News From ACFAS

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As of yesterday, all ACFAS members should have received one of two important ACFAS surveys by email from the sender “ACFAS President.”

Fifty percent of ACFAS members received the Practice Economics survey in May, and the remaining fifty percent received the Member Insights survey yesterday. The survey recipients were all determined by random sample.

If you haven’t done so already, please click on the link in the email to take you to the confidential survey website. Your responses will be anonymous and only reported in the aggregate by a third-party survey consultant. Results will be posted on acfas.org in August 2012.

Respondents will be eligible to win one of six thank you gifts of your choice. Choose from any of these prizes:

• A new iPad
• Your 2013 ACFAS membership dues paid
• A complimentary registration for the 2013 Annual Scientific Conference in Las Vegas

Hear four distinct surgical viewpoints and scenarios on the treatment of Hallux Limitus from expert surgeons in the newest ACFAS podcast, Hallux Limitus: My Favorite Procedure.

The podcast begins with an informative discussion on the most common causes of Hallux Limitus, including mechanical problems, trauma, elongated first metatarsals, and then dives into the latest on:

• Injection Therapy – What role does it play? How common is it and what are some risks and/or rewards of using this method?
• Orthotics – Do they help heal Hallux Limitus?
• Surgical Intervention – When is this necessary? What types of surgery provide the best results?
• Salvaging Mobility – Expert panelists discuss their go-to methods given specific situations that may arise during surgery
• New Procedures – Joint resurfacing, osteotomies and more!

Download the Hallux Limitus: My Favorite Procedure podcast today!

Foot and Ankle Surgery

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A study was held to characterize the anterior fibrous bundle as an intra-articular residual disorder following ankle sprain, using a sample of 10 patients who had the atypical problem of anterior ankle pain accompanied by restriction of plantar flexion following an ankle sprain. Arthroscopy was performed on the patients between January 1998 and January 2009, and magnetic resonance imaging performed prior to surgery showed osteochondral lesions (OCLs) of the talar dome in three patients, but no other findings that could account for restricted plantar flexion. The three patients with OCL underwent additional arthroscopic drilling, and results were quantified using the AOFAS, Visual Analogue Scale (VAS) for pain, and active plantar flexion angle. The anterior fibrous bundle was verified under arthroscopic probing as the cause of symptoms in all patients, and was resected arthroscopically. Average AOFAS and VAS scores improved significantly from 65 and 70 preoperatively to 95 and four at final follow-up, respectively. Meanwhile, median active plantar flexion angle showed significant improvement from 40 degrees preoperatively to 55 degrees.


Researchers assessed the reliability and validity of different radiographic measurements to evaluate the most precise technique for determining talar three-dimensional position in varus and valgus osteoarthritic ankles. They carried out nine measurements executed blindly on weight-bearing mortise, sagittal and horizontal radiographs of 33 varus and 33 valgus feet in 63 patients. Intra- and interobserver reliability was ascertained with the intraclass coefficient, while effect size was used to assess discriminant validity of measurements between varus and valgus feet. The researchers evaluated convergent validity through correlation of measurements to the dichotomized varus and valgus groups, and acquired measurements in both groups were compared with each other and with 30 control feet. All but two measurements, sagittal and horizontal, showed excellent reliability. Four measurements exhibited substantial differences among all groups. Talar positional tendency was found toward dorsiflexion or endorotation in the varus group and toward plantarflexion or exorotation in the valgus group. The frontal tibiotalar surface angle, sagittal talocalcaneal inclination angle, and horizontal talometatarsal I angle demonstrated the best reliability, validity, and difference among the groups.


A study was conducted to evaluate the treatment results of relapsing clubfoot deformity after age four, using a cohort of 39 patients and 60 feet that satisfied the inclusion criteria. The treatment of late relapse followed one of five courses: observation, bracing, casting followed by bracing, casting followed by tibialis anterior tendon transfer (TATT) with or without open tendon Achilles lengthening (TAL), or primary TATT with or without TAL. Thirty-three of the 37 feet treated initially with observation, bracing, or casting went on to have TATT. Multiple other concurrent procedures were executed in accordance with specific deformities, including plantar fasciotomy, extensor hallicus longus recession, limited posterior release and others. Revision surgery was performed on five feet following TATT, two of which ended in triple arthrodeses. The average age at final follow-up was about 23 years. Ninety percent of patients wore regular shoes, 41 percent experienced pain with activities but just 18 percent had limited foot function. Median ankle dorsiflexion was 6 degrees, and mild residual deformities were observed in 55 percent of feet.

Practice Management

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Physician practices do not have to invest a lot of money into online bill paying systems for patients, and the system that suits a practice best depends on various factors, such as the goals the practice wants to achieve, what systems are already in place and how much money it wants to spend. If all a practice requires is electronic payment acceptance capability, then setting up an account with a third-party credit card or merchant account service such as PayPal is the simplest option. Most services can accept payments from debit or credit cards as well as a direct transfer from a checking account. Setup fees range from nothing to less than $100, and the cost of operating an online account is typically either a per-transaction fee of a few cents or a portion of the payment, in addition to whatever credit- and debit-card processing fees a practice pays.

A website upgrade may be necessary for practices that have an online presence, and there are several third-party electronic commerce software vendors with credit card processing capabilities that can be incorporated within a website. Selecting the optimal software will hinge on what additional tools the practice wishes to embed on its site. Some offer tools to construct a whole site using an e-commerce component with search engine optimization tools, while others offer only the tools needed to build a payment processing service on an existing site. Choosing the right solution could depend on the practice staff's computer skill level, while the cost of e-commerce software varies.

Some solutions come with a one-time price for the software that ranges from $20 to over $100. Others have no setup fee but charge a monthly fee, a per-transaction fee based on set fees or percentages, or a combination of both monthly and per-transaction fees. Stronger billing systems can be integrated with patient portals and link with electronic health record systems, and these solutions can provide patients with a more complete view of billing statements and a better understanding of their bills. Even stronger systems integrate with the practice management system or other business intelligence software.


Although the process can be frustrating, physicians can persuade a health insurer to change a policy, fix a problem or reverse a bad decision. They must do so with persistence and by gathering strength in numbers. The best way to get insurers to listen and make changes is to become bigger than one physician. This can be done by gathering a group of doctors who want the same thing, forging an alliance with government authorities who have the power to force insurers to change or getting wider media attention for the issue. Organized medicine is often the first place to find allies who share the same values and challenges. Whether a physician is best served by a county, state, specialty or national medical society depends on the problem, but the objective is the same no matter which part of organized medicine is the first stop — finding other doctors with the same frustration.

Physicians may also seek government assistance, including certain legal protections available in their respective states. When insurers appear to be going beyond just creating hassle, state officials are the best choice for physicians trying to fight health plans. All states have offices within their insurance departments that will deal with complaints about health plans. Physicians should keep in mind, however, that change made through government policy can be slow. Finally, physicians can turn to the media, which has the potential to reach broad audiences. The media tend to be most interested in health coverage from a consumer’s perspective, not necessarily a physician’s. Still, physicians and their advocates say that regardless of how they raise the alarm about insurance company behavior, doing it is preferable to remaining silent.

Health Policy and Reimbursement

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For the first time since it began publishing a quarterly Medicare compliance newsletter, the Centers for Medicare & Medicaid Services has released comprehensive error rate testing (CERT) findings on problematic billing errors. The April issue of the Medicare Quarterly Provider Compliance Newsletter, CMS' seventh issue, contains CERT findings in addition to recovery auditor findings. According to Donna Wilson, senior director at Compliance Concepts in Wexford, PA., the inclusion of this new information should prove beneficial to providers. "Including CERT findings is an added bonus to this priceless resource tool from Medicare," she said. "Providers should consider adding these issues to their internal compliance monitoring."


Many hospitals and physicians charge patients much lower prices for hundreds of standard outpatient services and tests if they use cash. Hospitals began offering cash prices over the last several years in response to criticism that they were charging uninsured patients their highest rates and that they were being overly zealous when trying to collect money from patients who did not pay. In addition, new government rules have been put into place to limit the amount of money that hospitals can charge lower-income patients who do not have insurance and have to use cash to pay their bills.

Some doctors are trying to make it known that they charge lower prices to patients who use cash, and they are urging their patients to put pressure on hospitals and their insurance providers to obtain better negotiated prices. If doctors are able to increase awareness about cash prices among patients, they could provide additional impetus to the trend toward greater disclosure of all types of medical costs, health policy experts say. However, Deloitte Center for Health Solutions Executive Director Paul Keckley said that healthcare industry insiders do not want to lose control over information about lower cash prices, though he also said that he thought greater price transparency in the healthcare industry is inevitable.


Increasing numbers of physicians are earning reporting bonuses, but hundreds of thousands caring for Medicare patients have yet to participate in a program that turns punitive next year, and thus run the risk of incurring penalization via rate cuts. Nearly 750,000 eligible healthcare professionals did not report any quality data to the Centers for Medicare & Medicaid Services (CMS) in 2010. CMS has been urged by the American Medical Association and other organized medicine groups not to base 2015 physician quality reporting system (PQRS) penalties on the 2013 disclosure year. In addition to the 2015 PQRS penalty, a one percent reduction would be applied to Medicare rates for that year for healthcare professionals who do not achieve meaningful use of an electronic health record system. Furthermore, CMS is planning to adjust pay with a value-based modifier for physicians starting in 2015, which would boost pay for some doctors deemed to provide high-quality, efficient care but would lower rates for an as-yet-unknown pool of other doctors. Participation in PQRS was raised somewhat by a new disclosure option in 2010, and academic organizations elected to submit physician quality data as group practices.

Medicine, Drugs and Devices

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A new report from IDC Health Insights rates the best electronic medical record (EMR) vendors for small physician practices. It also warns that the short-term incentives of meaningful use should not overshadow those offices' long-term care strategies. The report assesses 11 products from nine vendors aimed at helping small physician practices qualify for meaningful use incentive money. IDC experts say they expect the U.S. market to move from less than 25 percent adoption in 2009 to more than 80 percent adoption by 2016.


Georgia resident Bobby Rice's diseased right foot and ankle is being rebuilt using cutting-edge stem cell treatments facilitated by technology from Osiris Therapeutics. Rice, who has diabetes, stepped on a piece of glass last fall and his foot quickly became infected. Rice went to the hospital emergency room where doctors found he had a rapidly spreading necrotizing fasciitis. Physicians treated the infection with antibiotics. However, Rice had one toe amputated. Doctors had to strip away much of the flesh from Rice’s foot and a great deal of flesh along his ankle.

Osiris supplied two products called Grafix and Ovation, which are cultivated from adult stem cells derived from donated placentas. Rice's doctor, Spencer Misner, has applied the stem cell treatments nine times so far, and he reckons that the foot is now more than 90 percent regenerated. Misner expects the foot to be fully healed after at least three more treatments, and he says stem cell therapy has never before been attempted on this scale, involving so many different tissues.


Researchers and doctors are using tiny snakelike robot to perform surgery on hearts, prostate cancer and other diseased organs. The snakebots carry tiny cameras, scissors and forceps, and even more advanced sensors are in the works. For now, they're powered by tethers that humans control, but the day is coming when some robots will roam the body on their own.

Credentialing/Privileging

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The Illinois-based Accreditation Association for Ambulatory Health Care (AAAHC) has introduced an accreditation program that targets smaller physician practices offering office-based surgery. The accreditation is for groups with no more than four doctors or dentists, and it is less expensive than the AAAHC's ambulatory surgery center accreditation and is part of an initiative to adapt the shifting healthcare environment. "All organizations, including [office-based surgery] centers, must meet nationally recognized standards to be accredited by AAAHC, but as healthcare evolves, new types of organizations with different needs and perspectives have sought accreditation," says AAAHC CEO John Burke.