News From ACFAS

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Book your hotel room today for you and your office staff to attend the 2013 Perfecting Your Practice: Coding/Practice Management Workshop, which takes place July 19-20 in Chicago at the Millennium Knickerbocker Hotel. The room block closes tomorrow, June 27, so book now to guarantee you and your office staff will be there to brush up on the latest changes on how best to manage your practice. After the seminar, venture out to explore Chicago's Gold Coast or enjoy the wonderful night life the city has to offer along State Street, Navy Pier, or in the popular River North neighborhood.

The seminar brochure and registration form are available at acfas.org, under the Practice Management heading in the Education and Professional Development tab. Register today! Availability is limited. Start a conversation with your patients and community by taking advantage of FootNotes, ACFAS' free, customizable patient newsletter. The latest edition is now available for download at acfas.org/footnotes or at the web link below (member login required). Be sure to include your practice's contact information in the space provided so potential patients know how to reach you.

Topics for summer 2013 include:

• Fix Your Feet to Improve Your Golf Swing
• Exercise Alternatives for People with Foot Pain
• Is This a Corn or a Callus?

If you are involved in a study that would benefit the advancement of the profession, submit your manuscript for presentation consideration at the 2014 Annual Scientific Conference in Orlando, Florida, February 27 to March 2.

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

Be sure to read the detailed information provided on manuscript requirements and policies and how to submit your manuscript. The deadline to submit manuscripts is August 15, 2013. Congratulations to the Class of 2013! Did you know that all first-year podiatric surgical residents receive a complimentary first-year membership to ACFAS thanks to the support of the Regional Divisions? As a resident member, you not only have your dues for the first-year waived (a $116 savings) but you also receive the all cost-benefits of membership including member pricing on conferences, products and services.

Kick-start your career with ACFAS! We connect residents to a community of your peers — the best and brightest foot and ankle surgeons in the country. You will also have access to the College’s premiere website, and access to the prestigious Journal of Foot & Ankle Surgery (JFAS) through the new JFAS iPad app — a must-have to increase your knowledge of the latest surgical techniques and research.

Applications for membership are available through acfas.org; joining now will provide an additional three months of membership, through September 2014 — and put JFAS in your mailbox that much sooner!

Once again, congratulations to the Class of 2013. The ACFAS Regional Divisions look forward to welcoming you to the College. Have you listened to the latest ACFAS e-Learning offering, the podcast Starting a Successful Fellowship Alongside an Existing Residency? Hear from ACFAS Fellowship Directors themselves and gain insight into their opinions about the trends they see taking place in fellowship and residency training. The main topics discussed in this podcast revolve around the differences between competency-based, numbers-based and specialty-based training programs, as well as the philosophies they follow and the effects that fellows may have on residency programs.

Listen to this quick 22 minute podcast when you visit acfas.org/e-learning.

Foot and Ankle Surgery

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A recent study tested the hypothesis that increasing the lateral column lengthening (LCL) of the calcaneus--a procedure that is often used to correct adult acquired flatfoot deformity--by two millimeters will result in a linear increase in the plantar pressures in the lateral aspect of the forefoot. The study examined eight fresh-frozen cadaveric foot specimens, each of which were compressively loaded to 400 N using a robot. Researchers also applied a 310 N tensile load to the Achilles tendon. A flatfoot model was created by resecting the medial and inferior soft tissues in the midfoot, followed by an axial load of 800 N for 100 cycles. Researchers found that performing LCL in increments of two millimeters consistently reduced talonavicular abduction and consistently increased plantar pressure in the lateral aspect of the forefoot. They cautioned that the lateral column should be lengthened judiciously since a two millimeter difference results in significant differences in terms of angular correction of the talonavicular joint and in pressure in the lateral aspect of the forefoot.


Researchers recently performed a comparative study of Lapidus bunionectomy using different types of osteosynthesis methods. During the study, researchers performed tarsometatarsal (TMT I) arthrodesis using an interfragmentary screw and a plantar plate and compared that technique with the use of an interfragmentary screw and a dorsomedial locking plate. Researchers performed clinical and radiological exams both before and after the operation. They also recorded pre- and postoperative American Orthopaedic Foot and Ankle Society (AOFAS) and Visual Analogue Pain Scale (VAS) scores. Researchers said that they saw a significantly increased rate of negative effects in mediodorsal plate positioning.


Researchers from Thomas Jefferson University Hospital and the Rothman Institute in Philadelphia have performed a study that examined the outcomes of near-anatomic ligament reconstruction using an allograft tendon for recurrent or complex lateral ankle instability. All of the 28 participants underwent the procedure with a semi-tendinosis allograft for severe or recurrent lateral ankle ligamentous instability, and all of them were assessed for several metrics both before and after the operation. Among the metrics that researchers examined were Visual Analog Scores (VAS) for pain, Foot and Ankle Ability Measures (FAAM), and patient satisfaction.

After following up with patients at an average of 32 months, researchers found that the median VAS scores for pain decreased from eight before the procedure to one afterwards. Median FAAM scores, meanwhile, rose from 41.7 to 95.2. All but three of the patients reported their satisfaction with the outcome of the procedure as being good or excellent. None of the patients required revision surgery, and none developed subsequent subtalar arthritis or pain after the surgery.

Researchers concluded that lateral ligament reconstruction that used a near-anatomically placed and tensioned allograft was a viable treatment option for patients suffering from recurrent and complex lateral instability. They also noted that by not sacrificing the peroneal tendons, patients were able to avoid losing eversion strength.

Practice Management

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MGMA-ACMPE (Medical Group Management Association-American College of Medical Practice Executives) has released the results of a survey that examined physician attitudes about the implementation of the ICD-10 diagnostic and procedural codes, which is scheduled to take place on Oct. 1, 2014. Of the 1,200 office-based physician practices that took part in the survey, more than 55 percent said they were very concerned about the overall cost of implementing ICD-10. One of the costs associated with transitioning to ICD-10 comes from upgrading or replacing electronic health-record systems. The physician practices surveyed by MGMA-ACMPE said that they expected to incur costs of roughly $10,000 per physician to upgrade or replace their EHRs to use the new ICD-10 codes. Many practices also said they would have to upgrade or replace their practice management systems to prepare for the adoption of ICD-10. The process of upgrading or replacing practice management systems, which more than 83 percent of respondents said they would have to complete, also is expected to cost roughly $10,000 per physician. But only about 37 percent of respondents said they would have to pay the cost of replacing or upgrading their practice management systems, with the remainder saying that either their vendors would pay these expenses or that they were unsure who would.


Marty Manning, the executive vice president of the healthcare consulting firm Health Directions, says that his experience of developing accountable care organizations (ACOs) has helped learn what it takes to make these organizations successful. One of the most important factors in an ACO's success is the creation of a culture in which participating physicians share a common language, a common way of doing things, a common value, and common dialogue, Manning says. He notes that it is also important for physicians to be engaged in running an ACO and to provide leadership for the organization. One of the best ways to get physicians engaged and to develop leaders, Manning says, is to hold leadership retreats where a great deal of time is spent "explor[ing] issues, not just approving reports." Another way to facilitate engagement is for the executive team to ensure that they do not cater to one doctor over others, or become overly involved in particular clinical specialties, Manning says. He adds that while physicians will have their own specialties and interests, they should make sure that these interests are secondary to the ACO's goals. Finally, Manning says that ACOs should have leadership committees that develop specific work plans that deal with issues such as governance and best practcies.


Healthcare industry observers say that the gradual implementation of the Affordable Care Act coupled with the slow development of accountable care organizations (ACOs) will force a growing number of physician practices to consolidate. Such consolidations can take one of several forms, including physicians joining up with others from similar specialties or doctors merging their practices with different types of specialists. Other practices are opting to sell themselves to hospitals in order to avoid having to deal with managed care and to remain close to their referral base.

Merging practices offers a number of benefits, experts say, including reducing costs at a time when reimbursements from the federal government are on the decline. Experts also say that merging practices can sometimes, but not always, give the new larger practice more clout in negotiations with third-party payers. Whether practices gain additional leverage in these negotiations is dependent upon several factors, including the geographic location of the practice, the demographics of the practice's patient base, and how active third-party payers are in the practice's area, experts say.

But while merging practices can sometimes be advantageous, experts urge doctors to carefully consider such a move before making it, including what type of practice to form. One expert said that he recommends that physicians join multi-specialty practices rather than going to work for hospitals because physicians in these groups will have more control over the future of the practice.

Health Policy and Reimbursement

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Roughly 2 million people are expected to receive insurance through the small business health insurance exchanges that are being set up under the Affordable Care Act, though the Government Accountability Office (GAO) says that it is not sure whether those exchanges will open smoothly on Oct. 1 as scheduled. The GAO released a report saying that it was concerned about the launch of the small business exchanges for several reasons, including the fact that officials still need to review plans that will be sold under the exchanges. In addition, consumers aides who can help companies and individuals find the best plans still need to be trained and certified, the report said. The report also noted that the 17 states that have opted to run their own exchanges were late on an average of 44 percent of the important activities that they were supposed to have completed by the end of March. While missing those deadlines may not have an impact on the launch of the exchanges, the report said, there could be negative ramifications if deadlines that are closer to the introduction of the exchanges in October are missed. The Obama administration, for its part, says that it expects the exchanges to be up and running in October as scheduled.


The American Medical Association House of Delegates voted June 18 to classify obesity as a disease. The resolution, which was approved at the AMA's annual meeting in Chicago by a vote of 276 to 181, says that obesity should be considered a disease "with multiple pathophysiological aspects" that require "a range of interventions." The resolution passed in spite of concerns that classifying obesity as a disease will "medicalize" the condition, as well as concerns about the effects that the move could have on issues such as physician reimbursement and diagnostic and procedure coding. However, the House of Delegates' reference committee said that there needs to be a "paradigm shift" in the way healthcare providers deal with obesity due to the ramifications of the condition.


Sen. Ron Wyden (D-Ore.) said June 13 that there are four things Congress should do to ensure that accountable care organizations (ACOs) are improving care for chronically sick patients. For instance, Wyden called for changes to the Affordable Care Act's attribution rule, which he said prohibits ACOs from avoiding treating expensive patients but has made it difficult for them to specialize in coordinating care for chronic conditions. Another issue that Congress should address, Wyden said, is the uneven distribution of ACOs across the country. He noted that there are no ACOs being established in Alabama, a state which is home to a large number of senior citizens in poor health, though six Medicare ACOs have been established in Massachusetts. As for Medicare reimbursement, Wyden said that it should be reformed to target areas with the highest rates of chronic illnesses while simultaneously rewarding practitioners who help improve care and keep healthcare costs down. Finally, Wyden called for individual plans to be more widely available for seniors who have more than one chronic condition and for incentives to be provided to help seniors stay healthy. Wyden said that he hopes to include these proposals in a bipartisan piece of legislation in the next several months.


The U.S. Supreme Court on June 10 ruled in favor of a New Jersey pediatrician and other doctors who had to enter into arbitration with Oxford Health Plans after the insurer reportedly underpaid them. The legal dispute between Dr. John Sutter and Oxford began in 2003, when Sutter claimed that Oxford failed to fully and promptly pay him under the terms of a fee-for-service contract that called for him to provide medical services to the insurer's members. The contract also called for binding arbitration of contractual disputes.

After Sutter filed his proposed class action lawsuit in New Jersey Superior Court, the court ruled that the matter should be settled by an arbitrator. The arbitrator eventually decided that class arbitration was authorized--a decision which Oxford objected to. The insurer subsequently filed a motion in federal court to vacate the arbitrator's decision on the grounds that he exceeded his authority, though both the U.S. District Court and the Third Circuit Court of Appeals denied that motion.

The case eventually made its way to the U.S. Supreme Court, which ruled that it did not have the authority to overrule the arbitrator's decision. Justice Elena Kagan wrote for the majority, saying that Oxford agreed to arbitration and "must now live with that choice." The American Medical Association and others praised the decision, saying that it will allow doctors to use class arbitration against health insurers that underpay them.

Medicine, Drugs and Devices

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A recent study has concluded that device-assisted ultrasound-guided injection results in better therapeutic outcomes than palpation-guided injection does when treating plantar fasciitis. Researchers came to that conclusion after selecting a group of plantar fasciitis patients and randomly dividing them into two groups: a device-assisted ultrasound-guided group and a palpation-guided group. Pain intensity evaluations were performed before injecting betamethasone and 1 percent lidocaine into the inflamed plantar fascia, as well as at three weeks and three months after the injection. The intensity of pain was measured using a visual analog scale and tenderness threshold. Patients in both groups exhibited significantly lower visual analog scale scores and higher tenderness threshold following the injection. However, patients in the device-assisted group had higher tenderness thresholds, lower visual analog scale scores, and lower hypoechogenicity incidence in the plantar fascia after three months than did patients in the other group. Researchers also observed that the heel pad was significantly thin in the palpation-guided group following the injection.


The Food and Drug Administration (FDA) has approved a drug called Xgeva for use in treating giant cell tumors of the bone (GCTB), a condition which can destroy bone and cause bone fractures. The drug has already been approved for several other indications, including the prevention of osteoporosis in women who are at high risk of the disease as well as the treatment of bone metastasis from solid tumors. The newly-approved indication calls for Xgeva to be used to treat GCTB patients who are at risk of losing a limb or a joint if they undergo surgery to have bone tumors removed, as well as those who cannot undergo surgery at all. The drug works by targeting the Receptor Activator of Nuclear Factor Kappa B ligand (RANKL) protein to prevent tumors from growing and spreading.


Researchers from the University of Pittsburgh wrote in a study published in the Journal of the American Medical Association that medication adherence measures should be implemented in electronic health record (EHR) systems. Doing this could allow doctors and health insurance plans to share data about medication adherence, which in turn could allow them to identify trends and establish quality improvement benchmarks, the researchers said. In addition, researchers noted that medication noncompliance should be seen by doctors as a diagnosable and treatable condition. They added that the problem of patients not taking their prescriptions as directed costs the healthcare system $100 billion a year.