News From ACFAS

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Feedback from ACFAS members on the College’s recommendations to CPME on reforming the profession’s continuing medical education (CME) standards has been positive, according to ACFAS President Jordan Grossman, DPM, FACFAS (see 3/27/2013 issue of This Week @ ACFAS). “What I’m hearing is ‘long overdue,’ ‘necessary,’ and ‘more than reasonable,’” said Grossman. The College’s comments were in response to CPME’s call for community input as they rewrite CPME Documents 720 and 730 this year. Visit the CME Reform webpage to view the proposed CPME changes and the College’s comments. Mark your calendars for you and your office staff to attend ACFAS’ 2013 Practice Management Seminar, July 19-20 in Chicago at the Millennium Knickerbocker Hotel. Our first-class speaker panel will provide a thorough overview of the essential concepts and skills required to manage today's medical practice. Attendees will be exclusively privy to our speakers’ analyses of these topics:

• Coding for Evaluation and Management, Surgical Procedures and Use of Modifiers
• Electronic Health Records and Meaningful Use Attestation
• HIPAA Omnibus Final Rule Requirements
• Transitioning to ICD-10
• Providing and Getting Reimbursed for Durable Medical Equipment
• Measuring Practice Success

The seminar brochure and registration form are available at acfas.org/pmm/seminars. Register today! Availability is limited. To streamline internal processes and to allow for a better focus on program support, visibility and high standards of the programs currently recognized by ACFAS, the Fellowship Committee has implemented an annual deadline for submission of applications by fellowships for official recognition by ACFAS. Completed applications for the 2013-2014 academic year received by August 31 will begin the recognition process in September. Newly created programs that show that they have met all minimal criteria for recognition will be held in “Conditional Status” until the following year.

For more information, or to request an application for fellowship program consideration, please contact ACFAS Director of Membership Michelle Brozell.

Foot and Ankle Surgery

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A comparison of the clinical and radiological outcomes of proximal and distal chevron osteotomy in severe hallux valgus deformity with a soft-tissue release in both was performed, with a prospective randomized controlled study of 110 consecutive female patients comprising 110 feet. Fifty-six patients received a proximal procedure and 54 a distal operation. Average follow-up was 39 months in the proximal group and 38 months in the distal group. The hallux valgus angle, intermetatarsal angle, distal metatarsal articular angle, tibial sesamoid position, AOFAS hallux metatarsophalangeal-interphalangeal score, patient satisfaction level and complications were similar in each group at follow-up. Both procedures demonstrated significant postoperative improvement and high levels of patient satisfaction.


A study was held to assess the effect of postacute rehabilitation environment on functional outcomes among patients who underwent major dysvascular lower extremity amputations, with 297 patients analyzed on the basis of whether they were treated at home, in a skilled nursing facility (SNF) or in an acute inpatient rehabilitation facility (IRF). About 43 percent of the cohort received care in an IRF, while 32 percent were treated in an SNF and 24.6 percent were treated at home. On the Short Form-36 subscales, substantive improved outcomes were observed for the patients receiving postacute care at an IRF compared to those treated at an SNF in physical function, role physical and physical component summary score. Better role physical and physical component summary score outcomes also resulted for patients getting care in IRFs versus those sent directly home. Furthermore, patients receiving postacute care in an IRF were more likely to score in the top quartile for general health in IRF compared with SNF or home and less likely to score in the lowest quartile for physical function, role physical and physical component summary score in IRF compared with SNF. Reduced activity of daily living impairment was noted in IRF versus SNF.


In a study of diabetic patients presenting with a foot ulcer and no signs of soft-tissue infection, bone infection was safely and accurately diagnosed in a two-step method. The method, which included a less invasive bedside bone puncture rather than a bone biopsy, successfully identified osteomyelitis with a specificity of 88 percent and a sensitivity of 94 percent and cut down on unneeded use of antibiotics.

Researchers enrolled 55 consecutive patients with diabetes aged 18 years and older presenting at a clinic for diabetic foot conditions at a single center in France between 2007 and 2009. The patients underwent 67Ga SPECT/CT scans. A total of 42 patients, mostly men with a mean age of 63, had scans showing a marked uptake of gallium, consistent with a diagnosis of osteomyelitis. At follow-up after one year, of the remaining 53 patients, three had died, three had undergone amputation and 47 met the primary study end point of having no clinical evidence of foot infection at follow-up. None of the patients with negative 67Ga SPECT/CT scans had any evidence of bone infection at follow-up, and use of this technique made it possible to avoid bone puncture in 13 of 55 cases. The screening method also provides cost advantages. The study was published online March 20 in Diabetes Care.

Practice Management

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There has been a significant increase in the pace with which physicians are being employed by hospitals, with employment of physicians and surgeons expected to grow by 24 percent from 2010 to 2020, nearly twice the rate of growth for all other occupations, according to the Bureau of Labor Statistics. The fervor by physicians to become employed by hospitals stems from the decline in reimbursements as well as the increase in practice expense and the complexities associated with adding electronic medical records and tackling billing changes. Statistically, the medical staff model of working with independent physicians is in decline, according to the September 2012 HealthLeaders Media Intelligence Report, Physician Alignment: Integration Over Independence. While the medical staff model is currently used by 67 percent of organizations, that will drop in three years to 50 percent, the report shows. The change in the healthcare environment is causing seasoned and green physicians to make a flight to safety by working for hospitals.


Busy practice managers are typically fast to hire new employees and slow to fire them, and the result can be a high rate of turnover that can prove expensive for the practice. While filling vacancies in the practice as soon as possible might seem like the best decision, this decision depends on two false truths: that bad help is worse than no help, and that even the best new help is a drag on experienced staff. Managers would do best to tighten their hiring protocols. This can be achieved by first designating what skills are essential to the position and writing them down. This way, a staff member other than the manager can screen candidates before sending them on for final approval.

Managers should also record what intangible aspects they are looking for in a new worker. If a good screening practice is in place, interviews with the potential hire will primarily focus on these traits. Managers should try to get the interviewee to interact with other employees before or after the interview and then ask those employees how they felt about the candidate. Once a candidate is selected for hire, a trial period can be used to test out the new employee.

Underperforming employees should be fired quickly in order to minimize damage to practice productivity, patient satisfaction, quality of care and quality of life for staff. Patients and high-performing staff will not hesitate to leave a practice that tolerates underperforming employees. When firing, a manager should make sure they have clear criteria, including disciplinary steps, laid out in a form that is accessible to all employees. The manager should make sure the employee in question has been made aware of their underperformance and has been given the opportunity to correct it. If the employee fails to change his or her ways after being approached, then it is time for the manager to fire them.


ICD-10 implementation carries with it several challenges for medical practices in addition to having to learn new medical codes and purchasing new technology. For one, ICD-10 will require the coordination and oversight of several parts of a practice, meaning practice managers will need to schedule additional meetings, create new teams of workers, plan education and training sessions, create impact assessments, communicate with vendors and communicate with and hire consultants. ICD-10 implementation will also come with financial challenges. Under it, reimbursements can be affected by diagnosis-related group shifts, the accounts receivable cycle can increase because of payer delays and medical coding productivity can decrease, possibly requiring that a practice manager hire more staff to cope with the decrease.

Managers can potentially increase productivity by using computer-assisted coding and implementing electronic health records. ICD-10 implementation will also require increased communication among various groups, including healthcare payers, vendors and consultants; executive levels of the medical practice; and project teams. Practices undergoing the ICD-10 transition will likely also encounter morale issues among their workers, with physicians likely having reservations about new documentation requirements, medical coders not wanting to learn new diagnosis and procedure codes and IT staff having to balance ICD-10 implementation with other system upgrades.

Health Policy and Reimbursement

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President Obama's fiscal 2014 budget proposal likely will include a cut in federal healthcare spending of about $400 billion over 10 years, in part by reducing payments to Medicare providers and making the wealthy pay more for their care, according to the White House. The budget will include his offer to House Speaker John Boehner (R-Ohio) made in late 2012 in the fiscal cliff talks. That offer, which included $400 billion in healthcare spending cuts, was rejected by House Republicans.



House Republicans have released a revised proposal to replace Medicare's sustainable growth-rate physician payment formula. The proposal includes specialty-specific performance measures, payment rates partially based on patient experience and the creation of an appeals process to challenge or reconsider a provider's quality score among other changes.


The Centers for Medicare and Medicaid Services (CMS) has published updated hospital clinical quality measures (CQMs) for Stage 2 of the electronic health records meaningful use program. CMS will accept all versions of the CQMs for meaningful use beginning with those finalized in an interim final rule issued on Dec. 4, 2012. But in a notice, the agency encourages use of updated electronic specifications as they include new codes, logic corrections and clarifications. Also available with the updated measures are corresponding specifications for electronic reporting and access to related data elements and value sets.

More information on 2014 specifications can be found here, with a new CQM Library accessed here. Information on the Cypress tool to test an EHR’s capability to accurately capture, calculate and report CQMs is here. Information on the 2014 Edition Test Method for certifying EHRs and EHR modules is here.


Representative Diane Black (R-Tenn.) is proposing a bill to bring exemptions and amend penalties for Medicare providers have trouble attesting to meaningful use. The Electronic Health Records Improvement Act would decrease the regulatory burden for Medicare providers and make meaningful use requirements better suited to their resources and needs. In addition, the bill would allow small physician practices and physicians nearing retirement to be exempt from installing a costly EHR system. The reporting period for Medicare EHR payment adjustment applications would also be shortened. The bill would also allow some providers to participate in specialty registries and allow rural healthcare providers to participate in the EHR Incentive Program. Lastly, the bill would give providers the chance to contest penalties levied by the Centers for Medicare & Medicaid Services in a formal appeals process.


In a reversal of policy, the Centers for Medicare & Medicaid Services (CMS) April 1 said it will assume that Congress will override an impending cut in Medicare physician payment in 2014 and announced that Medicare Advantage (MA) rates will increase by more than 3 percent in 2014, rather than decline by more than 2 percent as had been proposed. The average combined effect of the estimated MA growth rate and the fee-for-service growth percentage in 2014 is a 3.3 percent increase, rather than the agency's draft estimate of a 2.2 percent drop, CMS said. The final estimate of the MA growth percentage in contract year 2014 is 2.96 percent, and the final estimate of the increase in the fee-for-service growth percentage is 3.53 percent.

Medicine, Drugs and Devices

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Researchers have published a paper in the journal Polymer Degradation and Stability in which they propose a new type of bioglass bone graft that could represent a significant breakthrough in treating broken bones. The bioglass bone graft is chemically altered with plasma treatment on the surface in order to prevent the adverse reactions that would occur when untreated bioglass is used as a bone graft. The plasma treatment will also make the bone graft more stable. Researchers say that one advantage of their graft is that it will dissolve after the bone heals, thus eliminating the need for another surgery after the graft is implanted.


The Safe in Common nonprofit coalition is striving to reinitiate safety efforts around injection devices such as needles and syringes, convinced that the healthcare environment has become complacent. Safe in Common's website says 5.6 million healthcare staff in the United States lack access to safety-engineered medical devices that can shield them from occupational exposure to bloodborne pathogens such as HIV and hepatitis C. "We recognize that there has been significant progress in safety, but we've also heard from nurses and students, housekeepers, patients and visitors that they still have concerns for sharps safety and injury prevention," says former American Nurses Association President Mary Foley. She also sees stagnation in the innovation of demand for safer products.

A poll on Safe in Common's website found that 42 percent of visitors think developing better injection devices is the most important action to take to enhance injection safety, and 35 percent believe more awareness of the issue is most important. A recent Joint Commission monograph is meant to provide guidance on correlation and integration on worker and patient safety, and it warns against a safety culture that excludes certain groups from the organization. The monograph calls on hospitals to realize that adverse events and near misses that endanger one group of people at the hospital frequently imperil another group. The document also demonstrates that the advantage of improving sharps safety to both patient and staffer is less exposure to bloodborne pathogens.

Foley wants the Joint Commission to focus more on their accreditation and inspection process, noting that while sharps containers and other sharps-related items are included in the Environment of Care section, not enough attention has been devoted to the culture of safety and device selection processes in the last several years. Meanwhile, Premier Safety Institute Vice President Gina Pugliese says the same elements that call attention to and work for patient safety efforts, such as visible support from management, also are applicable to healthcare worker safety. She notes that practices that work for patient safety in the operating room are typically most effective in occupational safety as well.