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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

HIPAA Changes to Include Increased Penalties

The President’s Stimulus Bill (American Recovery and Reinvestment Act of 2009) makes several important changes with respect to HIPAA Privacy and Security Rules. While most Stimulus Bill provisions relating to the HIPAA Rules are effective next year, one change that is effective immediately is an increase in the civil monetary penalties that may be imposed on any person who violates the Rules.

In the past, such penalties were limited to $100 for each violation of a provision up to a maximum of $25,000 per provision per year. These civil monetary penalties are now tiered based on the severity of the violation and the covered entity’s response.

Practices should begin immediately to review and revise their health information policies, procedures, training processes and business associates’ agreements in light of these new requirements.

More information is available via the web link below.
Keep Current on Medical Research

Read abstracts of medical research from non-podiatric journals on such topics as whether low molecular weight heparin can prevent venous thromboembolism and whether foot elevation is optimal for wound healing of a diabetic foot.

Podiatric residents, the future stars of our profession, compile the abstracts from journals such as the Journal of Plastic Reconstruction & Aesthetic Surgery, Journal of Trauma and Plastic Reconstructive Surgery for ACFAS' Scientific Literature Reviews.

The Web link below will take you to the 10 abstracts featured this month.
Fight the Recession and Boost Revenues

Today’s economy has made it more important than ever to increase revenues and reduce expenses. And that’s what you and your staff will learn when you attend the ACFAS Coding and Practice Management Seminar Friday and Saturday, May 15-16 in Charleston, SC.

You’ll hear it all… management…physician quality reporting incentives (PQRI)…E-prescribing and marketing…from leading specialists in the field. Walk away with what you need to know so your practice won’t just survive, it’ll thrive!

Learn more and register at the Web link below.

Foot and Ankle Surgery

Correction of Arthrogrypotic Clubfoot With a Modified Ponseti Technique

An inquiry as to whether arthrogrypotic clubfoot can be corrected by a modified Ponseti method studied 10 patients with 19 arthrogrypotic clubfeet who underwent an initial percutaneous Achilles tenotomy to release the calcaneus from the posterior tibia followed by weekly Ponseti-style casts. More than half of the patients' clubfeet underwent a second percutaneous Achilles tenotomy. From pretreatment to completion of initial series of casts, mean scores of Dimeglio et al. improved from 16 to 5, while Catterall scores improved from 4.8 to 0.9 and maximum passive dorsiflexion shifted from -45 degrees to 10 degrees. Ankle-foot orthoses maintained correction. The mean maximum dorsiflexion was 5 degrees at the minimum 13-month follow-up while two patients had posterior releases and no patient's ambulatory ability was compromised by foot shape. Arthrogrypotic clubfeet can be fixed without extensive surgery during infancy or early childhood, and limited surgery may be necessary as the children get older.

From the article of the same title
Clinical Orthopaedics and Related Research (05/01/09) Vol. 467, No. 5, van Bosse, Harold J.P.; Marangoz, Salih; Lehman, Wallace B.

Link between Widely Used Osteoporosis Drugs and Heart Problems Inconclusive

Researchers at the Wake Forest University School of Medicine have evaluated the link between bisphosphonates, a common class of drugs used to prevent bone fractures in patients with osteoporosis, and the development of an irregular heartbeat. "Some trials show there could be a potential link between the use of bisphosphonates and the development of serious heart rhythm problems, but in our study the link wasn't conclusive," says Sonal Singh, MD, MPH, lead investigator for the study. Though bisphosphonate use was found to be associated with a significant increase in the incidence of "serious" heart rhythm disturbances, when "non-serious" cases were factored in, the analysis showed no overall increased risk of atrial fibrillation. For the study, the medical records of more than 13,000 patients who had osteoporosis or fractures and were given bisphosphonates were compared to the records of more than 13,000 patients who received a placebo during study participation. "We found no risk of stroke and cardiovascular mortality in the trials," says Singh. The review of observational studies found different results, with one showing an increased risk of irregular heartbeat in patients taking bisphosphonates and others showing no associated risk. "The amount of data on the outcome of bisphosphonate use is insufficient to make a definitive conclusion," says co-investigator Vinodh Jeevanantham, MD. Singh said that doctors should closely monitor patients at risk for atrial fibrillation who are taking bisphosphonates. Further details can be found in the April issue of Drug Safety, a publication of the International Society of Pharmacovigilance.

From the article of the same title
Ortho Supersite (04/01/2009)

Practice Management

Health Care Industry Moves Slowly Onto the Internet

The healthcare industry's adoption of the Internet is in a state similar to where many industries were a decade ago, with a great deal of interest and a number of innovators but still a lack of real mainstream adoption. The shift toward Internet-style systems is sure to be prompted by the Obama administration's $19 billion spending plan for interoperable electronic health records, and the recent health information technology trade show in Chicago demonstrated plenty of evidence of the transition. For example, the Centers for Disease Control and Prevention and GE Healthcare announced a joint project to send individually tailored public health alerts to doctors' electronic health records systems. "Public health mostly deals with problems now as broadcast communication, with warnings to the general population," says Dr. Charles Safran of the Harvard Medical School, who serves as a senior scientist at the CDC's Center for Public Health Informatics. "This changes that communications paradigm from broadcast to targeted." Meanwhile, Mayo Clinic researchers are working with IBM on a project called the Open Health Natural Language Processing Consortium that aims to create a Web site for collaboration in tools used for searching all sorts of records and data stores. "By making it an open-source initiative, we hope to enable wide use of natural-language processing tools so medical advancements can happen faster and more efficiently," says Dr. Christopher Chute, a Mayo Clinic bioinformatics expert.

From the article of the same title
New York Times (04/05/09) Lohr, Steve

Interactive Kiosks Expanding Beyond Patient Check-ins

A study from the California HealthCare Foundation says that more and more physician practices are adopting interactive computerized kiosks that patients can use for self-service tasks, and they are expanding beyond just being used for check-in. Among the routine tasks that kiosks can help automate are insurance verification and billing, patient education, and asking patients routine clinical questions or post-visit satisfaction questions. Gary Grandovic, director of Florida's West Boca Diagnostic Imaging Center, which became a kiosk beta test site a year ago for parent company Tenet Healthcare, says the technology has slashed check-in time to the point that the center can see some 15 to 20 more patients per day than it could before. Kiosks are not expected to eliminate administrative staff forever, in part because kiosks are not suited for every patient. Still, the successful pilot test at West Boca has the center adding a payment function, and experts say that kiosks could reduce paper costs and chart filing time if they are used in conjunction with EMRs. Someday, says Virginia Cardin, DrPH, senior research health care consultant for the market research firm Frost & Sullivan, practices could be sufficiently computerized that patient kiosks could provide interactive programming responsive to patient medical history.

From the article of the same title
American Medical News (03/30/09) Dolan, Pamela Lewis

DOTmed Industry Sector Report: Electronic Coding and Payments

One area where the healthcare industry has been making progress in moving from paper to electronic systems has to do with the way physicians and insurance companies work together. Electronic coding systems helps physicians ensure correct coding with proper support documentation, providing more power to physicians. "In many countries, like Austria, they are 100 percent electronic," says Tom Turi of revenue and payment solutions provider Emdeon. "Our country in the last several years has finally crossed the tipping point where electronic transactions have exceeded paper." Adopting electronic coding makes things faster and cheaper, with less theft and fewer errors, in addition to cutting down on paper, says Ragui Selwanes, a partner with the healthcare payment consultancy Philliou Selwanes Partners. "You go to the doctor or hospital and get care. They treat you, and then later fill out a claim form, either paper or electronic, for what they did. They submit that form to the insurance company-in the electronic case through a clearinghouse, which routes the claim to the right health-plan. ... The insurance company scrubs the claim, applies their discount, or rejects it as it were, and adjudicates it [i.e. they tell you how much you owe, how much they owe, and the discount applied]." In the past, surgeons have done procedures first then dictated their operative notes, from which the surgeon or office staff would code the case later. However, EMR-based coding systems change this workflow so that the surgeon performs the procedure, codes the case, then analyzes and optimizes the code set, which is used afterward as an outline for dictation, helping empower the physician. "The new coding EMR placed the responsibility squarely on my shoulders. It also helped ensure proper coding even before I began dictating the operative or clinic record," says J. Brian Gill, an orthopedic surgeon at Nebraska Spine Center. "Finally, knowing the appropriate codes enabled me to document my services properly, resulting in improved reimbursement."

From the article of the same title
Dotmed (04/02/09) Loria, Keith

Health Policy and Reimbursement

Physician's Organizations Ask FTC to Reconsider New Identity Theft Requirements

Medical societies are locked in dispute with the Federal Trade Commission (FTC) over new identity theft prevention rules' application to physicians, and the compliance date of May 1 is fast approaching. The FTC rules demand that various business entities, primarily in finance and banking, have written programs for preventing, detecting, and responding to identity theft. However, the American Medical Association (AMA) and other medical societies have raised objections to a lack of forewarning and what they believe is unreasonable breadth of application. AMA Secretary Ardis D. Hoven, MD, says that the FTC "did not give physicians an appropriate opportunity for notice and comment on the ruling that the red flags would be applied to them. The AMA is calling on FTC to re-publish its rule so that we can make the case that physicians should be excluded." The rules were mandated under the 2003 Fair and Accurate Credit Transactions Act, but it was not until last summer that physicians learned they would need to comply as well; the FTC responded by extending the Nov. 1 compliance deadline to May 1, but the commission says there will be no more extensions. Medical societies are questioning the FTC's viewpoint that physicians' practice of billing patients after the completion of services means that physicians are creditors. The Medical Group Management Association has also raised concerns that if physicians are considered creditors for the purposes of this rule, then other additional regulations having nothing to do with health care may end up applying to them as well. On the plus side, the existing HIPAA policies at physician practices should give them a head start in implementing the new rules, and the AMA is planning to release physician guidance on the matter by April 10.

From "Medicine Slams FTC Over Forcing Physicians to Police Identity Theft"
American Medical News (04/06/09) Sorrel, Amy Lynn

'Medical Home' Approach Brings Back Managed Care

Managed care is resurging, especially among Democratic policymakers now sculpting a proposed revamp of the U.S. healthcare system. Gaining favor is the medical home model, in which the facility pays doctors to coordinate all of a patient's needs, and awards them bonuses for meeting quality standards. During the 1990s, insurers greatly bolstered their bottom lines by imposing strict rules on patients and forcing physicians to accept increasingly lower compensation. The majority of HMOs also paid doctors a set amount per patient, often irrespective of the patient's degree of illness. This made doctors shoulder most of the financial risk and de-incentivized them from providing more care and managing sicker patients. These policies eventually provoked a backlash that resulted in an exodus of patients from HMOs in favor of preferred provider organizations, which have higher costs but fewer patient rules. Modern medical homes place an emphasis on quality, and pay physicians or their staffs for checking up on patients, coordinating tests and specialist visits, and communicating with patients by phone or email. "In the 1990s, we had clerks talking to physicians; now we have physicians talking to physicians about whether [a patient] should go directly to an MRI and not have X-rays or CT scans," notes America's Health Insurance Plans President Karen Ignagni.

From the article of the same title
Boston Globe (04/08/09) Wangsness, Lisa

More Doctors Are Opting Out of Medicare

Finding a doctor who accepts Medicare is a difficult prospect, as more physicians are opting out of the insurance system or are no longer taking new patients with Medicare coverage because reimbursement rates are too low and the paperwork is too much of a headache. estimates that there are currently some 40 million Americans with Medicare insurance, with coverage supplied to people 65 and older, some younger handicapped people, and people of all ages with end-stage renal disease. Doctors enrolled in Medicare are either participating or nonparticipating physicians, with participating doctors receiving a lower Medicare reimbursement, in which case the patient is responsible for a bigger portion of the bill. Doctors who have opted out of Medicare can charge what they like, but neither they nor their patients can bill Medicare for reimbursement. A national shortage of internists is converging with internists' growing unwillingness to accept new Medicare patients. Patients nearing Medicare eligibility should consult with their physicians, and even doctors unwilling to accept new Medicare patients may allow their existing patients to stay in their care; if they are not willing, then patients should start searching for a new doctor who accepts Medicare. A list of enrolled doctors is provided by the Web site, while online directories of doctors can be found at state medical societies and local hospitals. Concierge or boutique care is a more costly option, and the most popular kind of boutique care involves physicians accepting Medicare and other insurance coverage, but charging patients a yearly retainer of $1,600 to $1,800 to get in the door and get services not covered by Medicare. The other type of concierge care, involving doctors who have opted out of Medicare, is even more costly.

From the article of the same title
New York Times (04/02/09) P. F9; Connelly, Julie

Technology and Device Trends

Surgeon Pioneers Portable Musculoskeletal Ultrasound

John S. Reach Jr., MD, director of the Yale Foot and Ankle Service, is using ultrasonography to identify, detect, and treat musculoskeletal disorders. Reach has pioneered the use of hand-held, portable ultrasound to help diagnose patients at their initial surgical consultation. "Ultrasound—which is very familiar to pregnant women—is rapid, uses no radiation and can be delivered at the point of care by the treating surgeon," says Reach. "It can reduce the need for expensive, time-consuming tests and return visits by the patient. A process that used to take days or weeks is now accomplished in less than 10 minutes." A series of studies led by Reach found that orthopaedic surgeons appropriately trained in the technique can reduce overall time to patient diagnosis, enhance clinical outcomes, and significantly lower out-of-pocket expense for patients. "Ultrasound allows surgeons to see structures hidden by the patient's skin at the initial time of consultation," says Reach. The laptop-like scanner used by Reach was developed in part by the U.S. Defense Advance Research Projects Agency and can be easily moved from office to operating room. "In the treating surgeon's hands, this imaging produces accurate diagnostic results that can be immediately acted upon by the surgery team in the operating room. ... Each day, I share my patients' amazement when we identify their exact area of discomfort and immediately look beneath the skin and confirm the diagnosis using images of their own anatomy. This way, we can outline a personalized surgical plan of care during the same visit. We also use this same technology in the OR prior to surgery so the entire team can see what is beneath the skin in real time."

From the article of the same title (04/08/09)

Artificial Cartilage Performs Better Than the Real Thing

Researchers have developed a new lubricating technique incorporating "molecular brushes" that can replace and even outperform the natural cartilage in knee and hip joints. According to Jacob Klein of Israel's Weizmann Institute of Science, who led the project with U.K. colleagues, the small imperfections in artificial joints' stainless steel can rub together and release particles of debris that soften bone. In the past, synthetic alternatives to cartilage failed to maintain their lubricity at the high pressures found in skeletal joints, but Klein believes he may have a solution with his "molecular brushes." The nanoscale filaments of the brushes slide past each other with friction coefficients on par with those of cartilage, and with the ability to withstand even more pressure than cartilage does—they are still highly effective at 7.5 megapascals of pressure, while cartilage tops out at about 5 megapascals, which joint pressure rarely exceeds. The groups of molecules surrounding the brush filaments attract as many as 25 water molecules apiece via electrostatic forces, maintaining the lubrication of the brushes even at high pressures. Meanwhile, the filaments are attached to their mica-based backbone via strong covalent bonds, helping avoid the sort of tearing away of filaments seen in earlier prototypes of the concept. The new material could one day be used to make improved, longer-lasting artificial joints.

From the article of the same title
New Scientist (04/10/09) Vol. 202, No. 2702, P. 18; Barras, Colin

Plantar Pressure Relief in the Diabetic Foot Using Forefoot Offloading Shoes

The common clinical treatment of plantar forefoot ulcers in the diabetic foot is forefoot offloading shoes (FOS), and the offloading effectiveness of four different FOS models was assessed in comparison to a cast shoe and control shoe. In-shoe plantar pressures were calculated during walking in each of the half-dozen footwear conditions in two dozen neuropathic diabetic patients at high risk for plantar foot ulceration. Peak pressure, pressure-time integral and force-time integral were measured for each of six foot regions, and load transfer diagrams were devised to evaluate the footwear mechanisms of action. A visual analog scale was employed to measure perceived walking comfort. Substantial reduction in peak pressures and pressure-time integrals at the metatarsal heads and hallux regions was recorded in all FOS models when compared with the control shoe, while relief from metatarsal head peak pressure by the FOS was significantly larger than the cast shoe. However, the control shoe and cast shoe scored higher than the FOS in terms of perceived walking comfort. Data indicated that all FOS models effectively relieved forefoot pressure in at-risk neuropathic diabetic patients, so the shoes may be efficacious in offloading and healing plantar forefoot ulcers.

From the article of the same title
Gait & Posture (06/09) Vol. 29, No. 4, P. 618; Bus, Sicco A.; van Deursen, Robert W.M.; Kanade, Rajani V.

FDA to Review Medical Devices Marketed Prior to 1976

The FDA announced that it has asked the manufacturers of 25 types of medical devices marketed prior to 1976 to submit safety and effectiveness data for their products to the agency so that it can evaluate the risk level for each device type. Devices found by the FDA review to be "high risk" will be required to undergo a strenuous premarket review process. The review is being conducted following a congressional report made by the Government Accountability Office in January 2009 that recommended the FDA complete a review of all Class III medical device types marketed in the United States prior to the Medical Device Amendments to the Food, Drug, and Cosmetic Act of 1976.

From the article of the same title (04/08/09)

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April 15, 2009