News From ACFAS

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ACFAS has written the Federal Trade Commission (FTC) supporting their recent actions to encourage competition in the healthcare market. The FTC had recently commented on proposed legislation in some states that would severely limit non-MD health professions from practicing to the full extent of their education, training, licensure and board certification. In response, the FTC received some pushback from Capitol Hill citing “states’ rights.” ACFAS, the Coalition for Patient Rights, and other healthcare professions have followed with letters encouraging the FTC to continue their work in this area.

ACFAS President Michelle Butterworth, DPM, FACFAS, wrote, “The FTC has expressed opinions on pending state legislation … which would affect the practice of our licensed and highly trained physicians. But this is just the tip of the iceberg. ACFAS members have been the target of anticompetitive business practices in virtually every state over the past 25 years. Such anticompetitive measures limit competition, impair free markets for healthcare services, risk additional cost increases to our already costly health system, and fail to improve patient safety. Restraint of trade and anticompetitive initiatives promoted through legislation and regulation can also discourage the growing trend of interprofessional, team-based patient care."

For the full text of the ACFAS FTC letter, click here.
Here is your chance to share your research and help advance foot and ankle surgery by submitting your manuscript for the 2013 Annual Scientific Conference in Las Vegas. If you are involved in a study that would be beneficial to the profession, the Annual Conference Program Committee invites you to submit your manuscript for presentation consideration at the Conference February 11-14, 2013.

Winners of the ACFAS Manuscript Awards of Excellence divide $10,000 in prize money from a generous grant from the Podiatry Foundation of Pittsburgh.

To read detailed information on manuscript requirements and policies and to submit your manuscript, visit acfas.org/lasvegas. The deadline to submit manuscripts is August 15, 2012. Attention: Physicians and Office Staff Members

Does getting new patients from the Internet or social media seem confusing? Don't know where to begin on developing a successful Internet marketing strategy? Join ACFAS and Officite for the complimentary one-hour webinar Grow Your Practice with an Online Presence on Wednesday, May 23, 8-9pm CDST and learn how you can easily launch and manage a complete Internet strategy for your practice.

Experts from Officite will walk you through:

• How a Typical Patient Searches for a Podiatrist on Google and Other Major Search Engines
• The Important Elements You Need to Build a Successful Website and Marketing Strategy Including:
  • Website Design
  • Search Engine Marketing
  • Reputation Management
  • Social Media
  • Mobile Marketing

To register, visit officite.com/company/webinars. After you register, you will receive a confirmation email containing further details about joining the program.


Let ACFAS help resuscitate your practice by attending the 2012 Practice Management/Coding Workshop June 1-2 in Portland, Oregon.

Learn the latest in:

• CMS' Meaningful Use EHR Incentive Program
• How to avoid HIPPAA 5010 claim rejections
• What Independent Payment Advisory Board (IPAB) means for the foot and ankle surgeon
• What life is like after the Superbill

Plus, when you sign up for the two-day workshop, you can attend one of two evening Roundtable events (which are also available as stand-alone programs), Contracts--understand what you are signing or Coding and Practice Professionals Interactive Session--ICD-10 today and in the future.

To register or learn more, visit acfas.org/pmm/seminars.

Foot and Ankle Surgery

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Researchers determined that diagnosis of acute Achilles tendon ruptures can be accomplished without magnetic resonance imagery (MRI), based on assessment of sensitivity of physical examination in diagnosing such ruptures, comparison of the sensitivity of physical examination with that of MRI, and evaluation of care delays and impact attributable to MRI. Sixty-six patients with surgically verified acute Achilles ruptures and preoperative MRI were retrospectively compared to 66 patients without preoperative MRI. Clinical diagnostic criteria were an abnormal Thompson test, reduced resting tension, and palpable defect. Time to diagnosis and surgical procedures were compared with those of the control group. All three clinical tests were administered to all patients preoperatively and complete ruptures intraoperatively. MR images were interpreted as complete tears in 60 patients, partial in four, and inconclusive in two. It took an average of 5.1 days to acquire MRI post-injury, 8.8 days for initial assessment, and 12.4 days for surgical intervention. Initial assessment occurred at 2.5 days and surgical intervention at 5.6 days after injury in the control group, while 19 patients in the MRI group had additional procedures whereas none of the control group patients had additional procedures.


Researchers studied the effectiveness of platelets rich plasma (PRP) treatment for chronic plantar fasciitis. Twenty-five patients with chronic plantar fasciitis were treated by PRP injection. The mean follow-up was 10.3 months. Using a visual analog pain scale, the average pre-injection pain in patients of was 9.1. Prior to injection, 72 percent of patients had severe limitation of activities, and 28 percent had moderate limitation of activities. Average post-injection pain decreased to 1.6. Twenty-two patients (88 percent) were completely satisfied following the treatment, two patients (8 percent) were satisfied with reservations, and one patient (4 percent) was unsatisfied. Fifteen patients (60 percent) had no functional limitations post-injection and eight patients (32 percent) had minimal functional limitations. Two patients (8 percent) had moderate functional limitations post-injection. The researchers noted significant changes not only in thickness but also in the signal intensity of the plantar fascia after PRP injection. None of the patients experienced any complications.



Researchers compared the outcomes of tibial fractures treated using the U-grooved locking compression plate (U-LCP), characterized by a U-groove at each end, compared with the less invasive stabilization system (LISS). Seventy-eight patients with unilateral tibial fractures treated with either the U-LCP (group I) or LISS (group II) were enrolled. In group I, a U-LCP was inserted subcutaneously with two Kirschner wires embedded into the U-grooves to temporarily secure the plate. A second identical plate was placed over the first to guide screw insertion. In group II, the LISS was used to fix the tibial fractures. The average operation and fluoroscopic times in group I were significantly less than those in group II (p<0.05). At follow-up, all fractures healed. There were no significant differences between both groups in time to bony union, wound complication rate, or functional recovery of injured limbs (p>0.05).

Practice Management

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In order to protect themselves from unintended consequences and to maintain public trust, physicians who use social media should protect the privacy and confidentiality of their patients; avoid requests for online medical advice; and act with professionalism, according to model policy guidelines for the appropriate use of social media adopted by the Federation of State Medical Boards. The guidelines also recommend that physicians be forthcoming about their employment credentials and conflicts of interest, and be aware that information they post may be available to everyone, may be misconstrued, “may be taken out of context or remain publicly available online in perpetuity.”

The new guidelines provide some examples of questionable online behavior and included a complaint registered by a patient after she saw her physician's Facebook page that reportedly showed pictures of the doctor intoxicated and noted that “the patient begins to question whether her physician is sober and prepared to treat her when she has early morning doctor's appointments.”

The guidelines also note that “physicians should not use their professional position, whether online or in person, to develop personal relationships with patients,” and “the appearance of unprofessionalism may lead patients to question a physician's competency.”

While peer-to-peer education and online dialogue is encouraged, the guidelines state that physicians should never mention patients' room numbers, refer to them by code names or provide any other identifying information.

The complete guidelines can be found here.


A physician practice needs to tread carefully when regulating the look of its employees. Policies delineating what is acceptable about hygiene, visible body modifications, hair, and clothing will rarely get a practice into trouble if there is some flexibility; but rules governing physique are more likely to land a practice in hot water. Consultants say it is important to have a policy, because a well-crafted one can make some issues easier to tackle. The first step when devising an appearance policy is to consider the goal. Determine whether the goal is a formal atmosphere or casual environment. How the policy will affect current employees and whether exceptions should be made for religious requirements or health needs must also be considered. Some adaptability usually will be required to comply with the Americans with Disabilities Act (ADA) or various nondiscrimination statutes, which vary by state.

Those writing policies prohibiting tattoos and body piercings must consider details like whether the piercing must be completely removed and which is the most appropriate cover-up methods for tattoos. For clothing policies, they will have to determine exactly what is and is not acceptable. Some simply switch to uniforms to solve the problem of broadly interpreted rules. In most states, making hiring decisions on the basis of weight is legal, even if a job does not require physical work. However, attorneys say that, beyond any unintended worldwide publicity, regulating employees’ weight could result in legal problems. Also, attorneys say weight restrictions could affect women and minorities disproportionately, which could trigger scrutiny from agencies enforcing state and federal nondiscrimination laws. ADA provides protection for people who are obese.

Health Policy and Reimbursement

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The Centers for Medicare and Medicaid Services (CMS) has issued two final Medicare rules that loosen regulatory bureaucracy and are expected to enable health providers and payers to save $1.1 billion over one year and $5 billion over five years. The revisions aim to mitigate or remove what Health and Human Services Secretary Kathleen Sebelius describes as "unnecessary, obsolete, or burdensome regulations" imposed on hospitals and other healthcare providers. The biggest savings, around $330 million, will stem from provisions that widen the definition of a hospital's medical personnel in a manner that lets hospitals grant privileges to both doctors and non-doctors even if they are not on the medical staff. Also, podiatrists, who are not MDs, may have a role in hospital leadership. About $300 million in savings will come from amendments to rules pertaining to hospital outpatient services. For instance, the new regulations eliminate the duplicative requirement that a single director of outpatient services supervise all outpatient departments. Some $110 million will be saved as a result of a change in nursing care plan rules, in which hospitals currently have the option of having a standalone nursing care plan or an interdisciplinary plan rather than several.


The Centers for Medicare & Medicaid Services (CMS) has again extended implementation of the Physician Payments Sunshine Act and will not require drug and device manufacturers to begin collecting data on payments to providers until 2013. The CMS said in a May 3 blog post that it plans to issue a final rule this year and that it will not require data collection before 2013. The final rule had been expected to be released in June.


Two House members have introduced bipartisan legislation that would repeal the Medicare sustainable growth-rate formula. The Medicare Physician Payment Innovation Act from Reps. Allyson Schwartz (D-Pa.) and Joe Heck (R-Nev.) would freeze payments to physicians at 2012 levels through Dec. 31, 2013. It would then provide positive annual increases of 0.5 percent for all physician services each year for four years. Between the years 2014 to 2017, the bill would provide an annual increase of 2.5 percent for primary care, preventive and care coordination services that are offered by clinicians for whom 60 percent of their Medicare charges are for those services.

The legislation also instructs the Center for Medicare & Medicaid Services to develop a menu of no fewer than four healthcare delivery and payment model options by Oct. 1, 2016. Then the agency must issue guidance to clinicians about best practices in transitioning from current to new practice models. The bill calls for maintaining fee-for-service payments at 2017 levels before the new delivery models begin in 2018.


The National Quality Forum has endorsed 28 measures, nine related to surgical care and 19 related to prevention and screening. The preventive care measures cover a range of areas, including influenza immunization, colorectal and cervical cancer screenings, and osteoporosis testing in older women. The nine surgical-care measures address topics such as in-hospital mortality, antibiotic use, and patient experience. The preventive care measure can be found here. Click here for the surgical-care measures.

Medicine, Drugs and Devices

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The Obama administration announced $122.6 million in Centers for Medicare and Medicaid (CMS) grants to 26 health organizations throughout the U.S. that have proposed money-saving concepts for healthcare improvement. CMS received more than 2,000 applicants, according to Health and Human Services Secretary Kathleen Sebelius. The winning projects are said to be able to enhance care for an estimated 750,000 people, and at least $250 million would be saved by the final year of these three-year grants. The biggest grant, $12.8 million, is allocated to University Hospitals' (UH) Rainbow Babies and Children's Hospital at UH Case Medical Center in Cleveland to improve care for 65,000 children with Medicaid who often receive care through the emergency room. More than 50 nurses, care coordinators, and other health professionals will be trained through the intervention to make referrals and provide care coordination via telemedicine and home nurse hotlines. Financial incentives also will be provided to primary care physicians to reach performance quality performance targets. The second largest grant of $10.7 million is apportioned to Emory University's Center for Critical Care for a telemedicine intensive care unit (ICU) training and assistance program for 40 critical care professionals and 400 clinical, technical, and administrative staff. The goal is to allow over 10,000 Medicare and Medicaid patients in rural communities who require ICU care to receive it in facilities near their homes, but who currently cannot because of a dearth of critical care doctors in their areas.


An analysis published by the Food and Drug Administration online in the New England Journal of Medicine suggests that women practice caution in the use of popular bone-building bisphosphonate drugs such as Boniva and Fosamax without making specific recommendations. The concern is that long-term use may in rare cases weaken bones in certain users, contributing to "rare but serious adverse events." FDA analysis found little if any benefit from bisphosphonates after three to five years of use, which may spur doctors throughout the U.S. to reconsider how they prescribe them. The rarity of serious complications has led most doctors to think that the drugs' benefits far outweigh the risks for women with documented osteoporosis who are at high risk for spinal fractures, but some women with moderate bone density and no other risk factors continue to take the medications for years even though they are unlikely to derive any benefits. The FDA report says the decision to maintain or discontinue treatment should be based on an individual evaluation of risks, benefits, and preferences discussed between patient and physician. However, an accompanying article indicates that women most likely to benefit from long-term bisphosphonate use are those who, after three to five years of therapy, still have very low bone density, as well as those with a history of spinal fracture or with an existing fracture. But many women prescribed bone drugs have been diagnosed as having osteopenia, moderate to low bone density that is not sufficiently low to rate as osteoporosis. Such women are unlikely to benefit from long-term use and should probably discontinue the drugs after about three years. In addition, there have been many case reports of unusual fractures and other side effects related to bisphosphonates.


The New Hampshire State Senate is considering legislation dealing with the prescription and referral of certain implantable medical devices by healthcare practitioners. Under HB 1725, all healthcare practitioners would be forbidden from prescribing or referring any Food and Drug Administration class II or class III implantable medical device if they have a direct or indirect ownership interest in the supplier of that device and would thus make a direct or indirect profit from the sale of the device. Supporters of the bill say the legislation is intended to address the concerns about physician-owned distributors, which can implicate the regulations against kickbacks that have been adopted at the state and federal levels. But opponents of the legislation say that the definition of "ownership interests" is too vague and that it could include "royalty arrangements" between healthcare practitioners and the makers of medical devices. However, some say that these royalty arrangements could be considered "compensation arrangements" involving the transfer of intellectual property instead of "ownership interests," which means that these arrangements would not be governed by HB 1725.