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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

Red Flags Program Enforcement Begins May 1

Medical practices often hold sensitive information about their patients. Because identify theft has become such a serious concern in the United States, the federal government has created rules to prevent and detect it (The Fair and Accurate Credit Transactions Act of 2003).

Foot and ankle surgeons who regularly bill their patients for services rendered are considered "creditors" under these rules, known as the Red Flag Rules. The rules require "creditors" to develop a written identity theft prevention program to identify, detect and minimize the damage from identity theft.

The Federal Trade Commission will begin enforcing the Red Flag Rules on May 1, 2009, which means most medical practices must have a plan in place by that date. The Web link below provides details.
Deciding When to Use Osteobiologics

In the past 10 years, we have seen an increase in the use of osteobiologics, orthobiologics and other products that assist in healing. When is it appropriate to use them?

Are they primarily hype or is there a real need for them to augment healing? And what determines which osteobiologic you choose in a given case?

Listen to Jarrett Cain, DPM moderate an ACFAS podcast with Michael McGlamry, DPM, on this topic via the Web link below. It's free and available anytime.

Save Money on Medical Books

You can save 50 percent off a selection of clinical books focusing on various areas of medicine, including orthpedics and pain management, by clicking on the Web link below. The sale ends after April 24.

Foot and Ankle Surgery

Interosseous Nerve Transfers for Tibialis Anterior Muscle Paralysis (Foot Drop): A Human Cadaver-Based Feasibility Study

Researchers from the Texas Tech University Health Sciences Center in El Paso, Texas, studied the anatomical feasibility of using an interosseous nerve transfer, routed between the tibia and fibula, to restore motor function to the tibialis anterior (TA) muscle following injury to the common peroneal nerve resulting in a foot drop. Studies were performed on human cadavers for the purpose. Potential donor nerves included the nerves to the medial gastrocnemius, the lateral gastrocnemius, and the soleus muscles. Nerve transfers were accomplished using a direct interosseous route and a direct repair, as well as interpositional grafting in one instance. The distance from the repair site to the TA muscle was shortest for the transfer using the nerve branch to the soleus. The nerve branch to the soleus was most similar to the branch to the TA for both axonal count and cross-sectional area histologically. The researchers concluded that the best method was a two-incision surgical approach using a fibular window (mobilizing a fibular segment after double osteotomy) and interosseous routing of the transfer.

From the article of the same title
Journal of Reconstructive Microsurgery (04/01/09) Pirela-Cruz, Miguel A.; Hansen, Uel; Rossum, Alfred

A Biomechanical Analysis of Posterior Tibial Tendon Dysfunction, Medial Displacement Calcaneal Osteotomy and Flexor Digitorum Longus Transfer in Adult

Higher loads in the arch of the acquired flat foot have been affiliated with posterior tibial tendon dysfunction, and researchers analyzed whether these increased loads in the flat foot are reduced by a 10-millimeter medial displacement calcaneal osteotomy and flexor digitorum longus transfer to the navicular. The researchers used a biomechanical model to examine the response of a normal foot, a foot with posterior tibial tendon dysfunction, and a flat foot to an applied load of 683 Newton, and this involved the computation of the distribution of load on the metatarsals, the moment about each joint, the force on each of the plantar ligaments and the muscle forces. They concluded that the load on the first metatarsal and the moment at the talo-navicular joint is significantly decreased by a 10-millimeter medial displacement calcaneal osteotomy, while the load on the fifth metatarsal and the calcaneal-cuboid joint is increased. The impact on the flattened foot is slight with the addition of the flexor digitorum longus transfer to the medial displacement calcaneal osteotomy. The researchers found that the flattening of the foot causes the force on the talo-navicular joint to rise substantially from its value for the normal foot, and that medial displacement calcaneal osteotomy can reduce this increased force back toward the value occurring in the normal foot.

From the article of the same title
Clinical Biomechanics (05/09) Vol. 24, No. 4, P. 385; Arangio, George A.; Salathe, Eric P.

Distribution and Correlates of Plantar Hyperkeratotic Lesions in Older People

A random sample of 301 people between 70 and 95 years who underwent a clinical evaluation of foot problems was studied to gain insight into the frequency or distribution of plantar hyperkeratotic lesions. Analysis determined that plantar hyperkeratotic lesions affect 60 percent of older people and are most commonly associated with women, hallux valgus, toe deformity, higher ankle flexibility and time spent on feet. No connections between plantar lesions and obesity, body mass index, foot posture, dominant foot or forefoot pain were drawn. Most lesion distribution patterns can be classified into medial, central or lateral groups. "Roll-off" hyperkeratosis on the medial aspect of the first metatarsophalangeal joint accounted for 12 percent of all lesion patterns. Further details of the research can be found in Australia's Journal of Foot and Ankle Research.

From the article of the same title
7thSpace (03/30/09) Spink, Martin J.; Menz, Hylton B.; Lord, Stephen R.

Practice Management

What's in the Stimulus Package for Physicians?

President Obama vowed during his campaign to commit $10 billion annually over the next five years to health IT, and the economic stimulus package provides $44,000 to $64,000 to physicians who acquire and can demonstrate "meaningful use" of a "certified" electronic medical record (EMR) over the next five years. Doctors who still are not using a certified EMR after the expiration of the five-year period will face cuts in their Medicare payments. An Allscripts poll estimates that 68 percent of physicians say they would probably participate in a pay-for-purchase program, while 37 percent of surveyed physicians are already participating in such a program. A Congressional Budget Office analysis finds that the "incentive mechanism would boost ... adoption rates to about 70 percent for hospitals and about 90 percent for physicians" by 2019. Critics are concerned that the $44,000-and-up per-physician payment may be insufficient, and SRS Soft CEO Evan Steele argues that "the price [of the software] is dwarfed by the problems it [an EMR] causes the office." He contends, for example, that if a specialist billing $750,000 a year loses only 5 percent of her productivity once she has to start fiddling around with templates or a keyboard, the EMR can cost her more than $162,000 over five years. Rob Tennant with the Medical Group Management Association's government affairs office counters that a properly deployed EMR can improve productivity when coupled with proper training for staff and doctors. The government wants to make it possible for physicians to access every patient's records on an as-needed basis, no matter where or by whom the patient was treated, and regardless of the patient's insurance carrier or the physician's EMR vendor. The stimulus package might shake down the industry and make interoperability less difficult.

From the article of the same title
Physicians Practice (04/09) Moore, Pamela

Tying the Partnership Knot

A number of factors must be weighed before a practice decides to take on a new associate, writes practice management consultant Jack Valancy, MBA. Such factors include whether the partnership is affordable, which calls for the drafting of a hypothetical budget that includes how much the prospective associate will cost and how much revenue he or she might produce, among other things. Candidate associates should be evaluated on such things as whether they are willing to make a commitment of five years or longer, whether they find the practice's location or lifestyle appealing, whether they have the necessary training and whether they fit into the culture of the practice. The details of the offer should be clear to the associate and be incorporated into the employment agreement. The impulse to pay associates less than the going rate in exchange for a very low buy-in price should be resisted, and Valancy says fair compensation lays "the foundation for productive, mutually beneficial long-term relationships." The practice's buy-sell agreement specifies how shares in the practice are to be bought and sold, and Valancy warns that offering the associate a minority share or an inferior class of the practice's stock can engender acrimony that endangers the culture, stability and financial performance of the practice. The price of each physician's portion of the practice should be determined the same way for both buyers and sellers, and should be sufficiently thorough to cover any contingency. "Just as the buy-sell agreement defines the methodology for valuing shares of partners buying into the practice, it also defines the buy-out methodology for physicians who leave for retirement or other reasons," writes Valancy. "The fairest approach is to use the same valuation methodology for buy-ins and buy-outs."

From the article of the same title
Family Practice Management (04/09) Vol. 16, No. 2, P. 23; Valancy, Jack

Health Policy and Reimbursement

Senator Investigates Health Insurers' Out-of-Network Rate Practices

U.S. Sen. John D. Rockefeller IV (D-W.Va.) is leading a congressional inquiry into whether patients who used doctors out-of-network have been treated unfairly by health insurers. Companies are charged with underpaying consumers by understating the fees charged by such doctors, and Rockefeller called this practice "outright fraud" in an interview. The practice was exposed three months ago following a probe by New York Attorney General Andrew M. Cuomo of the UnitedHealth Group database insurers use to ascertain out-of-network payments. Cuomo reached a settlement in which UnitedHealth promised to stop running the databases and replace them with an independent source of rate data. Rockefeller intends to question the CEOs of UnitedHealth and its Ingenix unit on the selective use of doctors' bills to determine out-of-network payments. UnitedHealth denied any wrongdoing, insisting that the settlement with Cuomo resolved issues about the database's independence by agreeing to spin it off. Rockefeller said he wants to halt the practice of underpaying for out-of-network doctor visits on a national scale, and added that he is considering some kind of federal legislation. Insurers usually reimburse patients for only 70 percent to 80 percent of the "reasonable and customary" cost of medical services when they go to out-of-network physicians, and patients are shortchanged if the insurer understates the prevailing market rate for those services. A recent hearing raised the issue of whether all insurers would use the independent database or would come up with some other way to estimate the local "reasonable and customary" rates of medical care, which skeptics said would allow them to keep underpaying patients and doctors.

From the article of the same title
New York Times (03/31/09) Abelson, Reed

Congress Hears Arguments for a Clean Slate on Medicare Payment Formula

The American Medical Association (AMA) and other physician organizations are urging Congress to embrace a new, more realistic budgetary baseline for doctors' Medicare pay so that they can more accurately project spending and make a move toward fixing the problem of the sustainable growth rate (SGR) formula. "Re-basing is a smart, realistic and transparent approach to addressing rising health care costs because it allows accurate forecasts of what those costs are going to be," stated AMA Board of Trustees Chair Joseph M. Heyman, MD, at a hearing of the House Committee on Small Business. The re-basing concept was aided in late February by President Obama, who included in his fiscal 2010 budget proposal the assumption that correcting Medicare pay would cost $330 billion over a decade. Even if Congress re-based the SGR, it would still need to reform or repeal the system via new legislation. American College of Physicians President Jeffrey P. Harris, MD, warned at the House hearing that concealing the costs of halting the pay cuts merely delays rather than eliminates them, which raises the actual cost of the next patch. "President Obama's budget is a marked departure from past practices because it acknowledges what we all know to be true, which is that preventing pay cuts to doctors will require that Medicare baseline spending be increased accordingly," he testified. Heyman said that a more permanent payment solution would be particularly beneficial for doctors who operate their practices as small businesses that cannot absorb the precipitous losses forecast under the present SGR formula. He contended that a major retooling of the pay system is required this year to guarantee that senior citizens have access to medical care in the long term. "We need to find ways to keep practicing physicians caring for seniors and encourage the best and brightest students to become physicians," Heyman noted. "Permanent Medicare physician payment reform will help us achieve that goal."

From "Organized Medicine Pushes Congress for Clean Slate on Medicare Payment Formula"
American Medical News (03/30/09) Silva, Chris

New Rules for Medicare

The White House has raised the standards for Medicare private insurance plans seeking government approval. The plans, criticized for marketing abuses and charging high costs to the government, are offered by major insurers such as UnitedHealthcare and Humana. They are seen by many Democrats as undermining the traditional Medicare program. The changes include reducing the number of versions of a plan that insurers can offer, protecting patients with chronic diseases from excessive co-payments, and banning a practice that can add to the costs of brand-name prescriptions. About 10 million seniors get comprehensive medical coverage through the plans, while another 17 million are signed up in private drug plans.

From the article of the same title
Chicago Tribune (03/31/09)

Technology and Device Trends

MRI and MR Arthrography of the Ankle and Posterior Subtalar Joint

MRI and combined ankle and posterior subtalar MR arthrography in cadavers were used to evaluate the ligaments of the posterior and lateral talar processes by researchers from the University of Sao Paulo in Brazil and the University of California, San Diego. In all subjects, MR arthrography provided improved delineation of the articular and periarticular structures as well as the ligaments. The lateral talocalcaneal and medial talocalcaneal ligaments were best seen in the axial and coronal planes, respectively. The axial plane was best for visualizing the fibulotalocalcaneal ligament, while the sagittal plane was best for evaluating the posterior talocalcaneal ligament. The axial plane was best for seeing the anterior and posterior talofibular ligaments and the posterior tibiotalar ligament. The researchers concluded that combined ankle and posterior subtalar MR arthrography improves visualization of the ligaments attaching to the posterior and lateral talar processes, including the posterior, lateral, and medial talocalcaneal and fibulotalocalcaneal ligaments.

From the article of the same title
American Journal of Roentgenology (04/01/2009) Vol. 192, No. 4, P. 967; Pastore, Daniel; Cerri, Giovanni G.; Haghighi, Parviz

Accuracy of a CT-Based Bone Contour Registration Method to Measure Relative Bone Motions in the Hindfoot

A CT-based bone contour registration method (CT-BCM) was devised to ascertain the three-dimensional position and orientation of bones so that the hindfoot's in-vivo range of motion could be measured, and the researchers theorized that the hindfoot's range of motion could be measured with equal accuracy by roentgen stereophotogrammetric analysis (RSA). The test involved installation of tantalum bone markers in the distal tibia, talus and calcaneus of a cadaver specimen, and with a fixed lower leg, the foot was held in neutral and subsequently loaded in eight extreme positions. RSA radiographs were made immediately after a CT-scan with the foot in a position was obtained, and bone contour registration and RSA was carried out. Helical axis parameters were computed for talocrural and subtalar joint motion from neutral to extreme positions and between opposite extreme positions, and then differences between CT-BCM and RSA were calculated. The CT-BCM data registered an overall root mean square difference (RMSd) of 0.21 degrees compared with RSA, and 0.20 millimeters translation along the helical axis for the talocrural and subtalar joint and for all motions combined. The RMSd of the position and direction of the helical axes was 3.3 millimeters and 2.4 degrees, respectively, and the latter errors were larger with smaller helical rotations. The differences are clinically irrelevant because of their similarity to those reported for validated RSA. The researchers concluded that CT-BCM is an accurate and accessible alternative for studying joint motion, as it eliminates the risk of infection and overlapping bone markers.

From the article of the same title
Journal of Biomechanics (04/09) Vol. 42, No. 6, P. 686; Tuijthof, G.J.M.; Beimers, L.; Jonges, R.

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April 8, 2009