July 18, 2012

News From ACFAS

Perfecting Your Practice
Register for the Practice Management/Coding Workshop from October 12-13, to learn leading-edge tools to get your practice running at top speed. If you are a foot and ankle surgeon, part of the practice management team or a staff member, everything you need to know regarding changes in ICD-10, CMS regulations and reimbursement issues are here in one place. The Perfecting Your Practice program is designed to answer all of your vital medical practice questions in one fell swoop.

Considering changing employment, buying a practice or becoming part of a hospital or ACO? You, too, will gain knowledge and insights by participating in this highly-interactive program with your colleagues thanks to the roundtable discussions offered with this course.

This two-day seminar is chock full of groundbreaking advice for dealing with many of the policies associated with running your practice. Hear tips and advice from certified professionals who have dealt with their fair share of helping practices achieve success. Also, participate in one or both of the roundtable sessions offered as part of your two-day workshop registration. Note: Registration includes one roundtable event.

Sign up for this eye-opening event today!
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Board Nominations Now Being Accepted
The ACFAS Board of Directors is now accepting nominations for two three-year director terms. ACFAS Fellows who meet criteria for election are encouraged to submit a nomination application to the executive director by August 25. The Nominating Committee will announce recommended candidates to the membership no later than October 5. Candidate information and ballots will be e-mailed to all voting members no later than November 29. Electronic voting will end on December 29. New officers and directors will take office during the ACFAS 2013 Annual Scientific Conference set for February 11-14, 2013, in Las Vegas, NV.

For complete details on the recommended criteria for candidates and the nomination application, visit, or contact Executive Director Chris Mahaffey at 773-693-9300 or Questions regarding eligibility criteria should be directed to Nominating Committee Chair Glenn M. Weinraub, DPM, FACFAS, at 510-248-3039 or

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Want Access to the Best Place to Recruit Foot and Ankle Surgeons?
Today, there are more places than ever to advertise your open career opportunities, but where will you get the best ROI? is the official online career center of the American College of Foot and Ankle Surgeons (ACFAS).

Here, you get access to the most qualified candidates: ACFAS Members. Affordable pricing packages are available depending upon your hiring needs. Post your jobs today! Call (888) 884-8242 or visit the web page for more information and to see prices for ACFAS member discounts on job posts.
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Foot and Ankle Surgery

Correlates of Diabetic Foot Complications Identified
Researchers performed a study to determine if patients at high risk of diabetes displayed specific skin structural and metabolic deficits that could predispose to foot complications such as diabetic foot ulceration (DFU), using a cohort of 46 patients comprised of nine diabetic control subjects, 16 with diabetic peripheral neuropathy (DPN) alone and 21 with recurrent DFUs. They were compared with 14 nondiabetic control subjects, with DPN evaluated using the Michigan Neuropathy Screening Instrument (MNSI). Skin punch biopsies were executed on upper and lower leg skin for measurements of intraepidermal nerve fiber density (IENFD), structural analysis, type one procollagen abundance, tissue degrading matrix metalloproteinases (MMPs) and poly(ADP-ribose) (PAR) immunoreactivity. MNSI scores were comparable across DPN groups, with diabetes and DPN causing IENFD to decline, although it did not differ between neuropathic groups. All neuropathic subjects, especially those in the DFU group, exhibited elevated skin structural deficit scores. Type one procollagen abundance was lowered in DFU subjects 387 plus or minus 256 units, while diabetes activated MMP-1 and MMP-2. PAR immunoreactivity was increased in DFU, especially among subjects with Charcot neuroarthropathy, compared with other DPN subjects.

From "Cutaneous Structural and Biochemical Correlates of Foot Complications in High-Risk Diabetes"
Diabetes Care (06/12) Tahrani, Abd A.; Zeng, Wei; Shakher, Jayadave; et al.
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Deficits in Heel-Rise Height and Achilles Tendon Elongation Occur in Patients Recovering From an Achilles Tendon Rupture
Assessment of whether side-to-side differences in maximal heel-rise height can be explained by differences in Achilles tendon length was the purpose of a study involving eight patients with acute Achilles tendon rupture and 10 healthy subjects. Heel-rise height, Achilles tendon length and patient-reported outcome were quantified three, six and 12 months after injury, while motion analysis and ultrasound imaging were used to evaluate Achilles tendon length. The healthy subjects exhibited no side-to-side differences in tendon length and heel-rise height, while subjects with Achilles tendon ruptures had significant differences between the injured and uninjured side for both tendon length and heel-rise height. Significant negative correlations were observed between the side-to-side difference in heel-rise height and Achilles tendon length at the six- and 12-month assessments, respectively.

From the article of the same title
American Journal of Sports Medicine (07/01/12) Vol. 40, No. 7, P. 1564 Silbernagel, Karin Gravare; Steele, Robert; Manal, Kurt
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Effects of Foot Orthoses on Balance in Older Adults
A study was performed to determine whether foot-orthotic intervention could be used to significantly improve balance in older adults, with the participation of 13 individuals older than 65 years who reported at least one unexplained fall during the past year and exhibiting poor balance. Participants were tested for one-leg stance, tandem stance, tandem gait and alternating step tests during the first (SCREEN) and second (PRE) sessions before foot-orthotic intervention. Tests were repeated during the second testing session immediately following custom foot-orthotic intervention (POST) and two weeks following foot-orthotic use (FU). Each balance measure displayed statistical equivalence between the SCREEN and PRE measurements, while one-leg stance times for PRE were significantly less than POST and FU measurements. Tandem stance times for PRE were substantially less than POST and FU measurements, and steps taken for the tandem gait test during the PRE measurements were significantly fewer than steps taken for the FU test. Steps taken during the alternating step test for the PRE test were significantly fewer than steps taken during the POST and FU tests. There were no significant differences between POST and FU measurements for any of the four outcome measures.

From the article of the same title
Journal of Orthopaedic & Sports Physical Therapy (07/01/2012) Vol. 42, No. 7, P. 649 Gross, Michael T.; Mercer, Vicki S.; Lin, Feng-Chang
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Practice Management

Carefully Discharge Difficult Patients
Patients can be a problem, and physicians have a right to terminate their relationship with them. Here are steps physicians should take to avoid legal complications:
  • Put your dismissal policy in writing and practice it consistently. Make sure staff members understand what constitutes a reason for dismissal and apply the policy consistently so no legal ramifications result.
  • Check your insurance carrier contract regarding discharge, and inquire about any responsibilities you may have to it in the process.
  • Check your responsibilities to your malpractice insurance carrier. Document all correspondence of discharge.
  • State the reason for dismissal in a letter to the patient; be as objective as you can. A recommended 30 days should be given for continuance of care. Make a referral for other physicians, but never suggest a specific physician. Send a copy of your medical records transfer form for the patient to fill out so that the new doctor has the information necessary to provide continuing care.
  • Send the discharge letter to the patient through both regular and certified mail. Be sure to keep all documentation. If the certified letter is returned undeliverable, mark the return date on the envelope and attach the letter and envelope to the patient's chart.
  • Always offer to send medical records to the patient's new physician. Be sure to obtain a written request for the release of a copy of the medical records. If you elect to charge the patient for the copy of the medical records, inform the patient.
  • Should a patient subsequently request medical attention from you, agree to treat the patient only if the situation is a genuine emergency. If it is not an emergency, then inform the patient diplomatically but firmly that their physician-patient relationship is irretrievably damaged, refer to the letter previously sent, and indicate a willingness to find the patient another doctor and transfer his or her medical records. Document these actions in the patient's record, and send a letter confirming the conversation to the patient at the new address, with a copy of the original letter of dismissal enclosed.

From the article of the same title
Medical Economics (07/10/12) Salz, Terry
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How to Get Patients to Pay Their Bills
When it comes to asking patients for payment, experts say it should be done early and often. But an effective collection strategy isn’t just about asking over and over again. It’s about how the asking is done. Timing plus delivery can get the response you want. The first step is to think about the best times to ask. The fact that a co-pay is due at the time of service can be mentioned when a patient calls to make an appointment or during the reminder notification. If the practice has the technology to retrieve the information quickly or link it to the reminder system, staff should give an exact amount.

Staffers then can ask for the amount of money known to be due when the patient is in the office, but proper phrasing is important. It should start with the patient’s name. If there is doubt about whether a patient wants to be addressed by first or last name and the appropriate title, staffers should ask. Patients should not, however, be asked whether they are going to or want to pay. Rather, the question should focus on how they want to pay and give the options available.

While patients should not be asked a yes-or-no question on this subject, staffers should be prepared with scripted answers if patients try to decline. Consultants recommend telling patients how valuable they are to the practice but that insurers require collecting certain amounts. If a patient hesitates because of economic or other issues, staff should acknowledge this. If full payment is not possible, an installment plan should be established. Other options include giving patients stamped, addressed envelopes to mail payments or a phone number of someone who will take down credit or debit card information when patients return home. Some practices may decide that in certain situations, a patient could be turned away.

The next issue to consider is who should do the asking. Experts who work with practices say money issues should be delegated to staffers who are not shy about asking for money but who can ask with tact.

From the article of the same title
American Medical News (07/09/12) Elliott, Victoria Stagg
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How Bundled Payments Pay Off in Joint-Replacement
Texas-based hospital Baptist Health System realized seven-figure savings in price concessions for joint-replacement devices over one year by uniting with orthopaedic surgeons and negotiating price guidelines with device vendors. "We had a major reduction of $2 million as a result of meetings with vendors and representatives from orthopaedics and cardiology," says Baptist Health Chief Development Officer Michael C. Zucker. The hospital's Wendy H. Solberg notes that with the bundled payment scheme "we got a lump sum from Medicare for both the hospital costs and physician costs. We made the physicians whole for their professional fee, but they received an incentive to help us with cost per case via their gainsharing methodology; that would not have been possible without a bundled payment arrangement."

Several issues lie at the core of the need for better financing frameworks specifically for orthopaedic programs to counter higher costs in joint-replacement procedures. One is the expected continued demand for new cases, while another is the higher device cost. A major motivator toward financial reform is mirrored in the move toward value-based payments based on outcomes and penalties associated with readmissions.

From the article of the same title
HealthLeaders Media (07/01/12) Cantlupe, Joe
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Health Policy and Reimbursement

CDC Updates Hepatitis B Recommendations for Infected Healthcare Workers
The U.S. Centers for Disease Control and Prevention (CDC) has issued an update to its 1991 recommendations for management of hepatitis B virus (HBV)-infected healthcare providers and students to prevent transmission of the disease. The recommendations are especially relevant to those carrying out exposure-prone procedures such as certain kinds of surgery. The recommendations no longer contain a requirement to prenotify patients of a healthcare provider's HBV status, while HBV DNA serum levels rather than hepatitis B e antigen status should be employed to monitor infectivity. In addition, the CDC now says an HBV level of 1,000 IU/mL or its equivalent is an appropriate threshold determining whether a healthcare provider performing an "exposure-prone" procedure needs an expert panel oversight. It is additionally recommended that monitoring be carried out with an assay that can detect levels as low as 10 to 30 IU/ml, while HBV infection alone does not require any halt of practices or supervised learning experiences for most providers and students with chronic hepatitis B who adhere to current infection control standards. Among the issues addressed by the new guidelines are precautions and preventive strategies that should be practiced when HBV-infected providers and students treat patients, which include work practice and engineering controls. The CDC recommends that all healthcare providers and students receive a hepatitis B vaccine with the 3-injection series.

From the article of the same title
Medscape (07/06/12) Hitt, Emma
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CMS Details Plans for eRx Changes, ACO Reporting
Included in the Centers for Medicare & Medicaid Services' (CMS) proposed revisions to the 2013 physician fee schedule are potential additions and clarifications to the agency's electronic prescribing and electronic health record (EHR) incentive programs along with details on expanded reporting of provider performance data. The agency recommends updating the Electronic Prescribing Incentive Program with new criteria, new hardship exemptions, and an informal review process. For its Medicare EHR Incentive Pilot, CMS also proposes maintaining use of the same method of reporting clinical quality measures finalized in 2011's physician fee schedule. CMS also clarifies the next phase of the Physician Compare website, which will supply physician quality information to consumers. The agency proposes posting performance data from accountable care organizations and from group practices participating in the Physician Quality Reporting System, starting with data submitted next year.

From the article of the same title
Modern Physician (07/09/12) McKinney, Maureen
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Physicians Should Have More Freedom to Coordinate Care, MedPAC Says
The Medicare Payment Advisory Commission's (MedPAC's) annual June report says physicians should be given more latitude in their participation in new Medicare payment models if the success of care coordination is to be realized. MedPAC Chairman Glenn Hackbarth says Medicare's fragmented fee-for-service model has generated gaps in care coordination, which ill-serves patients in a system marked by elevated spending while also not holding physicians accountable for coordinating care. Among the coordination-improving approaches cited by MedPAC are revising incentives to provide better instead of just more care and allowing physicians the freedom to use available resources to raise quality of care for beneficiaries. MedPAC commissioners want Medicare to move away from dependence on fee-for-service models. Care coordination models such as accountable care organizations and shared savings programs remunerate physicians for quality and hold them liable if health spending for their patients climbs above certain thresholds. Hackbarth asserts that the system should apply pressure and "make it difficult" for doctors who remain in fee for service over the long term.

From the article of the same title
American Medical News (07/09/12) Fiegl, Charles
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Medicine, Drugs and Devices

FDA Won't Order Doctors to Get Pain-Drug Training
The Food and Drug Administration (FDA) overrode an expert panel's recommendation in its decision not to require physicians to have special training before they could prescribe long-acting, addictive narcotic painkillers, but also mandated that drug manufacturers must underwrite the cost of voluntary programs designed to educate doctors on how best to use them. In introducing the plan, FDA commissioner Margaret A. Hamburg and White House drug policy adviser R. Gil Kerlikowske expressed hope that Congress would eventually pass a measure making physician training a requirement. Major physician organizations such as the American Medical Association have opposed the notion of mandatory training, arguing that the programs would be onerous and could reduce the number of pain-treating doctors. However, concerns are mounting that long-term use of narcotic drugs can cause various problems, such as increased falls and fractures in people over 70.

From the article of the same title
New York Times (07/09/12) Meier, Barry
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Insurers Pay Big Markups as Doctors Dispense Drugs
Insurers say that when pharmacies dispense medications it costs up to 10 times less than when doctors dispense the same medications. Healthcare costs continue to rise and insurers and employers suggest that doctors, middlemen and drug distributors are contributing millions of dollars per year. The operation of in-office pharmacies from which doctors can dispense medications directly to patients during an office visit earns doctors additional money and the bills are sent directly to insurers. In some cases, private equity firms have found the model to be so profitable that they are buying stakes in these doctors' practices. While selling drugs in the doctors' offices is convenient for patients, there are some loopholes in state workers' compensation insurance rules that enable doctors to sell drugs at large markups. Regulatory and legislative battles over the practice are being waged in Florida, Hawaii and Maryland, and some states, like California and Oklahoma, have already taken action.

From the article of the same title
New York Times (07/12/12) P. A1 Meier, Barry; Thomas, Katie
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Raising Vitamin D Concentrations May Reduce Hospital Acquired Infection Rates
A study published by Dermato-Endocrinology has found that increasing vitamin D concentrations in hospital patients can significantly reduce the risk of those patients developing hospital-acquired infections such as urinary tract and surgical site infections. Vitamin D is helpful in reducing the risk of these infections because it acts as an antimicrobial. In addition, vitamin D can help strengthen patients' innate immune responses by overcoming the resistance that bacteria in hospitals has developed to antibiotics.

From the article of the same title
Medical News Today (07/05/12)
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