News From ACFAS

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At the American College of Foot and Ankle Surgeons, we know that our physician and student members value the research performed by colleagues. After all, this is essential to the medical profession. If you’re involved in a study, submit your manuscript or poster to be considered for presentation at the ACFAS 2013 Annual Scientific Conference, February 11-14, in Las Vegas, Nevada.
Don’t wait — the deadline for research manuscripts is only a few weeks away!

• Manuscript submission deadline: August 15, 2012
• Poster submission deadline: October 15, 2012

Find applications and more details at the ACFAS website. ACFAS recently completed its triennial member opinion and practice economic surveys and received tremendous response. Watch for data from both surveys to appear soon in the Update print newsletter and the This Week @ ACFAS e-newsletter.

As promised, six respondents were randomly selected to receive their choice of an iPad, free registration to the 2013 Annual Scientific Conference or free 2013 membership dues. Thank you to ALL respondents! The winners are:

• Brandon W. Bishop, DPM, AACFAS
• Matthew W. Dinnon, DPM, FACFAS
• Mark T. Lewis, DPM, FACFAS
• Jody P. McAleer, DPM, FACFAS
• Anetra S. Miranda, DPM, AACFAS
• Harry P. Schneider, DPM, FACFAS

Did you know that ACFAS is an active member of the Coalition for Patients’ Rights (CPR)? This is a national coalition of more than 35 professional membership organizations representing more than three million licensed and certified healthcare professionals committed to ensuring comprehensive healthcare choices for all patients. ACFAS trusts that its members maintain the values of the CPR in order to advance the mission and promote the patient-centered approach which is valued among all.

Formed in 2006, the Coalition supports a patient’s right to choose the healthcare professional who best meets his or her health needs. To that end, the CPR advocates for the ability of all healthcare professionals to practice to the full extent of their ability, training, certification and licensure and works to ensure that transparent, patient-centered scope of practice guidelines promote consumer access to safe, high-quality and cost-effective healthcare.

The Coalition is comprised of a diverse array of healthcare professionals, including registered nurses, psychologists, speech-language pathologists, audiologists, occupational therapists, physical therapists, advanced practice registered nurses (certified registered nurse anesthetists, nurse practitioners, certified nurse-midwives and clinical nurse specialists) and foot and ankle surgeons. To view a full list of members and learn more about the Coalition, visit www.patientsrightscoalition.org. Does the word "surgery" send a shiver of fear through your patients? Now, you have the opportunity to educate your surgical patients with the information they need before and after their surgery! Give them peace of mind with the new Perioperative Patient Education CD.

The new educational CD is filled with over 11 printable handouts on the most common surgical procedures, including Achilles Tendon Disorders, bunions, chronic ankle instability, flatfoot, fracture repair, hallux rigidus, hammertoe, tailor’s bunion and ankle anthroscopy.

Each handout has been peer-reviewed, providing clear, concise and ample information that may be tailored to the patient’s specific needs and situation, such as:

• Risks and benefits of surgery
• Details on preparing for surgery
• Description of the procedure
• Post-op instructions
• Patient consent form

These handouts also provide space for your practice to include its logo and other information. To see a complete list of topics and to order your new patient education CD tool for only $95, visit acfas.org/perioperativecd.

Foot and Ankle Surgery

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A substantial proportion of patients with ankle sprains exhibit chronic symptoms, and a study was held to determine whether elastic stockings improve recovery. Thirty-six patients identified within 72 hours of injury were randomized to wear either Tubigrip or class II below-knee elastic stockings (ES) until they were pain-free and fully mobile. At four weeks post-sprain, the deep veins of the injured legs were imaged by duplex Doppler for deep vein thrombosis (DVT), and results were compared using the AOFAS and SF12v2 for quality of life. The average circumference of the injured ankle treated by ES was 23.5 cm initially and 22 cm at four and eight weeks, versus 24 cm initially and 24 cm using Tubigrip. The average AOFAS and SF12v2 scores were significantly improved by ES at 99 and 119 compared with 88 and 102 with Tubigrip at four weeks. A DVT was not identified in any of 34 duplex images at four weeks.


There are no existing guidelines concerning which type of fixation of Achilles tendon insertion is superior, so researchers tested the hypothesis that transcalcaneal drill pin passage does not put any major plantar structures at risk, and the addition of a Krackow stitch and suture button to the fixation method yields a significant increase in ultimate load to failure in Achilles tendon insertional repairs. The researchers detached Achilles tendon insertions in six fresh-frozen cadaveric ankles and passed transcalcaneal drill pins. Plantar dissection was carried out to assess how the drill pin related to the plantar fascia, lateral plantar nerve and artery, flexor digitorum longus tendon and master knot of Henry. Repair of Achilles tendons was then performed with a double-row suture anchor construct alone or with a suture button and Krackow stitch added to the double-row suture anchor construct. Repairs were then tested to maximum load to failure at 20 mm/minute. None of the selected anatomic structures were placed at risk with transcalcaneal drill pin passage, and the mean maximum load to failure for the suture bridge group and the suture button group was 239.2 N and 391.4 N, respectively. The structure placed at the greatest risk from drill pin placement was the lateral plantar artery, with a mean distance of 22.7 mm between the pin and artery.


Researchers compared the outcomes of extracorporeal shock wave (ESWT) with a modified endoscopic plantar fasciotomy method for the treatment of chronic heel pain, using 65 patients who were unresponsive to standard nonoperative therapy. Patients were assigned at random to two groups, one of which received high-energy ESWT while the other received modified endoscopic plantar fasciotomy. The primary measure of results was pain reduction from baseline to third-month post-intervention at the first few steps in the morning, with primary analysis being intention-to-treat and involving all randomized patients. Both patient groups exhibited improvement from the baseline at three weeks, three months and 12 months post-intervention. The success rate in the ESWT group at the 12th month was 70.6 percent while the fasciotomy group had a 77.4 percent success rate.

Practice Management

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A medical practice website can reduce administrative costs, allow doctors to spend less time answering routine questions on the phone and boost the number of loyal and engaged patients. But doctors must beware mistakes that can ruin a website's effectiveness. One mistake is asking a friend or relative to design a practice site, as the result will likely be unprofessional-looking. Physicians should probably conduct a full review of their website at least once yearly to see what is working and what is not, what has changed and what new components might be worth adding. Site design should likely be outsourced to a firm with an exclusive healthcare focus.

Physicians also should not set up a website without a specific goal in mind, and it may be sensible to consult with office staff about potential ways a site can be helpful. A partnership with a website design company should not be entered into without a firm budget cap, and a survey of companies and physicians determined that a basic site should cost no more than $6,000. Launching a site and then forgetting about it is another bad strategy, as neglected sites convey unprofessionalism. Practices that are strapped for time should at least ensure that all contact information on the site is updated, that the copyright date is the current year and that any page saying "under construction" is removed. Practices that ignore search engine optimization (SEO) do so at their own peril, as SEO can help patients find practice pages by helping Google, Bing and other sites find their page and move it nearer to the top of the search list.

Making a practice website easier to find can help reduce daily incoming calls for routine information. Sites that provide downloadable enrollment, patient history and HIPAA clearance forms can save patients and staffers time by reducing waiting room delays and guaranteeing accuracy of the paperwork. Making sites too high-tech can be counterproductive, as such options may render sites inaccessible or unusable to patients with old computers. Finally, the practice should ensure that the contract with the site design firm includes certain provisions so that it still retains its web address and content if it terminates the contract.


A new hire can be an initial drag on office productivity. Here are four ways to speed the process of integration and increase the likelihood of a good hire becoming a valuable employee:

• Be aware of the new employee's point of view. New employees have a strong tendency to be frightened and risk averse. They do not take initiative because they are just too vulnerable. It may be in your best interest to acknowledge the reality. It saves you the frustration of unmet expectations and can avoid behavior in you that produces a perennially tentative employee.

• Be very clear about the new hire's responsibilities. In the absence of clear expectations the new employee will hang back and wait for instructions.

• Give the new hire the tools necessary to succeed. Make sure that your new hire has a logon, password and appropriate hardware and software for your environment. One of the best and least common tools is an operations manual for the practice. It is a written record of practice expectations, priorities and non-clinical protocols. Written communication is generally clearer and less likely to be misunderstood than oral communication, and it gives the new hire something to rely upon in making decisions. Acclimating a new employee is a great way to review the need for edits to the current operations manual. In the absence of an existing operations manual, the new hire's notes can begin the process of accumulating the necessary information.

• Take the time to give and receive feedback. Make a point of checking in with the new hire each day, for at least a couple of weeks. If the new employee knows that he or she will have an opportunity each day to ask questions, then he or she can accumulate a list. Encourage questions and comments as part of this process. Also, be liberal in feedback, both good and bad.

Sending patients' overdue bills to a collection agency can hurt a physician's reputation and yield few financial gains for the practice. To avoid this, practice managers and medical practice consultants recommend physician groups implement good billing practices up-front, educate patients about what they owe and why and guarantee the correctness of demographic information in the system. Collecting part of the patient portion as soon as possible is the first step, and the practice ought to inform patients that the co-payment is due at the time of service by noting this when they call for an appointment and during the reminder notification. Staffers should be ready with scripted answers if a patient refuses to pay or cannot pay at that moment. Bills for deductibles or other amounts that are not immediately known should be sent out as soon as possible after the patient visit.

The next step entails educating patients about their financial obligations. Medical practice managers say most people wish to pay their debts and will do so if a bill makes sense to them, while problems are more likely to crop up when a bill is perceived as incorrect or inappropriate. The third step to avoid sending patient accounts to a collection agency is ensuring that demographic data is correct. A frequent reason underlying unpaid bills is they are sent to the wrong address, while problems also may develop if a patient's name is misspelled or the practice has erroneous insurance information. Medical practice managers urge that practices verify patient address and insurance information at every visit. Some practice management systems have embedded address verification software, which can be helpful to make sure that a patient's information matches that of the U.S. Postal Service. These various steps should boost the chance that patients pay their bills, but a few patients who do not pay are inevitable. Some practices have policies of writing off these amounts rather than turning to collection agencies, which can cause expenses to mount. Others use such agencies for bills that exceed a certain amount and are not paid by a set time.

Health Policy and Reimbursement

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A bipartisan group of lawmakers is questioning the role auditing contractors should play in the Medicare program, saying the audits place burdensome requirements on physicians and hospitals. The group has called on the Government Accountability Office to review contracted Medicare auditors, which include Medicare administrative contractors, recovery audit contractors and program safeguard contractors. According to a letter the lawmakers wrote, the GAO should study the coordination of audits and contractor interactions with physicians and hospitals.


There are indications that migrating physicians to a global budget framework is beneficial for patients, although savings for consumers have yet to materialize, according to a study published online in the journal Health Affairs. Twenty percent of patients in Massachusetts are currently under some kind of global payment through a Blue Cross Blue Shield experiment, which means that hospitals, or the group a patient's doctor is in, negotiates a budget for all the patients in their practice. Physicians are paid according to the number of patients in their care rather than how many patients they see in a day or the number of tests they order. The study found that the 11 physician groups and hospitals that joined in 2009 and 2010 did a better job than doctors in traditional medical contracts of ensuring that patients received standard check-ups, cancer screening tests and other preventive care, and overall they reduced spending by just under 3 percent. Sending patients to lower-cost hospitals was the chief way doctors saved money, and doctors say the next step, attempting to eliminate unnecessary care, is even trickier. Unless a change in the way we pay for healthcare leads to improved care and lower costs, consumers will face much higher costs or physicians and hospitals can expect significantly lower fees.


A new report from the Institute of Medicine (IOM) determined that the accuracy of Medicare payments could be augmented by adjusting them to reflect geographic differences in the cost of care provision, although such an approach may not enhance access and quality. The report applied recommendations outlined by IOM last year in the first phase of a two-part study that the Department of Health and Human Services commissioned in July 2010. In that study, the IOM suggested using the same geographic boundaries and payment areas for hospitals and healthcare practitioners; using different data sets for estimating the compensation of clinical and administrative hospital staff and others at office-based sites; and broadening the type of healthcare occupations used to make the geographic adjustments. The second study found that Medicare payments would rise or fall by less than 5 percent, on average, for most hospitals and physicians, but other means are suggested to ensure clinician access and reduce disparities in care. These other means could include using telemedicine and other services that allow clinicians to reach more patients in underserved areas; and boosting the supply of primary-care services in underserved areas if state licensing and credentialing laws permit wider scope of practice for the whole range of professionals, such as nurse practitioners and physician assistants.

Medicine, Drugs and Devices

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Seeking to make the feedback that health insurance companies provide in physician data reports more useful, the American Medical Association has developed "Guidelines for Reporting Physician Data." The guidelines promote greater format standardization and process transparency and a higher level of detail. More than 60 organizations have already pledged their support for the effort. The guidelines can be found here.


The most common type of computer used by physicians remains the desktop, according to a survey of 1,190 doctors which found that 75 percent of respondents use their desktops for practice management tasks. Desktops are the most common tool employed for clinical chores, electronic prescribing and accessing an electronic health record (EHR). Uncertainty about the security of mobile devices is partly why desktops make sense for physicians, while their persistent presence has given rise to a surrounding "desktop ecosystem" that includes EHRs and printers, says health IT consultant Ben Piper. Although smartphones and tablets are growing in popularity outside the doctor's office, Sharecare Senior Vice President for Medical Affairs Keith Steward expects a more gradual technological shift among physicians. Spyglass Consulting founder Gregg Malkary thinks mobile and tablet adoption will accelerate among doctors once developers adapt their clinical and practice management software to mobile devices.


The Centers for Medicare and Medicaid Services has submitted the final rule for Stage 2 of the electronic health records (EHRs) meaningful use program to the Office of Management and Budget for review, prior to publication. The rule will finalize criteria for providers to show they are using previous and newly mandated functionalities in EHRs in a "meaningful" manner.