News From ACFAS

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New regulations issued by the Centers for Medicare and Medicaid Services explain the framework of voluntary accountable care organizations (ACOs), a model focused on primary care professionals to create shared savings incentives. The rule defines an “ACO professional” as a physician (M.D./D.O.) or a practitioner (as defined in act and specifically including physician assistants and advanced practice registered nurses). The secretary of Health & Human Services is allowed discretion in expanding the list of eligible providers/suppliers based on program qualifications.

ACFAS has learned from CMS staff that physicians who are qualified and receive PQRS incentive payments will be recognized as ACO providers. The College is submitting comments related to the kinds of providers and suppliers that should or should not be included as potential ACO participants, emphasizing the role of the foot and ankle surgeon.

An ACO is one kind of physician and hospital integration model created by the 2010 healthcare reform law, but it is not the only way this integration can occur.
Perfect your practice management on May 13–14, 2011, at the ACFAS Practice Management/Coding Workshop, “Rock & Roll Your Practice,” in Cleveland, Ohio. Stay for one day or two as seasoned lecturers help you boost your revenues and adopt new trends in medical practice. For the complete agenda and online registration, visit the ACFAS website.
Stay a step ahead by visiting "Articles in Press" at the Journal of Foot & Ankle Surgery's online home page. New articles are available as soon as their proofs have been approved — even before they're assigned to an issue.

It's quick and easy with your free member access:

• Go to acfas.org/jfas.
• Click on “Read current and past issues online” (member login required).
• When you reach the JFAS home page, click on “Articles in Press” in the left menu.

Check out tomorrow’s news today, including original research, case reports, and tips, quips and pearls.

Foot and Ankle Surgery

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A study was conducted involving 10 patients with combined loss of the Achilles tendon and the overlying soft tissue who underwent reconstruction using peroneus brevis tendon transfer and reversed sural neurofasciocutaneous flap with suppuration. All but one of the flaps survived uneventfully, with the exception exhibiting distal marginal necrosis that was healed following a dressing change; all patients were able to execute heel lift with the operated limb and resumed walking, and there was no occurrence of Achilles tendon re-rupture or misbalance of ankle joints. As a one-stage procedure, peroneus brevis tendon transfer and reversed sural neurofasciocutaneous flap serves as an ideal treatment for reconstruction of the combined loss of the Achilles tendon and the overlying soft tissue.



Researchers assessed the results of patients undergoing an anatomic lateral ankle ligament reconstruction using an anterior tibial tendon allograft. Eleven patients (12 feet) undergoing lateral ankle ligament reconstruction were followed at a mean of 3.5 ± 1.7 years after surgery. The FAOS daily activity and sports activity subscores were 93.4 and 78.6, respectively. The SF-36v2 physical health and mental health components were 50.4 and 45.0, respectively. Four patients (five feet) reported no restriction; six patients reported mild restrictions, and one patient reported moderate activity restrictions. Tibiotalar tilt improved significantly from 20.2° to 4.6° after surgery. The radiographic anterior displacement of the talus from the tibia was 6.5 mm postoperatively.



Research was performed to assess the five-year outcome of midportion Achilles tendinopathy patients treated solely with exercise, and to examine if certain traits, such as level of kinesiophobia, age, and sex, corresponded to the treatment's effectiveness. The study involved 34 patients, 27 of whom fully recovered from the initial injury; of these, 22 exhibited no symptoms, and five had a new occurrence of symptoms. Continued symptoms were observed in seven patients, and no significant differences among the groups in regard to sex, age, or physical activity level before injury were seen; a significant negative correspondence between the level of kinesiophobia and heel-rise work recovery was observed. Because increased anxiety of movement might have an adverse impact on the effectiveness of exercise treatment, a pain-monitoring model should be employed when patients are treated with exercise.

Practice Management

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Keeping patient traffic moving smoothly starts with realistic scheduling. Patient flow can be expedited by preregistering new patients and updating addresses and insurance information when scheduling established patients. If your practice is fully computerized, you can have patients fill out registration, health history, and other forms from home via a secure Web portal. Or have someone on your clerical staff mail those forms to new patients so these patients aren't sitting in the waiting room writing when you're ready to see them. An inventory management system—which specifies where each item is stored, and includes a checklist indicating when supplies need to be replenished—can help ensure that clinical staffers aren't running around looking for instruments, charts, etc. It's also important to create a central workstation equipped with the needed tools that eliminates steps. Getting employees involved in improving patient flow and rewarding them for effective suggestions are also recommended.



When doctors become part of patients' health conversations via social media, ethical issues come to the fore. A recent National Research Corp. survey of 22,000 Americans found that close to 16 percent use social media sites as a source of healthcare information, and analysts say that because people are spending more time on social media sites, they have started to include questions and research about healthcare as a part of that experience. Although doctors can query patients about what health sites they consult and give them a list of recommended sites, social media carries a different dynamic, along with different moral and ethical expectations and obligations. For instance, American Medical Association policy discourages doctors from socially interacting with patients on social media, but not through professional sites; still, experts say physicians worried about what patients might find on social media can devise ways to get involved in their health conversations. A physician can, for example, maintain a Facebook page that is actively updated so that when patients have general health or wellness questions, they can ask the doctor directly.



The Centers for Medicare & Medicaid Services (CMS) has published additional answers for frequently asked questions on the electronic health records (EHR) incentive program, including the impact of healthcare providers participating in the agency's other reporting incentive programs. Some providers want to know if they can receive incentive payments from multiple programs. CMS says the Physician Quality Reporting System incentive can be received regardless of a provider's participation in other programs, and providers who participate in the EHR Incentive Program through the Medicaid option can also receive the electronic prescribing (eRx) incentive. If providers choose to be a part of the Medicare or Medicare Advantage options for the EHR incentive program the still need to report the eRx measure to avoid a penalty, but they are only eligible to receive the EHR incentive payment.

Health Policy and Reimbursement

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The main concern in the proposed guidelines issued last week by the Centers for Medicare & Medicaid Services on accountable care organizations (ACOs) is physician-hospital alignment, according to Paul Keckley, executive director of the Deloitte Center for Health Solutions. "You have value-based purchasing, and episode-based payments and avoidable readmissions, and the medical home, the ACO, physician quality reporting initiative and the physician self-referral language and you step back and see they are compelled by the vision of integrated systems," he said. "That to me is the big cake here." The proposed rule can be found here.



Healthcare providers will soon be able to verify if they have met the requirements for meaningful use of electronic health records. On April 18, the Centers for Medicare and Medicaid Services is expected to launch its online attestation service. To receive Medicare incentive payments, providers will have to confirm that they have fulfilled the certified technology and quality objects for meaningful use through the CMS Web-based Medicare and Medicaid EHR Incentive Programs Registration and Attestation System. So far, CMS has paid out $27.6 million in EHR incentives under the Medicaid program. Providers can familiarize themselves with the look and feel of the system using a preview of selected screenshots, though CMS cautioned that the final appearance and language may feature some changes.



The U.S. Department of Justice is expanding an investigation a probe of Blue Cross Blue Shield health insurance plans in several states, examining whether they are effectively raising health insurance premiums by making agreements with hospitals that repress competition from rival insurers. Federal investigators and some state attorneys general have submitted civil subpoenas to "Blue" plans in Missouri, Ohio, Kansas, West Virginia, North Carolina, South Carolina, and Washington, D.C. The investigation is aiming to determine if dominant health plans around the country are forcing hospitals to sign anticompetitive contracts that prevent them from doing business with rival insurers. The investigation is looking into "most-favored nation" clauses that normally require hospitals to charge an insurers' competitors equal or higher prices for services.

Medicine, Drugs and Devices

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A new bionic foot is helping amputees at Walter Reed Army Medical Center in Washington D.C. The device is the first bionic lower-leg system to restore lost function of the foot and ankle. It simulates muscle function for people who have had amputations below the knee. Only five of these bionic feet are in existence. They are being tested by U.S. servicemen who lost a foot and lower leg while fighting in Afghanistan.



Hospitals lose about $200 million a year due to drug shortages that require them to buy more expensive substitutes, according to a survey of 311 hospital pharmacists by the Premier healthcare alliance. About 90 percent of respondents said they had a drug shortage during a six-month period in 2010, and over 50 percent had six or more shortages. Eighty percent of respondents said the shortages caused a delay or cancellation in care, and 34 percent said such delays or cancellations happened more than six times. Over 40 percent said they had to buy more expensive drugs from a gray market vendor, paying as much as 335 percent more, and 60 percent said pharmacists had to compound a drug that is commercially available but in short supply or too expensive. More than 240 drugs had shortages or were unavailable over a six-month period in 2010.



A biosynthetic bone graft substitute (Augment) is a safe and efficacious treatment alternative to autologous bone graft (ABG) during foot and ankle arthrodesis, according to the results of a recent clinical trial. A prospective, controlled, randomized, multi-center feasibility clinical trial compared the safety and efficacy of the bone graft substitute during ankle and hindfoot fusion, to ABG. Twenty adult subjects from three U.S. centers were randomized in a 2:1 ratio to receive the substitute or ABG. At nine months, a blinded independent radiologist evaluated radiographic osseous union, finding that 77 percent of the substitute and 50 percent of the ABG patients were fused. There were two nonunions in the substitute group. At 12 weeks, CT scans showed healing rates (50 percent osseous bridging) were 69 percent in the substitute and 60 percent in the ABG group, respectively. All functional outcome measures improved in both groups over time. Surgical procedures using ABG lasted an average 26 minutes longer than the procedures using the substitute.