April 18, 2012

News From ACFAS

ACFAS Offers Expertise in Multidisciplinary Approach to Diabetes Care
As a member of the Coalition for Patients' Rights, ACFAS is actively working with the national organization to help improve patient outcomes and increase DPMs inclusion in patient care through an interdisciplinary model approach to healthcare.

Recently through these efforts, ACFAS and Sean Grambart, DPM, FACFAS, collaborated with Coalition leaders to write the commentary, Collaborative Practice Benefits Patients: An Examination of Interprofessional Approaches to Diabetes Care.

The commentary, the first of its kind, promotes the role Board Certified Foot and Ankle Surgeons' in the multidisciplinary approach to effectively managing patients with diabetes with each member of the team offering their own expertise.

The full commentary is available in the April 2012 issue of Health and Interprofessional Practice.
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Contract Consternation?
With all the looming changes in healthcare, you will be making modifications to your practice that will affect how you do daily business. Don't be left to fend for yourself; plan to attend an upcoming ACFAS' Practice Management/Coding Workshop and take back a wealth of knowledge and exclusive handouts from a variety of speakers, including health lawyer Stacy Cooke, JD, LLM, who will provide annotated materials that will walk you through specific contract clauses that have implications you may not be aware of, and discuss explicit scenarios in this ever changing environment.

Upcoming dates for the 2012 Practice Management/Coding Workshops include:
June 1-2, 2012
Portland, Oregon

October 12-13, 2012
Arlington, Virginia

To register for the workshop or to see a full description of the program, visit
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ACFAS Research Call
Input is still being collected for the ACFAS Research-EBM Committee's survey on DVT Prophylaxis.

If you haven't already, please take a few minutes to participate in the short 15-multiple-choice questionnaire at and help advance ACFAS research!
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Foot and Ankle Surgery

Local Biochemical and Morphological Changes in Human Achilles Tendinopathy: A Case Control Study
Thirty Achilles tendinopathy patients were evaluated to characterize biochemical and morphological changes in chronic Achilles tendinopathy, in which expressions of growth factors, inflammatory mediators, and tendon morphology were determined in both chronically diseased and healthy tendon components. The researchers took biopsies from two areas in the Achilles tendon, and structural parameters including fibril density, fibril size, volume fraction of cells, and the nucleus/cytoplasm ratio of cells were ascertained. The researchers found significantly more small collagen fibrils and a higher volume fraction of cells in the tendinopathic region of the tendon. The tendinopathic region also exhibited a substantial increase in markers for collagen and its synthesis collagen 1, collagen 3, fibronectin, tenascin-c, transforming growth factor-beta fibromodulin, and markers of collagen breakdown matrix metalloproteinase-2, matrix metalloproteinase-9, and metallopeptidase inhibitor-2. The researchers did not observe any altered expressions of markers for fibrillogenesis, inflammation, or wound healing.

From the article of the same title
BMC Musculoskeletal Disorders (04/05/12) Pingel, Jessica; Fredberg, Ulrich; Qvortrup, Klaus; et al.
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Local Anaesthetics Use Does Not Suppress Muscle Activity Following an Ankle Injection
A study was held to determine if peroneus longus (PL), peroneus brevis (PB), medial gastrocnemius (MG), and tibialis anterior (TA) muscle activation patterns during inversion perturbation and running tasks are suppressed following the injection of lidocaine to the anterior talofibular (ATF) and calcaneofibular (CF) ligament regions, with a focus on 14 recreationally active men. Testing was carried out under five injection conditions to the ATF and CF regions—1 ml saline, 1 ml lidocaine, 3 ml saline, 3 ml lidocaine, or no injection. Traditional ankle taping was applied after injection, and electromyography patterns of the PL, PB, MG, and TA were obtained while subjects performed continuous lateral jumps on a custom-built device which elicited an ankle inversion perturbation and treadmill running. The muscle activation patterns of the PL, PB, MG, or TA did not exhibit any significant differences for any factor across injected conditions during both tasks. Statistical power was 0.214-0.526 for the PL, 0.087-0.638 for the PB, 0.115-0.560 for the MG, and 0.118-0.410 for the TA.

From the article of the same title
Knee Surgery, Sports Traumatology, Arthroscopy (04/07/12) Stone, David A.; Abt, John P.; House, Anthony J.
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Sports Activity After Osteochondral Transplantation of the Talus
To test the hypothesis that osteochondral transplantation of the talus allows patients to pursue regular and ongoing recreational sporting activities, researchers analyzed 131 patients to ascertain their activities at an average of 60 plus or minus 28.4 months following transplantation. The clinical assessment included the Tegner activity scale, the Activity Rating Scale (ARS), and a visual analog scale (VAS) for pain. Significant preoperative to postoperative improvements were demonstrated by the VAS, and 96.9 percent of the patients were engaged in sports during their lifetimes versus 83.8 percent the year before surgery and 89.3 percent at the time of surgery. The Tegner score fell from 5.9 preoperatively to 5 postoperatively, while the ARS declined from 8.9 preoperatively to 6.8 postoperatively. No significant change in sports frequency or duration of activities was observed following surgery, at 1.7 plus or minus 2 and 4.2 plus or minus 3.8 hours, respectively. The number of actual reported different sports disciplines did not change in comparison to the year before surgery. The 10 leading cited sports activities did not change for the lifetime, preoperative, and postoperative periods but were altered in terms of order. Patients were satisfied with the transplantation overall, but 15 percent were only partially satisfied, and 14 percent were unsatisfied with the surgery.

From the article of the same title
American Journal of Sports Medicine (04/01/12) Vol. 40, No. 4, P. 870 Paul, Jochen; Sagstetter, Michael; Lammle, Lena; et al.
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Practice Management

Mistakes Doctors Make When Borrowing Money
Experts say doctors often get into trouble borrowing money by failing to shop for the best terms and the best service, and not paying attention to the details associated with borrowing. Among the most common mistakes experts cite is failure to shop for a banker. Consultant David Shuffler says that "doctors need to interview banks." He recommends that physicians interview with at least three banks, and view the first meeting like a first date. "If the doctor can walk out with the feeling that this banker can be a partner, then they can do business and go to the next step," Shuffler says.

Using one borrowing tool for every situation is the wrong strategy, as there are unique borrowing tools for every scenario, according to consultant Mike LaPenna. He suggests that doctors should take time every two years to study financial matters, with a focus on whether practice debt is in the best spot, where it is subject to the lowest interest rate and has suitable terms. "The best piece of advice I could give is to use long-term debt for long-term needs and short-term debt for short-term needs," says Dave Kaneda with Wells Fargo Small Business Administration Lending. Borrowing to cover operating costs such as salary and rent also is a bad strategy, experts warn.

Another mistake is investing in new technology without first doing the math to see if it will pay for itself or how much income it will produce. Kaneda says doctors tend to be more likely to be too conservative in borrowing and do not expect savings to be realized from a piece of equipment. Another frequent mistake experts cite is failing on financing documentation, and if a doctor departs a practice, that physician should make sure that he or she carries no liability if the practice defaults on a loan. Most doctors should be prepared for the lender requiring a personal guarantee for a small practice loan, but Kaneda says they also have to protect themselves if the practice is reorganized or one or more partners exit.

From the article of the same title
American Medical News (04/09/12) Berry, Emily
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Noncompete Clause Once Again Relevant for Doctors
The Centers for Medicare and Medicaid Services’ (CMS) Phase II final rule on the physician referral portion of the Stark law has clarified that when a hospital recruits a physician to a medical practice, the employment agreement between the medical practice and the new physician may contain practice restrictions provided that they do not unreasonably limit the new physician’s ability to practice medicine within the recruiting hospital’s service area. The rule has hindered many medical practices due to a reluctance to hire new physicians without noncompete and non-solicitation provisions, until CMS issued an advisory opinion in 2011 that changed this provision.

It is important to know your state’s laws on noncompete clauses. For example, noncompete clauses are enforceable in Florida within a reasonable geographic zone, the duration is 2 years or less, and provided that stopping the ex-employee from practicing in the geographic zone does not create a health crisis or shortage, among other factors. In addition to knowing the law, it is important to know how to handle noncompete situations. Turning to litigation may seem natural, but going to court is risky, and once litigation has started it can cost hundreds of thousands of dollars.

In some cases, challenging a noncompete clause on legal grounds does not make business sense. For example, if an employee has been employed for only a few months and has patients that were all referred by his or her employer, the employee may not be a competitive threat to the employer. The employer will be able to find a replacement doctor and simply refer the patients to the new doctor. It may also be possible to work out a settlement by changing the geographic zone or reducing the duration of a contract. Buyouts of noncompete clauses can also be negotiated.

From the article of the same title
Modern Medicine (03/25/12) Cohen, Jeffrey L.
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Improving Communication in Your Medical Practice
Relationship experts say that the key to fulfilling, lifelong relationships is good communication. It is no different for the relationship lead physicians have with their staff -- the key to establishing relationships between staff members in a medical practice is communication. Establishing a good communication flow is a key to creating more engaged and passionate employees, as well as improving productivity. One way of improving communication is implementing a morning huddle with staff -- a quick, 10-minute gathering before the day gets started. In the huddle, team leaders can highlight things that went particularly well, as well as things that could have been improved from the day before. There must be a balance between the positive things and opportunities to improve.

Leaders can also talk about key metrics from the day before, always remembering that the huddle is a time for brief overview, not detailed discussion. Metrics can include things like patient counts, late appointments, reschedules, cancellations, and patient satisfaction. Though the discussion of these metrics will be brief, the team will quickly learn how to interpret the data presented. Lastly, leaders can talk through the upcoming day's schedule, needs, etc. All of this will further align staff, which will enhance productivity and morale, as well as reduce the number of interruptions throughout the day caused by staff asking questions and seeking direction.

On top of the huddle, leaders can schedule a consistent time once a week for a 30- to 45-minute staff meeting, which serves as an extension of the daily huddle meetings. Lunch is an ideal time for this meeting, which affords more time to cover complex topics, reinforce procedures and provide additional training for staff. This is a good time to discuss issues that may have come up in the huddle but needed more than a few minutes to address. Directing team members with these kinds of issues to the weekly staff meeting allows for an easy deferral and gives leaders an opportunity to think through the issue sufficiently before advising. Communication between leaders and staff is the key to success in practice, and implementing these simple activities will dramatically improve communication flow. Ultimately, as morale improves and teams become more cohesive, patient satisfaction scores will improve.

From the article of the same title
Physicians Practice (04/01/12) Taylor, George
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Health Policy and Reimbursement

CMS Picks 27 ACO Participants for Shared-Savings Program
The Centers for Medicare and Medicaid Services (CMS) have selected 27 healthcare entities in 18 states as the first accountable care organization (ACO) participants in its Medicare Shared Savings Program. The entities strive to produce financial incentives for doctors, hospitals, and other healthcare providers to better coordinate care and improve the health of Medicare subscribers while reducing their costs. The first ACOs will feature over 10,000 doctors, 10 hospitals, and 13 smaller physician-led entities and serve approximately 375,000 beneficiaries. "There were some people who feared that the only entities that would participate would be hospital-dominated systems," says director of CMS' Center for Medicare Jonathan Blum. "That has not happened." The new ACOs must comply with 33 quality measures for care coordination and patient safety, appropriate use of preventive health services, enhanced care for at-risk populations, and the patient and caregiver experience of care. CMS is reviewing over 150 applications for ACO status from other agencies and will choose the next round of program designees in July.

From the article of the same title
Modern Healthcare (04/10/12) Daly, Rich
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CMS Posts Stage 2 Clinical Quality Measures
The Centers for Medicare & Medicaid Services (CMS) has posted the clinical quality measures for Stage 2 meaningful-use criteria in a downloadable spreadsheet format. CMS posted the measures and descriptions about them for both hospitals and office-based physicians. The agency released a proposed rule containing the Stage 2 criteria in February. The criteria, slated to take effect in 2014, are part of the Medicare and Medicaid EHR incentive payment programs created under the American Recovery and Reinvestment Act of 2009. The public comment period on the proposed rule is open through May 7. A final rule is expected to be released in June. The proposed clinical quality measures can be found here.

From the article of the same title
Modern Healthcare (04/10/12) Conn, Joseph
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Senators Urge CMS on Sunshine Act
The authors of the Physician Payments Sunshine Act are urging the Centers for Medicare & Medicaid Services (CMS) to issue its final implementation rule by June, so that data collection and reporting on financial transactions between healthcare providers and the drug, device and group-purchasing industries can begin. In a letter to CMS Acting Administrator Marilyn Tavenner, Sens. Chuck Grassley (R-Iowa) and Herb Kohl (D-Wis.) called on the agency to narrowly define payment categories and work with stakeholders "so that reporting is complete, but that unintended consequences are avoided." The senators also express disappointment that the CMS had not met the Oct. 1, 2011 statutory deadline for implementing the act.

From the article of the same title
Modern Physician (04/05/12) Robeznieks, Andis
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Medicine, Drugs and Devices

Few Doctors Downloading Medicare Resource Use Reports
Physicians in four states—Iowa, Kansas, Missouri and Nebraska—have access to individual reports that measure the quality and costs of their care compared with other doctors treating Medicare patients, but large numbers of the doctors have failed to download the reports. The Centers for Medicare & Medicaid Services has compiled individual quality and resource use reports for physicians treating patients in the states. WPS, the Medicare contractor for the jurisdiction, has emailed practices a web link to access the reports, but only 3,300 out of 23,730 had downloaded the reports as of the end of March.

From the article of the same title
American Medical News (04/09/12) Fiegl, Charles
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CMS Backlog Shortchanges Doctors on E-Prescribing Exemptions
Some doctors report that the Medicare payments they have received for services in 2012 are being reduced for a failure to make enough electronic prescriptions in 2011, even though the doctors filed waiver requests seeking hardship exemptions. Officials with the Centers for Medicare & Medicaid Services say the agency was unable to process all hardship application requests before beginning to charge the 1 percent penalty for noncompliant physicians in 2012, and CMS says it since has approved or denied all of those exemption requests, requiring contractors to reprocess claims for doctors unfairly penalized earlier in the year. E-prescribing physicians who did not report a minimum of 10 e-prescribing encounters on claims for qualifying services between January and June 2011 got letters in February 2012 stating that the 1 percent penalty was being assessed on their payments, but doctors filing for hardship exemptions in the autumn also received the letters, which said that the notice did not account for whether the recipients' exemption applications had been received by a Nov. 8, 2011, deadline. Medicare contractors are responsible for notifications of approval or denial of exemptions, says CMS' Joseph Kuchler. American Medical Association president Peter W. Carmel says his organization is calling on CMS to reassess the penalty timelines associated with the e-prescribing incentive program, as well as other health information technology incentive programs that are going into effect concurrently.

From the article of the same title
American Medical News (04/09/12) Fiegl, Charles
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