will become more common due to the weak economy. Despite pulling in less money, some doctors are happy they switched to cash-only because they have a larger patient base but see fewer patients per day and have lower overhead costs. Cash-only practices differ from concierge practices in that they do not charge annual membership fees for more access to the physician. "Nothing much changes in a cash-only practice except getting out of the insurance billing business," says La Jolla, Calif.-based practice management consultant Jeffrey Denning. Thus, cash-only practices need fewer staff members because they do not have as much paperwork and do not have to deal with third-parties. To set fees, cash-only physicians should determine the cost of business, research competitors' charges, and ensure they make a profit. The lack of third-party contracts means more advertising, and some doctors use fliers, billboards, and television ads to get the word out. If cash-only physicians want to keep their Medicare patients, they can become nonparticipating Medicare providers, meaning that they do not accept assignment and have lower reimbursement rates. However, patients must pay cash-only physicians for their services and be reimbursed by Medicare, which is beneficial to the physician.

From the article of the same title
MedPage Today (03/19/09) Weiss, Gail Garfinkel

Technology and Device Trends

New MRI Technique Could Mean Faster Scans

Researchers have reported that two new magnetic resonance imaging (MRI) technologies could lead to faster, more detailed imaging scans. Both rely on control of the spin of molecules to provide more detailed scans. "Our method has the potential to help doctors make faster and more accurate diagnoses in a wide range of medical conditions," says Gary Green of the University of York in the United Kingdom, who led one of the studies. "The technique could ultimately replace current clinical imaging technologies that depend on the use of radioactive substances or heavy metals, which themselves can create health concerns." Green's team based its technique on manipulating parahydrogen—the fuel used in space shuttles—by transferring its magnetism to a rage of molecules that are more easily detected. The technique, now being tested on animals, could increase the sensitivity in some scans by more than 1,000 times so data on biological systems could be obtained in seconds rather than months. A U.S. research team, meanwhile, was able to see these molecules by "hyperpolarizing" some atoms, changing the spins of their nuclei to drastically increase their signal. Their technique creates large imbalances among the populations of the spin states, making the molecules into more powerful magnets and thus producing more detailed images. "You thus have a signal that, at least transiently, can be thousands or tens of thousands times stronger than regular hydrogen in an MRI," says Warren Warren of Duke University, who led the U.S. team. Both techniques are discussed in more detail in the journal Science.

From the article of the same title
Reuters (03/26/09)

Eccentric Loading Versus Eccentric Loading Plus Shock-Wave Treatment for Midportion Achilles Tendinopathy

While results of a previous randomized controlled trial have demonstrated the comparable effectiveness of a standardized eccentric loading training and of repetitive low-energy shock-wave treatment (SWT) to treat chronic midportion Achilles tendinopathy, no randomized controlled trials have tested whether a combined approach could lead to better results. Sixty-eight patients with a chronic recalcitrant noninsertional Achilles tendinopathy were enrolled in the randomized controlled study whose results are outlined here. All patients had received unsuccessful management that included peritendinous local injections, nonsteroidal anti-inflammatory drugs, and physiotherapy. For all outcome measures, the combined eccentric loading and repetitive shock-wave treatment showed dramatic improvements over eccentric loading alone at the four-month follow-up.

From the article of the same title
American Journal of Sports Medicine (03/01/09) Vol. 37, No. 3, P. 463; Rompe, Jan D.; Furia, John; Maffulli, Nicola

Augmentation of Bone Healing by Specific Frequency and Amplitude Compressive Strains

Researchers led by Azadeh Shadmehr, PhD, of the University of Tehran recently developed a mechanical stimulator to study bone fracture healing under controlled cyclic loading. The researchers tested the effectiveness of the device via a randomized, prospective in vivo animal study using rabbits. Mid-diaphyseal tibial osteotomy was performed on the right legs of 16 male Dutch white rabbits. Under general anesthesia and aseptic conditions, four 2-mm stainless steel pins were inserted mediolaterally into each tibia, and a 2-mm gap was made by removing the bone segment between the osteotomy sites. The rabbits were randomly assigned to 4 groups, with control animals receiving no mechanical stimulation. Mechanical stimulation was conducted at regular intervals with the device to examine displacement and force curves verses time using special software. The researchers concluded that bone healing is enhanced by externally applying mechanical stimulation with cyclic uniform compression strains, although additional research is needed to ensure greater sampling size and a wider criteria range.

From the article of the same title
Ortho Supersite (03/04/2009) Shadmehr, Azadeh; Esteki, Ali; Oliaie, Gholam

Football Playing Surface and Shoe Design Affect Rotational Traction

Researchers investigated a hypothesis that shoe design and surface type can impact rotational traction at the shoe-surface interface. They used a mobile testing apparatus with a compliant ankle to apply rotations and measure the torque at the shoe-surface interface, for the comparison of five football cleat patterns and four football playing surfaces—two natural grass systems and two artificial—on site at actual surface installations. The results of the comparison revealed that both artificial surfaces generated substantially higher peak torque and rotational stiffness than the natural grass surfaces. The turf-style cleat was the only cleat pattern that produced a peak torque significantly different than all others, and it boasted the lowest torque. The researchers concluded that the material or materials used to construct the shoe's upper may influence rotational stiffness. The continued updating of football shoe and surface designs require new performance assessments under simulated loading conditions to guarantee that player performance needs are satisfied while the risk of injury is kept to a minimum.

From the article of the same title
American Journal of Sports Medicine (03/01/09) P. 518; Villwock, Mark R.; Meyer, Eric G.; Powell, John W.

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April 1, 2009