News From ACFAS

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CMS estimates the 2012 conversion factor to be $23.9635, representing a cut of 29.5 percent unless Congress intervenes. Additionally, the rule continues with the Physician Quality Reporting System (PQRS) allowing bonus payments of 0.5 percent of allowed charges for physicians and other healthcare professionals who successfully participate, and adding 26 proposed new measures to the program; 2012 e-prescribing incentive program has a 1 percent bonus of allowed charges and guidance on how to avoid penalties in 2013-14. Other proposals include:

• Misvalued code initiative – which expands on the highest volume and dollar codes billed by physicians to determine which codes are over- or undervalued
• Value-based modifier – uses the CY 2013 as the initial performance year for purposes of adjusting payments in CY 2015.
• Meaningful use – lays out additional ways to satisfy the clinical quality measure reporting objective
• Multiple procedure payment reduction (MPPR) – extends the professional component (PC) of the same diagnostic imaging codes subject to the current MPPR for the technical component (The highest PC payment would be paid in full and each additional procedure would have the PC payment reduced by 50 percent when additional procedures are performed on the same patient on the same day in the same imaging session.)
• Physician payment during 3-day payment window – payment of physician services using the facility (vs. non-facility) rate when non-diagnostic services are performed in the three days prior to an inpatient admission, are related to the admission, and are performed in a physician practice that is wholly owned or operated by the hospital.

The use of orthobiologics is a complex topic with many elements to consider. Tune in for “Orthobiologics and Bone Healing,” a timely free podcast from ACFAS e-Learning. Four experienced foot and ankle surgeons discuss the role of orthobiologic products in treatment and the factors in deciding whether, when and what type to use.

Visit ACFAS e-Learning’s online library any time for reliable information on foot and ankle conditions, medical practice, podiatric education and more. Find answers for the issues you may be facing at ACFAS’ “Practice Made Perfect” practice management/coding seminar in Las Vegas, Oct. 14–15, 2011. You’ll gain a competitive edge with insights from respected experts including Douglas G. Stoker, DPM, FACFAS, and Lynn Homisak.

Members of the College can sign up for a free coding consult with Dr. Stoker at the seminar by contacting kristin.hellquist@acfas.org – and can e-mail coding questions at any time to coding@acfas.org.

Visit the ACFAS website for the full brochure and online registration. The ACFAS Fellowship Committee has added another program to the growing list of Recognized Fellowships on the ACFAS website. This program has met the minimal criteria set by ACFAS to assure adequate post-graduate training is occurring:

• Pennsylvania Intensive Lower Extremity Surgery and Research Fellowship, Alamogordo, N.M.
  Fellowship Director: Jason R. Miller, DPM, FACFAS

For details on the Recognized Fellowship initiative, including a complete listing of ACFAS Recognized Fellowship Programs, ACFAS planned support for programs, and the criteria and application for recognition, visit the ACFAS website. The July/August issue of the Journal of Foot & Ankle Surgery is in the mail, but you can read it online today. Features include a new instructional course, “Reconstructive Options for Defects after Melanoma Excision in the Foot and Ankle Region,” and an eye-opening analysis of manuscripts presented at the ACFAS Annual Scientific Conferences that found over 65 percent become published in peer-reviewed journals.

Use your free member access to read original research, case reports, reviews, and quips, tips and pearls. Just visit acfas.org/jfas, click on “Read current and past issues online” and log in with your ACFAS member ID to enjoy this valued resource.

Foot and Ankle Surgery

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Researchers assessed the need for radiographic evaluation in children with a clinical diagnosis of calcaneal apophysitis by determining the frequency of abnormal radiographic findings in a group of patients with this clinical diagnosis. The review identified 98 patients (134 feet) 10.8 years old on average with a clinical diagnosis of calcaneal apophysitis. Positive radiographic findings were recognized in five patients (five feet). Three calcaneal unicameral bone cysts, one distal tibial nonossifying fibroma, and two calcaneal stress fractures were detected. One patient exhibited both a calcaneal unicameral bone cyst and a stress fracture in the same foot. The rate of abnormal radiographic findings in the 96 patients was 5.1 percent, or 3.75 percent in the 133 feet. The abnormal radiographic findings typically led to more aggressive therapy, including close radiographic follow-up or immobilization.


Researchers performed a study to determine the clinical outcomes of deep-fascial medial and lateral portals in executing endoscopic surgery for plantar fasciitis on 10 feet in eight patients. After a patient was placed in the supine position, a medial portal was made 5 mm deep to the plantar fascia and 10 mm anterior to its origin on the calcaneus under fluoroscopy. The lateral portal was established by placing a blunt trocar deep and perpendicular to the plantar fascia. A 2.7-mm-diameter arthroscope was passed through the deep-lateral portal, and the operative devices were inserted through the deep-medial portal. A motorized shaver was used for making a working space to excise the fat tissue along with a portion of the flexor digitorum brevis muscle. If a heel spur existed, it was resected to establish a clear view of the plantar fascia by use of an arthroscopic burr. After exposure of the plantar fascia, its medial half was removed. The average score on the AOFAS Ankle Hindfoot Scale was 64.2 plus or minus 6.3 points prior to surgery and 92.6 plus or minus 7.1 points at two years following surgery. The average duration to full weight bearing following surgery was 13.9 plus or minus 8.4 days. All patients resumed full athletic activities by an average of 10.7 plus or minus 2.6 weeks. The researchers concluded that endoscopic surgery for plantar fasciitis via a deep-fascial approach permits a wide field of vision and working space, enabling reliable resection of the plantar fascia and heel spur.

Practice Management

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Few doctors use e-mail to communicate with patients, mainly because they are concerned about security and do not wish to add more uncompensated tasks to their workloads. However, physicians who have embraced e-mail say it offers numerous benefits. Austin, Texas-based family physician John Frederick, MD, says e-mail has not expanded his workload because patients generally send messages to determine whether an appointment is necessary or to follow up on a past appointment. Others say it strengthens the physician-patient relationship by making physicians more accessible and eliminating unnecessary visits. Practices that want to implement e-mail communications should lay some ground rules, telling patients e-mail should not be used for emergencies or to make diagnoses, for instance. They should create e-mail policies and have patients sign off on them. As for the messages themselves, experts says physicians should check for typos; provide specific and detailed information; and avoid humor, sarcasm, excess familiarity, bad language, and statements that could be taken out of context. To ensure compliance with HIPAA, patient portals and file attachments should be password protected.


Two new surveys suggest that private practices will diminish in the coming years as the physician employment trend expands. A survey by Merritt Hawkins of physician recruiting incentives found that 56 percent of all physician job openings are currently in hospitals. This is up from 51 percent a year ago and 23 percent five years ago. Just 2 percent of Merritt Hawkins' search assignments in 2010 featured openings for independent, solo practitioners, down from 17 percent five years ago. Hospital employment and healthcare consolidation are expected to rise so quickly that less than a third of physicians will be in private practice by 2013, according to a separate survey by Accenture Health. Practices have started responding by offering such incentives as signing bonuses, loan forgiveness, and housing assistance. Physician salaries are also rising and have nearly replaced income guarantees as a compensation model. But "real-world" payment models still tend to reward physician productivity over quality or cost control, according to the Merritt Hawkins survey. It reveals that 90 percent of recruited jobs in 2010 were linked to traditional "fee-for-service style volume." Although 74 percent of jobs offered performance bonuses, only 7 percent of recruited jobs provided individual physicians financial rewards for quality or cost reduction objectives.


Despite implementing EHRs and other assessment tools to collect clinical data, a recent HIMSS survey commissioned by McKesson indicates that physician practices are not reaching their "clinical transformation" goals. "Most organizations say it's hard to pull that data into a single source to analyze it," says Deborah Bulger, executive director of product management with McKesson's Health Systems Performance Management division, who says many providers lack a good data warehouse tool. However, experts say there are indications that practices are using EHRs to improve patient outcomes, going beyond the Stage 1 meaningful use criteria. According to a Better Health Greater Cleveland report, the number of diabetes patients receiving all the necessary care was greater at facilities with EHRs (51 percent) than at facilities with paper-based systems (7 percent). Additionally, 44 percent of patients in facilities with EHRs, versus 16 percent in paper-based facilities, reported positive outcomes for certain measures.

Health Policy and Reimbursement

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The Obama administration triumphed June 29 in the first appellate review of the 2010 healthcare law as a three-judge panel from the United States Court of Appeals for the Sixth Circuit maintained that it was constitutional for Congress to require that Americans purchase health insurance. Lawyers on both sides of the case by and large expect the Supreme Court to take at least one of the cases, perhaps as soon as its approaching term, which begins in October. In the 2-1 ruling, a judge appointed by a Republican president joined one named by a Democrat to write the majority opinion. Justice Department spokeswoman Tracy Schmaler welcomed the decision. While suits remain pending before appeals courts in Atlanta, Richmond, Va., and Washington, D.C., "we believe these challenges to health reform will also fail," she said. Judge Boyce Martin wrote the court's lead opinion, but it was Judge Jeffrey Sutton's concurrence that got the most attention. A former law clerk to Supreme Court Justice Antonin Scalia, Sutton rejected the core argument against the insurance mandate: that individuals who fail to carry insurance are, by definition, not participating in commerce, and therefore fall beyond the federal power to regulate commerce.


An audit by the Office of Inspector General (OIG) found that states' collection of Medicaid drug rebates from pharmaceutical companies is inconsistent. The audit tried to ascertain how many states were fulfilling federal mandates for the collection of physician-administered drugs in the first half of 2009, the dollar amount of what the states required and what they collected from drug makers in that period, and what factors prevented the collection of rebates. The audit determined that 36 of 49 states responding to OIG's query reported collecting rebates on single-source physician-administered drugs and 20 multiple source physician-administered drugs with the highest dollar value; another 12 states reported collecting rebates but were non-compliant with federal requirements. Although there appears to have been significant improvements in the states' collection process over the last 10 years, the quality of disclosure was so poor in some instances that OIG concluded that it "could not determine the financial impact of collecting rebates for physician-administered drugs because of incomplete and potentially inaccurate data provided by states."


The Centers for Medicare & Medicaid Services reports it is now using predictive modeling technology to fight Medicare fraud on a national basis. The technology, previously used on a pilot basis, uses predictive models to identify potentially fraudulent Medicare claims before they are paid. "CMS has worked with public and private stakeholders throughout the process of developing this program, and the key insight they shared on their successes and innovations have helped ensure it will significantly help us address fraud in the Medicare program," says Peter Budetti, M.D, director of CMS' Center for Program Integrity.


Seven health industry organizations recently sent a letter to Department of Health and Human Services Secretary Kathleen Sebelius urging the agency to address barriers to meaningful use of electronic health records in five areas. Sebelius had asked the health care community in February to propose the "top five solutions" - short of regulatory or legislative change - that HHS could implement to ensure greater success in meeting Stage 1 meaningful use requirements in the Medicare and Medicaid EHR incentive programs. The letter proposes specific actions to reduce regulatory complexity; clarify certification and site certification processes; address providers' meaningful use resource requirements; clarify and improve registration, attestation, and compliance processes; and evaluate the regulatory timeline. The letter was sent by the American Hospital Association, American Medical Association, Association of Medical Directors of Information Systems, College of Health Information Management Executives, Electronic Health Record Association, Federation of American Hospitals, and Healthcare Information and Management Systems Society.

Medicine, Drugs and Devices

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Infection control chiefs are scheduled to discuss the most pressing challenges they face at the annual Association of Professionals in Infection Control and Epidemiology conference, and among those challenges is the risk of infection from Closteridium difficile. Experts also concur that improving and maintaining good hand-washing practices at medical facilities is a constant challenge, while another subject of debate is surveillance practice for Methicillin-Resistant Staphylococcus aureus and other infections. Additional challenges include the need for hospitals to engage with their rival and neighboring hospitals and nursing homes; emerging infectious organisms and resistance; persuading the C-suite that resources need to be invested into the prevention of hospital-acquired infections; lowering the unnecessary use of antibiotics by clinicians; engaging housekeeping and environmental services staff on the value of work ethic and thoroughness in infection control for their patients and each other; increasing levels of vaccination among healthcare employees; and the lack of standardization in the current reporting of infections.


Large health plans are offering mobile apps that let members do such things as access their virtual ID cards, search the plan's network directory, and sometimes access drug costs and coverage details. Adriana Murillo, director for strategic development at Blue Cross and Blue Shield of Florida, says apps may soon feature Bluetooth technology that would, for example, let doctors obtain patients' blood glucose level readings. A recent survey by Manhattan Research found that 81 percent of physicians currently use a smartphone, and other surveys found that 25 percent to 30 percent of physicians use a tablet, with many more ready to purchase one. Julie Kling, mobile executive business lead at Humana, says the health plan is working on apps that enable doctors to communicate in a secure environment and issue alerts to "gaps in care," such as when a patient is due for a mammogram. Such apps will likely require relevant coding to ensure that doctors are compensated adequately, according to Kling.


National Coordinator for Health IT Farzad Mostashari said at the National Health IT and Delivery System Transformation Summit that the final rules for Stage 2 of the meaningful use program should be released by 2012, and argued that the rules should be considered "the roadmap for delivering higher quality healthcare." For providers, meaningful use entails using certified electronic health records (EHRs) in ways that enhance the quality, safety, and efficacy of patient-centered care. Mostashari noted that the adoption rate of EHRs by primary care physician was 30 percent in 2009-2010 and could reach 50 percent by 2014, while surveys show that over 86 percent of hospital CIOs intend to apply for meaningful use, with 60 percent expected to apply in the next couple of years. In addition, 5,000 to 10,000 providers register for the meaningful use program each month, and 6,000 small provider practices sign up for help at the regional extension centers per month.


A leg cuff designed to help people with foot drop triggers the leg muscles to contract and correctly lift the foot from the ground by sending electric pulses into the knee. A study of 15 stroke patients suffering from foot drop who used the device five days a week for 12 weeks found that functional electrical stimulation boosted muscle strength and increased walking speed 38 percent. The Bioness NESS L300 is distinct from other devices with similar functions because it is wireless, and features electrodes that are placed against the skin and trigger the main nerve that travels down the leg into the foot; a sensor placed in the shoe tells the leg cuff if the heel is on the ground or in the air. Electrical pulses are emitted by the cuff into the nerve when the shoe sensor senses that the foot is in the air. The level of stimulation can be adjusted via a handheld remote control.