News From ACFAS

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ACFAS has submitted comments to the Centers for Medicare and Medicaid Services on its proposed regulations for implementation of accountable care organizations (ACOs). The College’s 12 comments focused on the fact that podiatric foot and ankle surgeons provide patients with high quality, efficient and effective healthcare, and should therefore be included in the definition of an “ACO professional” or healthcare provider.

ACFAS’ full comments on ACO implementation are available here (363 KB PDF).
The California Podiatric Medical Association (CPMA), the California Medical Association (CMA), and the California Orthopaedic Association (COA) recently formed the first-ever joint task force of its kind to review the education, curriculum and training of California’s podiatric medical schools. Their ultimate goal is to achieve accreditation as full-fledged allopathic medical schools and enable their graduates to become licensed physicians and surgeons. Click here for the full statement in a Word document.
Share essential foot and ankle health information and market your practice with FootNotes, the free patient education newsletter exclusively for ACFAS members. Download the Summer 2011 issue for season-friendly topics including:

• Safety tips for a barefoot summer
• Biking and swimming: great ways to take the stress off your feet
• Corn or callus, what’s the difference?

Include it in your billings, add it to your blog or distribute it at the next community health event. FootNotes is available now at acfas.org/footnotes.

Foot and Ankle Surgery

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Researchers performed a study to assess the pedographic outcome of the percutaneous arthroereisis with the use of a screw through the sinus tarsi into the talus, through the evaluation of 43 calcaneo-stop procedures of 25 pediatric patients. Patient satisfaction rate was excellent for 33 feet of 19 children, good for eight feet of five children, and poor for either feet of one child. No complications during or following the surgery were observed. The mean rest heel valgus decreased from 13.4° (10°–17°, SD 1.5) to 2.8° (0°–6°, SD 1.7) post op. The Meary’s angle improved from 160.2° (148°–177°, SD 6.8) to 175.9° (167°–179°, SD 3.5). The area and the pressure–time integral (load amount, PTI) values increased on the lateral regions of the sole (except for the lesser toes) and decreased on the medial areas (except for the hallux). The relative contact time in the lateral midfoot increased from 63.8% (39.6–78.4%, SD 10.6) to 75.1% (50–86.1%, SD 9.4), and that in the lateral forefoot region from 81.2% (60.4–89.2%, SD 6.6) to 86.8% (78.1–97.1%, SD 4.8).



Comparing the cosmetic and functional outcomes of secondary intention healing and full-thickness skin graft after wide excision of acral lentiginous melanoma on the foot was the goal of research that retrospectively reviewed 25 patients. The defects of 13 patients were healed by secondary intention, while those of 12 patients were repaired by full-thickness skin graft. The skin graft group (SGG) exhibited faster healing than the secondary intention healing group (SIHG), but the SIHG exhibited better cosmetic and functional results at complete re-epithelialization than the SGG as assessed by patients and independent physicians.



The distally based posterior tibial adipofascial flap is a useful option for distal leg and ankle coverage. Traditionally, its dimension is constrained by a length-to-width ratio of 2:1. Researchers increased the ratio to 4:1 by including the great saphenous vein and saphenous nerve with the flap. In their series of 21 flaps, 15 had ratios of 3:1 or higher. In the remaining 6, the ratio was 2:1, as the defects were more proximal. Complications include one complete flap loss due to compression from tunneling and one superficial tip necrosis. Postoperatively, the researchers performed wet-to-wet dressings, phlebotomy, and delayed skin grafting to optimize flap survival. Of 21 flaps, 20 were healthy after an average follow-up of 24 months.

Practice Management

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Patients could gain more insight into how their information is shared through changes to rules regarding the disclosure of patients' health information proposed by the U.S. Department of Health and Human Services' Office for Civil Rights. The revisions, posted in the May 31 issue of the Federal Register, reflect changes to the 1996 Health Insurance Portability and Accountability Act's privacy rule required by the Health Information Technology for Economic and Clinical Health Act (HITECH). Under HITECH, covered entities using electronic health record systems are obligated to be able to account for—and at patients' request, report to them about—disclosures of personal medical records, including those related to patients' treatment and payment.



Everyone covered by the Health Insurance Portability and Accountability Act will be affected by the transition to ICD-10. If you are a provider, here are a few of the many areas where the transition to ICD-10 will affect practices:

* Codes will grow from 17,000 to 140,000. Thus code books and styles will completely change. More detailed knowledge of anatomy and medical terminology will be required. Physicians, nurses, and billing and coding staff will all need to be trained on the new codes.
*Any office policy or procedure tied to a diagnosis code, disease management, tracking, or PQRS must be changed.
* Medical record documentation. ICD-10 codes will better reflect the specificity already inherent in the patient's medical record.



A small number of physicians are bucking the trend of consolidation and ever-larger medical groups by stripping their practices to the essentials, partly because it's the way they want to deliver medicine and partly because lean is the only way they can survive on their own terms. Lowering overhead sometimes means making changes within the existing framework of a practice, and sometimes it's more radical. Below are a few tips from consultants to reduce overhead:

* Notify patients of routine lab results through the mail to save staff time on the phone.
* Offer incentive bonuses rather than regular raises.
* If the practice needs to expand, hire a midlevel provider rather than another physician.
* Wait to pay bills until the last minute, but don't incur late fees.
* Check exam rooms for duplicate supplies.
* Drop unnecessary memberships, and reduce travel.
* Use bookkeeping software to keep ledgers.
* Renegotiate everything you can.

Health Policy and Reimbursement

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The American Medical Association (AMA) has named James L. Madara, a pathologist and former dean of the University of Chicago Pritzker School of Medicine, its new executive vice president and CEO. Current AMA CEO Michael Maves announced last December that he would step down from his post with the organization he has led since 2001. "Dr. Madara is a strong strategic thinker and planner who has a track record of bringing people together to accomplish significant, ambitious, health-related goals and projects," said Ardis Hoven, chair of AMA's Board of Trustees. "Having overseen a $1.6 billion integrated academic medical center, Dr. Madara understands many of the complex clinical, academic and business-related issues confronting medicine and health care today.”



A committee of the Institute of Medicine (IOM) released a report that said Medicare needs to make a "significant change" to the ways it evaluates salaries of healthcare workers and real estate costs based on geographic location. Because of the current payment system, doctors in many urban areas tend to be underpaid and some physicians in rural areas are overpaid, according to a 2007 report by the Government Accountability Office. The IOM committee set forth 11 recommendations for two sets of providers, hospitals and physicians, both of which could shift some of the $500 billion a year in Medicare spending from doctors and health systems in some parts of the country to those in others. Details can be found here.



Medicare's same-day notification rule for ambulatory surgery centers enacted in 2009 is among a wide range of federal rules and regulations being reviewed by the Department of Health and Human Services (HHS) as part of a White House mandate to simplify the regulatory system. The Centers for Medicare and Medicaid Services' Same-Day Services Final Rule (42 CFR Part 416) currently requires ASCs to notify patients of their rights and of the facility's ownership before the day of surgery, except in cases when the referral for surgery is made on the same day the procedure is to be performed and when the referring physician indicates that it's medically necessary for the patient to undergo surgery that day. CMS plans to review the rule and consider modifications that would benefit both patients needing surgery and facilities tasked with providing the paperwork, according to HHS' Preliminary Plan for Retrospective Review released last week. The 89-page plan focuses on eliminating rules that "are no longer justified or necessary," as well as "strengthening, complementing, or modernizing rules where necessary or appropriate — including, if relevant, undertaking new rulemaking."

Medicine, Drugs and Devices

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A shortage of medications for a variety of illnesses has hospitals searching for substitutes to prevent patient harm, but delays in treatments have occurred in some cases. The problem of short supplies or even unavailable medicines is not new, but it is getting significantly worse, with the number of shortages tripling over the past five years to 211 medications. While some of those shortages from last year have been resolved, another 89 drug shortages have occurred in the first three months of 2011, according to the University of Utah's Drug Information Service, which tracks shortages for the American Society of Health System Pharmacists.



Hands on surgical training (HoST) is a new teaching method that can give medical students the ability of move with the same dexterity as the world's most skilled surgeons. HoST uses a robotic surgical simulator to physically guide the hands of novice surgeons in the exact same movements used by experience surgeons during extremely complicated procedures. The new training method was developed to simulate the operations of the da Vinci robotic surgical system. The HoST software advances the technology by using augmented reality based real-time operative scenarios and haptic feedback to help medical students "feel" the movements made by surgeons.