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News From ACFAS
Foot and Ankle Surgery
Practice Management
Health Policy and Reimbursement
Technology and Device Trends

News From ACFAS

The Medicare Payment Formula: Feel Like Groundhog Day Again?

Once again, Congressional action is due on the Medicare physician reimbursement rate. The 21 percent reimbursement cut, set to take effect June 1, is caused by a flawed Medicare payment formula. The rate formula has been a political hot potato in Congress for years, but with contentious midterm elections and an anti-incumbency mood sweeping the nation, lawmakers have delayed "fixing" this issue three times already in 2010. In addition, Congress has also delayed fixing this issue seven other times since 2003. It is reported that multiple short-term fixes have raised the price of reform to more than quadruple — from $49 billion in 2003 to the current projection of $210 billion.

"Congress must act now and put in place a formula that reflects today’s actual healthcare costs,” said ACFAS President Michael S. Lee, DPM, FACFAS. “We aren’t going to be able to care for our seniors now or in the future unless this crisis is dealt with. A 21 percent pay cut will drive more physicians out of the Medicare system just as aging baby boomers and an increasingly complex mix of chronic diseases like diabetes creates the need for more physicians.”

ACFAS continues to monitor and act as needed in the best interest of foot and ankle surgeons. For future updates on this issue, visit the health policy and advocacy section of the ACFAS website.
Find Free Resources in the Podcast Archive

Every month brings news of the latest free podcast on ACFAS e-Learning. But while you’re on the site, you can also browse an expansive archive of lively, thoughtful and comprehensive discussions on issues affecting the practice of foot and ankle surgery.

More than 40 topics are available, including not only a variety of foot and ankle conditions, but also risk management, financial basics, residency, research and much more.

Tune in to learn from your peers in practice! Explore the podcast archive and the full library of ACFAS e-Learning offerings today.
ACFAS Recognized Fellowship Initiative

To foster high-quality fellowship programs through support, recognition and visibility, the ACFAS Board of Directors has approved the "ACFAS Recognized Fellowship" initiative. Programs meeting minimal requirements may be officially recognized by the College, which will provide support through grants and visibility. Fellows of these recognized programs will benefit from lower dues rates, job placement assistance and recognition of program completion.

The College is compiling a list of all existing podiatric surgical fellowships to be considered for recognition and support. For your program to be considered, request an application from ACFAS Director of Membership Michelle Brozell at
Short Takes on Research for Busy Surgeons

ACFAS’ Scientific Literature Reviews offer you the chance to quickly catch up on articles from journals you may not usually read. You’ll find a wealth of current research, abstracted especially for the interests of foot and ankle surgeons by podiatric residents. New abstracts for May include:

Foot Kinematics During a Bilateral Heel Rise Test in Participants With
Stage II Posterior Tibial Tendon Dysfunction
, from Journal of Orthopaedic & Sports Physical Therapy.
Reviewed by Jonathan Deming, DPM, St. John Hospital.

Subtalar Fusion After Displaced Intra-Articular Calcaneal Fractures: Does
Initial Operative Treatment Matter?
from Journal of Bone and Joint Surgery (American).
Reviewed by Seth M. Felice, DPM, St. John Hospital.

Read these reviews and many more on the ACFAS website.

Foot and Ankle Surgery

Digital Vascular Mapping of the Integument About the Achilles Tendon

Soft-tissue coverage and vascularity likely play a vital role in the genesis of wound complications and infections during open Achilles tendon repair. Planning an appropriate surgical approach might decrease the prevalence of these complications. For this study, five adult cadavers underwent whole-body arterial perfusion with a mixture of lead oxide, gelatin, and water. The skin of the foot and ankle was dissected, and the vascular supply was evaluated with angiography. All angiograms were analyzed with use of statistical software. The researchers identified three vascular zones: (1) the medial vascular zone, which had the richest blood supply; (2) the lateral vascular zone, in which the density of vascularity was good and much better than that in the posterior zone; and (3) the posterior vascular zone, which showed the poorest blood supply. Based on the results of the study, the researchers recommend using a medial or lateral incision in the integument covering the tendon.

From the article of the same title
Journal of Bone and Joint Surgery (American) (05/01/10) Vol. 92, No. 5, P. 1215; Yepes, H.; Tang, M.; Geddes, C.; et al.
Web Link - May Require Paid Subscription | Return to Headlines

Limb Salvage Surgery for Calcaneal Malignancy

Advances in oncologic treatment modalities and wide resection have made limb salvage procedures in calcaneal malignancy increasingly possible. However, reconstructions of the calcaneus remain a major surgical challenge because of the rarity and specific anatomy of this condition. Researchers retrospectively reviewed five patients who had primary calcaneal malignancy and underwent total calcanectomy and reconstructions with the distally pedicled osteocutaneous folded fibular flap. Patients were assessed functionally with Musculoskeletal Tumor Society (MSTS) score and American Orthopaedic Foot and Ankle Society (AOFAS) score. Four patients had no evidence of disease, and lung metastasis was found in one patient who was alive with disease. No local recurrence occurred in this series. At latest evaluation four patients had no evident limp or limitation of daily activities and one patient had mild limp. The average MSTS 93 score and AOFAS score were 83.2 percent and 86.4 percent at the last follow-up, respectively. All fibular flaps survived and bone unions achieved successfully. Fibula hypertrophies were seen in three patients. The overall mean time for bone union was 6.2 months. The mean time to full weight-bearing was 8.6 months. The average two-point discrimination was 2.3 cm at the time of final follow-up. Two patients had surgery-related complications including hematoma in one and skin margin necrosis in one.

From the article of the same title
Journal of Surgical Oncology (04/28/10) Li, Jing; Guo, Zheng; Pei, Guo-Xian; et al.
Web Link - May Require Paid Subscription | Return to Headlines

Segmental Fractures of the Tibia Treated by Circular External Fixation

Researchers conducted a retrospective review of 20 patients with segmental fractures of the tibia who had been treated by circular external fixation. The assessment of outcome included union, complications, the measurement of the functional IOWA knee and ankle scores and the general health status (Short-form 36). The mean time to union was 21.7 weeks (12.8 to 31), with no difference being observed between proximal and distal levels of fracture. Complications were encountered in four patients, with two suffering nonunion at the distal level, one a wire-related infection that required further surgery, and another shortening of 15 mm with 8 degrees of valgus which was clinically insignificant. The functional scores for the knee and ankle were good to excellent, but the physical component score of the short-form 36 was lower than the population norm, which the researchers thought could be explained by the presence of multiple injuries affecting the overall score.

From the article of the same title
Journal of Bone and Joint Surgery - British Volume (05/01/10) Vol. 92, No. 5, P. 687; Giotakis, N.; Panchani, S. K.; Narayan, B.
Web Link - May Require Paid Subscription | Return to Headlines

Practice Management

Exit Strategy: Tips on Selling Your Medical Practice

There are a number of strategies that physicians can follow to prepare their medical practice for sale, the first being to ensure that their books are in order, especially by removing costs with effects on net revenue that are difficult to justify. Another tip is to make sure that their workload is managed by the right number of staff. Physicians also must ascertain whether their new compensation will be equal to their current earnings, with healthcare consultant Carol Carden noting that some doctors may choose to receive a smaller compensation package so that they can get more upfront money for the practice. A fourth tip for selling one's medical practice is to ensure that its strengths and advantages over peers are spotlighted. The fifth and final tip is for the physician to determine the optimum time to sell the practice, and a physician intending to sell to a hospital or a new doctor in the community should prepare to remain with the practice for a certain number of years following the sale.

From the article of the same title
HealthLeaders Media (05/10/10) Vaughan, Carrie

Experts: Train Employees Not To Snoop; Fire Those Who Do

Marblehead Group President Kate Borten says that electronic health records represent a great risk to patient privacy and security because they can be accessed from anywhere. "Today the standard approach—after technically blocking access from those who don't need it, of course—is to have a policy prohibiting snooping and sanctions for violations, workforce training that makes this crystal clear, and then follow-through with technical and manual auditing and disciplinary action," she notes. Stiff penalties handed down to medical professionals who snooped patient records are "object lessons" for the industry, according to HIPAA blog author Jeff Drummond. He says organizations are required to detect snooping themselves, and fire snoopers to make it clear to the rest of the staff that such practices will not be tolerated.

From the article of the same title
HealthLeaders Media (05/11/10) Nicastro, Dom

Health Policy and Reimbursement

Florida Hospitals, Surgeons Launch Statewide Initiative to Improve Care

The Florida Hospital Association and the American College of Surgeons (ACS) has launched the joint Florida Surgical Care Initiative (FSCI), a statewide program developed to improve patient safety and surgical care while reducing costly complications. FSCI will focus on surgical site and urinary tract infections, colorectal surgery outcomes, and elderly surgery outcomes. The initiative is based on ACS' National Surgical Quality Improvement Program.

From the article of the same title
HealthLeaders Media (05/19/10) Commins, John

Increasing U.S. Medical School Spots Won't Increase Physician Supply

There are more spots in U.S. medical schools as more new schools start up, but the increase is unlikely to translate into more practicing doctors because the U.S. capacity for residency programs remains flat, according to a summary from the latest annual survey by the American Association of Medical Colleges. "It's residency training positions that are the driving factors of our supply," said Ed Salsberg, director of AAMC Workforce Studies. Increasing entry positions for GME are growing at less than 1 percent annually, not enough to meet the expected increase in demand and need for physician services.

From the article of the same title
HealthLeaders Media (05/11/10) Clark, Cheryl

Keeping Patients Safe: Joint Commission Updates Sentinel Events Data

The Joint Commission has updated sentinel event statistics on its website. Since the sentinel event database was implemented in January 1995, The Joint Commission has reviewed 6,782 sentinel events as of March 31, 2010. A total of 6,920 patients were affected by these events, with 4,642, or 67 percent, resulting in patient death.

The 10 most frequently reported sentinel events are:

1. Wrong-site surgery
2. Suicide
3. Operative/post-operative complication
4. Delay in treatment
5. Medication error
6. Patient fall
7. Unintended retention of foreign body
8. Assault, rape or homicide
9. Perinatal death or loss of function
10. Patient death or injury in restraints

From the article of the same title
Joint Commission News Release (05/11/10)

Missouri to Vote in August on Health Insurance Mandate

The Missouri House has given final approval to a measure that will appear on the Aug. 3 ballot stating that people and employers cannot be forced to have health insurance nor penalized for paying for healthcare on their own. The referendum seeks to defy the federal healthcare reform measure that requires most Americans to have health insurance or face fines beginning in 2014. The legal impact of the state measure is questionable, however, since courts generally rule that federal laws trump those in states.

Conservative lawmakers in 80 percent of the states have proposed measures attempting to let people opt out of the federal health insurance mandate. Laws have already been enacted in Arizona, Idaho, and Virginia, and proposed state constitutional amendments are to appear on the November ballot in Arizona, Florida and Oklahoma, according to the American Legislative Exchange Council, a nonprofit group that promotes limited government and helped coordinate some of the state measures. Missouri, however, may become the first state to put the federal health insurance mandate to a vote of its residents.

From the article of the same title
Associated Press (05/13/10) Lieb, David A.

Proposed Legislation Would Let Patients Compare Costs at Hospitals & ASCs

Even with the passage of the healthcare overhaul bill, healthcare changes are still being discussed in government, with lawmakers introducing multiple bills intended to provide consumers with cost and quality of care information about services provided at hospitals and ambulatory surgery centers (ASC). The ASC Advocacy Committee testified before the House Energy and Commerce Subcommittee on Health, supporting the Patients' Right to Know Act, which would require states to create laws requiring hospitals and ASCs to publicly disclose what they charge for services, as well as quality data on those services. ASC industry leaders say the proposal would allow patients to choose the most economical option for procedures without compromising quality.

Another bill being discussed is the Transparency in All Health Care Pricing Act of 2020, which calls for hospitals, physicians, nurses, pharmacies, pharmaceutical manufacturers, dentists, and insurance entities to "publicly disclose, on a continuous basis, all prices for such items, products, services, or procedures." The measure would require disclosure "at the point of purchase, in print, and on the Internet," and would allow the HHS Secretary to investigate and fine entities that do not comply.

A third measure being considered is the Health Care Price Transparency Promotion Act of 2009, which calls for pricing transparency, but it would require all 50 states to develop disclosure requirements without involving the HHS Secretary.

From the article of the same title
Outpatient Surgery (05/07/10) Tsikitas, Irene

Provider Groups Urge Congress to Move Fast to Avoid Medicaid Cuts

Various healthcare groups have urged lawmakers to quickly approve a six-month extension of the Medicaid Federal Medical Assistance Percentage (FMAP). The economic stimulus package provided a nearly $87 billion increase in additional Medicaid matching funds to the states. Current funding is due to expire at the beginning of next year.

With at least 47 states facing "massive budget shortfalls" in the coming fiscal year, extending FMAP funding will be "critical to ensuring Medicaid patients have access to care at America's hospitals and other healthcare providers," said a letter from the healthcare groups. Additionally, lawmakers were told that without additional funding, "many states will be forced to make significant reductions in Medicaid costs through cuts to eligibility, benefits and already low provider payment rates."

From the article of the same title
HealthLeaders Media (05/19/10) Simmons, Janice

Technology and Device Trends

New Ways to Treat Pain

A crop of new treatments, many of them derived from concepts in anesthesia, has emerged to help chronic pain sufferers who have not benefited from prescription pills, physical therapy, or acupuncture. Most of these nascent techniques aim to stop pain signals from reaching the brain, usually through the delivery of medication--often anesthetics--to muscle tissue or nerves at or near the source of pain. While so-called interventional therapies have eased the pain of some patients and helped to wean them from commonly prescribed opiate painkillers and their host of side effects, a dearth of scientific evidence for some of the new techniques--as well as the inherent risk and high cost of invasive procedures required to implant drug-delivery devices--has made them somewhat controversial. To help healthcare professionals and patients weigh their options, the American Society of Anesthesiologists in April released the first new guidelines on chronic pain management in more than 15 years. According to lead author, Richard Rosenquist, director of the University of Iowa's pain medicine division, the guidelines are intended "to give some guidance in an area of medicine that is growing like crazy, with new treatment coming out faster than the research can be published." Based on research as well as on consensus in the medical community, the new recommendations underscore how some treatments have not been demonstrated as effective with specific types of pain. For example, explains Dr. James Rathmell, head of the pain management unit at Massachusetts General Hospital, who helped Rosenquist draft the guidelines, epidural injections of steroids that can relieve acute leg pain following a herniated disc will not necessary ease chronic pain in the lower back.

From the article of the same title
Wall Street Journal (05/11/10) P. D1; Landro, Laura
Web Link - May Require Paid Subscription | Return to Headlines

Prosthetic Foot Up for MacRobert Engineering Prize

A prosthetic foot that emulates the muscle actions of actual feet is up for the Royal Academy of Engineering MacRobert Award in the United Kingdom. The Echelon foot and ankle prosthesis differs from other false feet in its use of hydraulics to align itself, and it incorporates carbon fiber springs and hydraulic dampers to put the foot in the correct position as it is lowered to take a step. The appendage can thus manage inclines better, and the hydraulics are configured so that they spread the body's load in the manner of real muscles. The Echelon has allowed some soldiers to return to combat duties.

From the article of the same title
BBC News (05/10/10)

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May 19, 2010