News From ACFAS

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Late last night, with one hour to spare before physicians started seeing a 21.2 percent reduction in Medicare reimbursements, the Senate approved a replacement for Medicare’s 18-year old “Sustainable Growth Rate” (SGR) reimbursement system. SGR, which has largely been ignored by Congress over the past 11 years with 17 short-term patches, will be replaced by a system emphasizing value- and risk-based incentives starting in 2019.

The House originated and approved the SGR replacement legislation last month due to the leadership of House Speaker John Boehner and Minority Leader Nancy Pelosi. President Obama said he would sign the bill.

Physicians will now receive a base 0.5 percent increase in each of the next four years, followed by six years of no base adjustments. Afterward, base reimbursements would increase by 0.25 percent annually. To receive higher payments, by 2019, 25 percent of a physician’s Medicare income must be tied to value-based payment models, such as accountable care organizations, bundled payments and medical homes; by 2023, that requirement increases to 75 percent of either Medicare or all practice revenues. The legislation also contains other bonus plans starting in 2020.
Every day, so many demands are placed on your time, yet you still find ways to give back to the profession. You serve on ACFAS’ committees and the Board of Directors, help develop and teach our educational programs and always go above and beyond the call of duty.

In honor of National Volunteers Week, the staff of ACFAS thanks you, our volunteers, for everything you do for the College. The continued success of the College could not be achieved without your dedication and drive, and while this week is a perfect opportunity to recognize your spirit of service, know that our appreciation lasts year-round.

Thank you!
Want to share your experience and expertise with your fellow colleagues? Consider applying to join the College’s educational program faculty.

As ACFAS’ surgical skills courses, regional programs, e-Learning offerings and Annual Scientific Conference continue to grow in size and popularity each year, instructors and faculty members are essential to meeting members’ needs and high educational standards.

If you are an active Fellow member of ACFAS, have attended our educational programs within the past three years and would like to apply to become an instructor, complete an Education Program Faculty Application or visit acfas.org for more information.

Foot and Ankle Surgery

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A study was conducted to compare clinical and radiographic results of proximal opening wedge osteotomy using a straight versus oblique osteotomy. A retrospective review of 104 consecutive first metatarsal proximal opening wedge osteotomies conducted in 95 patients with hallux valgus deformity was performed. Straight metatarsal osteotomy was performed on 26 feet in the first group, and 78 feet were treated with oblique metatarsal osteotomy in the second group. The hallux valgus angle (HVA), intermetatarsal angle (IMA), distal metatarsal articular angle and distance from the first to the second metatarsal were measured for radiographic assessment, while the American Orthopaedic Foot and Ankle Society (AOFAS) forefoot score was used for clinical evaluation. Significant corrections in the HVA, IMA and distance from the first to the second metatarsal were acquired in both groups at the last follow-up. No difference in the average IMA correction was observed between the two groups. Still, a greater correction in the HVA and distance from the first to the second metatarsal was seen in the second group versus the first group. AOFAS scores were improved in both groups, but the second group exhibited more improvement relative to the first group.


Researchers performed a reconstruction of a traumatic plantar foot defect with a medial triceps brachii (MTB) free flap in a 53-year-old male who suffered a gunshot wound to the right foot. The patient presented with a soft-tissue defect with calcaneal exposition and osteomyelitis, which was reconstructed with a MTB free flap anastomosed to his dorsalis pedis vessels. The duration of flap raising was 52 minutes, without any intraoperative complications. The total flap surface was 38.5 square centimeters, and the pedicle length was 3 centimeters. The diameters of the artery and vein of the flap pedicle were 1.1 mm and 1.4 mm, respectively. Ischemia time lasted 28 minutes. The patient's donor site healed uneventfully without morbidity, and the scar was well concealed. The flaps survived, and no partial flap necrosis was experienced. A split-thickness skin graft was conducted 12 days after the operation. The patient had a completely healed wound with no contour abnormality two months later. The total follow-up was 24 months, and the patient was able to walk normally.


A study was conducted to assess development of the tibia following Ilizarov lengthening and deformity correction depending on whether or not the simultaneous resection of fibular anlage was conducted in children with fibular aplasia type II, who did not receive early surgery. The outcomes of reconstructive treatment in 38 children at the age of more than four years were analyzed. One group of children who underwent bifocal tibial lengthening with the Ilizarov device was compared to a second group who underwent bifocal lengthening associated with resection of the fibular anlage. Outcomes were estimated at 12 months and in the long-term exceeding three years. Radiological data of measurement of the anatomical lateral distal tibial angle (aLDTA) demonstrated surgical correction of deformities was achieved in both groups. During the further limb growth, a tendency to normalization of the aLDTA was seen only in the second group. Rapid relapse of the angular deformities of the tibial shaft in the first group occurred primarily during further growth of the limb irrespective of complete correction at the time of treatment. However, no recurrences of diaphyseal deformities were observed in the second group.


Researchers developed an experimental protocol to measure the bilateral intrinsic ankle-foot stiffness during standing balance and to determine its amplitude dependency. Based on results, reflexive activity could not have biased the torque used to estimate intrinsic stiffness. Subjects also required less recovery action to restore balance after bilateral rotations in opposite directions compared to rotations in the same direction. The intrinsic ankle-foot stiffness appears insufficient to ensure balance, which implies that balance requires changes in muscle activation. The non-linear stiffness decrease with increasing rotation amplitude supports previous studies. The proposed method allows reflexive effects to be ruled out from the measured torque without any model assumptions, allowing direct estimation of intrinsic stiffness during standing.

Practice Management

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For better or worse, e-mail remains the most efficient way to communicate and transfer data. E-mail offers the ease of accessibility that no other communication platform can match, meaning that using it correctly is incredibly important in an age where security is more vital than ever. According to Asaf Cidon, co-founder and CEO of Sookasa, a cloud security and encryption startup, physicians must look for file encryption to ensure that protections follow emails and files no matter where they might end up. This protects a user in the event of sending important information to the wrong email address. In addition, physicians must look at the cloud as the most efficient method of storing information. The cloud is an inexpensive, jack-of-all-trades storage solution that can store encrypted files securely. Many security providers aren't as efficient as advertised, meaning HIPAA fines could be imminent. It is suggested to utilize solutions that offer to revoke access to a file if it is sent to the wrong recipient. The encrypted file will then be impossible to access and can be audited even if it was mistakenly downloaded. Finally, Cidon believes that universal encryption of files is unnecessary. It's not necessary to treat all information equally. Physicians should use solutions that allow the ability to set permissions according to importance. E-mail securities are less than ideal in many ways, so it is up to physicians to properly research their options to ensure the best security.


Direct secure messaging (Direct) is a standardized protocol for exchanging clinical messages and attachments. It is similar to e-mail, but it is hosted through an agent known as a Health Internet Service Provider (HISP) that handles the exchanges and encrypts the messages. Numerous physicians have yet to adopt Direct. The latest version of electronic health record certification requires Direct messaging capability and physicians can use Direct to meet the meaningful use stage 2 requirement, which states that they must exchange clinical summaries at transitions of care. However, many physicians are not aware of the technology or are not interested in it. Direct can help make interactions faster and easier and can reduce redundancy when exchanging lab testing and imaging, but some physicians disagree, claiming that Direct fixes a problem that never existed in the first place. Some hospitals provide secure texting services that make it even easier to communicate, which makes Direct seem even more unnecessary. Direct messaging is nowhere near as intuitive as Facebook or regular e-mail, according to Medhavi Jogi, MD, a Houston endocrinologist who uses the messaging service. Jogi and many others believe the service will continue to grow and improve, but until it creates a more efficient workflow and provides a reason to use it over regular e-mail, it will not reach a widespread audience.


Numerous healthcare changes over the last few years have spawned some interesting numbers regarding American physicians. For example, almost half of all practicing U.S. physicians are 55 or older, and more than 25 percent are at least 60 years old. In addition, a serious physician shortage is expected over the next decade, with high-end predictions estimating 90,000+ fewer physicians than are currently employed. Finally, the Affordable Care Act created an increase in acquisitions of independent practices and independent ownership fell from 61 percent in 2007 to 53 percent in 2012. These statistics indicate changes that are not only happening, but are also on the horizon. Expect more changes in ownership and alterations in the way practices are structured, and do not be surprised to see organizations crossing state borders to test different rules and regulations. Physicians who need help treading new water can incorporate multiple financial strategies such as using a broker to keep ahead of trends and changes. For the most part, being aware and staying closely tuned in to the details will allow physicians to smoothly transition into the changing years ahead.


Healthcare has become more about the customer than ever before, and a holistic approach to revenue cycle management means addressing evolving customer tendencies. To collect from patients more effectively and reduce costs while enhancing revenue, patient and provider interaction must be improved. Ben Colton, senior manager at ECG Management Consultants and leader of ECG’s revenue cycle practice, suggests appropriately investing in revenue cycle is needed because of the ever-increasing complexity of contract terms. Revenue cycles become mismanaged when practitioners wear too many hats and perform tasks more suited for specific workers. The new ICD-10 means an overhaul to this practice is necessary to avoid internal issues. Traditionally, revenue cycle management has been a tough job with little payoff, so attracting talent and emphasizing efficiency are difficult. According to Colton, it is up to the industry to articulate why it is a solid career path and not just a minor step to a larger career in healthcare billing. Compliance with ICD-10 is set for October 1, 2015, and while revenue cycle management issues will not be solved by then, it is critical to take the correct preliminary steps to ensure maximum efficiency in the future.

Health Policy and Reimbursement

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Under a new payment system that will soon apply to all physicians who accept Medicare, just 14 of 1,010 large physician groups that the government evaluated will receive payment increases this year. And only 11 groups will receive reductions for low quality or high spending. Within three years, the Obama administration wants quality of care to be considered in allocating nine of every 10 dollars Medicare pays directly to providers to treat the elderly and disabled. One part of that effort, revising hospital payments based on excess readmissions, patient satisfaction and other quality measures, is already underway. The new financial incentive for doctors, called a physician value-based payment modifier, allows the federal government to boost or lower the amount it reimburses doctors based on how they score on quality measures and how much their patients cost Medicare. How doctors rate this year will determine payments for more than 900,000 physicians by 2017.


The U.S. House of Representatives recently passed legislation to permanently repeal the Sustainable Growth Rate (SGR) formula and to establish an original reimbursement plan with fundamentally implemented, value-based care incentives. When the Senate returns from recess on April 13, it will have only one day to debate and pass the bill. This gives physicians an additional two-week hiatus before Medicare reimbursement cuts take place, according to the Centers for Medicare and Medicaid Services. Andrew Boyd, physician and assistant professor of biomedical and health information sciences at the University of Illinois at Chicago, says the positive implications of SGR involve confidently executed financial resolutions. Negative implications involve a merging of multiple smaller measures, such as concierge physicians only accepting cash or private insurance. As quality measures become more directly tied to financial reimbursement, Boyd expects them to become more detailed, and a simple quality metric on a single disease may not apply to a patient with multiple comorbidities.


Many medical experts are pushing for patients to have easier, full access to their own medical data, saying that they would be more likely to take care of themselves and notice early signs of illness. In one example, 26-year-old doctoral student Steven Keating collected an estimated 70 gigabytes of his own patient data. When he pressed doctors to conduct an MRI after noticing abnormalities, surgeons eventually removed a tennis ball-sized tumor from his brain. More medical groups are giving patients Web access to their health records, and even physicians' notes about them. Such a movement goes against conventions, but the economic incentives are becoming clear. More providers are being paid a set amount of money for a population of patients, rather than fee-for-service reimbursement. One effort to accelerate the adoption of open technology standards in healthcare is the Argonaut Project, which has representatives from a few large medical groups and from leading electronic health record suppliers. Questions raised by opening data to patients include whether worried patients will take up a physician's time with questions and whether sharing the data will increase legal risk.


The U.S. House of Representatives left out ICD-10 from the recent passage of the Medicare Access and CHIP Reauthorization Act, meaning that ICD-10 will not face any immediate delay. However, it does not mean that the threat of delay is gone. Congress could postpone the changes in three ways. In one case, the Senate could reject it. The SGR bill sailed through the House but was put on hold by the Senate, which could prove telling. Another threat to ICD-10 could be resurrection. There have been numerous examples of legislation being debated that could delay ICD-10 implementation, including the Cutting Costly Codes Act of 2013. Sen. Tom Coburn, who sponsored that bill, is now retired, but a coalition of Congress members who have expressed displeasure with ICD-10 could resurrect it at any moment to delay the deadline. Finally, a surprise twist could delay ICD-10. When the Protecting Access to Medicare Act passed in 2014, it included provision 212, which briefly mentioned that Health and Human Services could not enforce the ICD-10 compliance deadline. This stunned people everywhere and could conceivably happen again. Supporters of ICD-10 are more organized than before, meaning the fight will be more competitive. But tension still remains in the community, which is trying desperately to prepare for a deadline that for any reason, could be postponed even longer.

Medicine, Drugs and Devices

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U.S. Rep. Seth Moulton (D-Mass.) plans to meet with members of the state's medical community to highlight a bill aimed at rolling back a tax aimed at medical device makers. He is one of more than 270 co-sponsors of the bipartisan Protect Medical Innovation Act. Other members of the Massachusetts all-Democratic congressional delegation have also co-sponsored the measure. The state's two Democratic senators support rescinding the tax, which was included in President Barack Obama's 2010 healthcare law. Massachusetts is home to many medical device companies, which may explain the measure's support in the state.


After long delays, the U.S. Environmental Protection Agency (EPA) has sent its hazardous waste pharmaceutical (HWP) regulation to the White House Office of Management and Budget for pre-publication review. The regulation is meant to ensure safe disposal of HWPs by healthcare facilities under the Resource Conservation and Recovery Act. It would revise the act's Subtitle C hazardous waste regulations to improve the management and disposal of HWPs. Healthcare facilities have complained about the difficulties in complying with Subtitle C, which is oriented more toward manufacturing. Complaints include healthcare workers being made responsible for following the regulations and the difficulty of ascertaining which pharmaceuticals are HWPs.