News From ACFAS

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The ACFAS Nominating Committee seeks dedicated members to serve on the College’s Board of Directors. If you are an ACFAS Fellow, believe you are qualified and would like to help lead the profession, send your nomination application by September 20, 2016.

Visit acfas.org/nominations for the nomination application and complete details on the recommended criteria for candidates. For more information, contact Executive Director Chris Mahaffey via email or (773) 693-9300. Questions regarding eligibility criteria should be directed to Nominating Committee Chair Richard Derner, DPM, FACFAS, via email or (703) 491-9500.

The Nominating Committee will announce recommended candidates to the membership no later than October 31, 2016. Candidate information and ballots will be emailed to all voting members no later than December 15, 2016. Electronic voting ends on December 30, 2016. New officers and directors will take office during ACFAS 75, February 27–March 2, 2017 in Las Vegas. Class of 2016, your first year of ACFAS membership is free! Thanks to the Regional Divisions’ support, your dues for the first year are waived. You'll also receive:

• a subscription to The Journal of Foot & Ankle Surgery (JFAS);
• access to the Journal through the new JFAS iPad app;
• member pricing on conferences, products and services;
• member access to acfas.org.

Apply for membership now at acfas.org. Ready to sell or consolidate your practice, bring in a new business partner or retire? PodiatryCareers.org, an ACFAS Benefit Partner, offers these five tips to help you calculate the value of your practice before you take any action.

1. Examine Practice Growth
   Gather the numbers necessary to prove your existing revenue stream is steadily increasing or will be easy to maintain.
   
2. Examine Patient Loyalty
   Determine the number of patients within your practice, the average length of your relationship with them, the number of visits per patient, the revenue generated per patient and anything else that shows they are satisfied with your service and are likely to return.
   
3. Examine Practice Staff
   An efficient, smoothly functioning team with a low turnover rate is a valuable asset to an appraiser or buyer.
   
4. Examine Physical Assets
   Calculate the value of your office furnishings and any equipment you own outright. If you still owe payments, an appraiser or buyer will likely deduct those from your practice valuation.
   
5. Start Succession Planning
   Once you have determined the value of your practice, reach out to your social network, post your practice on PodiatryCareers.org and interview multiple candidates to make sure you find the right partner or buyer.

For more on how to best determine what your practice is worth, visit PodiatryCareers.org.

Foot and Ankle Surgery

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Some cases of repeated inversion ankle sprains are thought to have a neurological basis and are termed functional ankle instability (FAI). The purpose of the study was to examine the effect of cognitive demand on foot kinematics in people with FAI. Researchers recorded foot motion, cognitive performance, ankle kinematics and movement variability in 21 physically active subjects with FAI. Participants completed single tasks (normal walking) and dual tasks (cognitive tasks while walking). During normal walking, the ankle joint was more inverted in the FAI group than the control before and after initial contact. During dual task trials, frontal plane foot movement variability during the period 200ms before and after initial contact in the FAI group saw a significant increase over the control. Subjects with FAI also had significantly increased plantar flexion and inversion before and after initial contact.

Practice Management

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Changing regulations and reimbursement policies from insurance companies and high-deductible health plans have disrupted the consistent stream of revenue for many medical groups. Half of a group’s revenue now needs to be collected from patients, who can delay or ignore a bill if they do not understand the bill or do not have the means to pay. Setting clear expectations for payment is critical, and practices should make an effort to collect at the time of service. This way, the patient’s health plan coverage and reimbursement is known ahead of time, and patients can ask any questions regarding the bill while in the office. If a patient is unable to pay at the time of service, a payment plan should be established that is fair for all parties. In addition to instituting payment plans, practices should bill patients in a way that is easy, cost-effective, efficient and avoids paper-based methods. Paper statements can create a payment cycle of three months or more, severely limiting cash flow. Additionally, because multiple parties contribute to the creation of healthcare bills, patients often do not understand their statements. According to Deloitte, seven out of 10 healthcare consumers would prefer to receive and pay their bills electronically, and a study by Citibank shows that three out of four consumers would pay a bill right away if they understood the statement.


Healthcare information technology costs have risen by more than 40 percent since 2009, reaching an average annual cost of $32,500 per physician in 2015, according to a survey by the Medical Group Management Association. Significant increase has been seen in IT staff expenses, indicating a lack of administrative efficiency. The most dramatic increase in costs occurred between 2010 and 2011, reflecting implementation of the Health Information Technology for Economic and Clinical Health Act. “We remain concerned that far too much of a practice’s IT investment is tied directly to complying with the ever-increasing number of federal requirements, rather than to providing better patient care,” says MGMA’s Halee Fischer-Wright. Total operating costs continue to rise throughout the industry; physician-owned multi-specialty practices report an increase of nearly 15 percent in total costs in 2015.


Both the industry and patient advocacy groups are pushing for a more collaborative and holistic approach to medical decisions with a focus on increased access to information and communication, and many patients bring outside research, notes and questions to their appointments. However, patients often have difficulty presenting their concerns and asking questions of their physician. As a survey by Inspire shows, patients desire more active, insightful and collaborative engagement with their physicians. Patients look for an authoritative figure in the physician, but many emphasize the importance of good bedside manner in fostering more supportive relationships. As patients start to research their conditions, it is important for physicians to review presented information and make the most of the limited time available to react to patient concerns. Lastly, doctors should be aware of their own biases or nuances and encourage patients to accurately describe their experiences and give honest feedback. By engaging in active listening, physicians will be better able to treat and support the patient.


Newkirk Products Inc., which creates ID cards for health insurance companies, says its server was accessed without authorization, potentially affecting 3.3 million health insurance customers. Newkirk made the announcement on August 5, saying it discovered the breach on July 6 and believes the unauthorized access began on May 21. The company says the compromised data includes member names, mailing addresses, member and group ID numbers, types of plans for individuals, names of dependents enrolled in plans and primary care providers. In addition, some birth dates, premium invoice information and Medicaid ID numbers were accessed. No Social Security numbers, banking information or credit card information was on the server, according to Newkirk, which is sending letters to affected individuals and paying for two years of identity theft protection. Approximately 790,000 current and former members of Blue Cross and Blue Shield of Kansas City (KC) are among those affected, the Kansas City Star reports. A spokeswoman said that people who were issued ID cards between September 2, 2012, and July 7, 2016, were affected.

Health Policy and Reimbursement

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Physicians are performing more patient tests themselves due to an increase in availability of medical devices that allow them to provide services in their offices. The findings are from a Wall Street Journal analysis of recently released Medicare billing data, which found that four of the top 10 fastest-growing Medicare services from 2012 to 2014 involved new devices. For each of these four services, fewer than 10 percent of doctors accounted for more than half of the increase in spending for each service, according to the report, which looked at services performed during that period with at least $5 million in 2014 payments. For instance, more doctors are testing nerve damage in patients in recent years using a device to test whether people sweat in response to a low-voltage current. Testing for the neurological condition increased nationwide after the device became available. Medicare paid out $16.7 million for the test in 2014, according to the latest data, a 10-fold increase from 2012. A test to measure the saltiness of tears, known as tear osmolarity, was among the 10 fastest-growing services with high billings. The report noted that about 3,000 medical providers received nearly $15 million in payments for the test in 2014, compared to $1.75 million when the test was introduced two years before. Medicare spokesman Aaron Albright says the agency closely monitors spending on each service so "we can correct [billing] codes that may be misvalued and identify possible improper payment without limiting patient access to important new therapies."


Under the Medicare Access and CHIP Reauthorization Act of 2015, the U.S. Department of Health and Human Services will provide funding to Medicare physicians in solo and small practices for five years to help ease their transition into the Quality Payment Program. Most Medicare clinicians will report their performance through the Merit-based Incentive Payment System (MIPS), under which physicians will be paid based on scores regarding cost, quality, clinical practice improvement activities and advancing care information. Practices will begin participating through MIPS in 2017, and the first payment year will be 2019. Clinicians or groups with $10,000 or less in Medicare charges and fewer than 100 Medicare patients would be exempt from MIPS, but only 10 percent of physicians would be excluded under the low-volume threshold. The American Medical Association (AMA) is proposing a modification to include exemptions for those with $30,000 or less in Medicare charges or fewer than 100 Medicare patients. AMA is also asking for the initial transitional period to be pushed back from January 1, 2017 to July 1, 2017.


Federal rules and review controls governing the Section 1332 waiver under the Affordable Care Act (ACA) may discourage states from applying to the program. States can request the waivers for ACA coverage components if the state’s coverage is consistent with ACA standards and would not cause an increase in the federal deficit. The U.S. Departments of Treasury and Health and Human Services have issued rules to prevent states from using savings from other waivers to justify their 1332 applications. Stakeholder groups have warned the Government Accountability Office that states may not be able to meet the criteria for the 1332 waiver independently of the Medicaid waiver. So far, only Vermont has formally requested a waiver, and Hawaii is seeking public opinion on its own application before submitting the request.


The privacy and security of electronic health records used by noncovered entities is not regulated by the Health Insurance Portability and Accountability Act (HIPAA), but consumers often assume that HIPAA protects their health data everywhere it is collected and stored. The Office of the National Coordinator (ONC) for Health IT sent a report last month to Congress drawing attention to the data disparity and the need for clear guidance. ONC’s report focused on technologies managed by vendors not considered to be covered entities or business associates under HIPAA, such as mobile health apps, wearable health-tracking devices, health social media websites and other personal health records. The report highlights the gaps in policies around these entities, which are not required by law to meet certain privacy, security and access standards. "Within HIPAA, individuals have a right to access the data about themselves in a way that has meaning to them and to require said data be sent to the place they choose—that is not true for noncovered entities," says Lucia Savage, ONC chief privacy officer. ONC released the report to facilitate discussion on the issue and did not provide specific recommendations for legislation.

Medicine, Drugs and Devices

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Several biomechanical studies have compared different Krackow stitch configurations used for repairing acute Achilles tendon ruptures. However, no previous studies are believed to have compared the clinical outcomes of these different suture methods. Researchers conducted a study to compare the clinical outcomes and complications of the two-stranded single and four-stranded double Krackow techniques. Sixty-eight consecutive patients who underwent open repair by using the four-stranded double Krackow (33 patients, Group A) or the two-stranded single Krackow (35 patients, Group B) techniques between September 2011 and August 2014 were reviewed retrospectively. The isokinetic strength of plantar flexion and dorsiflexion of both ankles was assessed on a Cybex dynamometer 3 months and 6 months after surgery. Clinical outcomes were evaluated 3, 6 and 12 months postoperatively. No significant differences were found between the groups regarding patient demographics or activity levels prior to treatment. Significant differences in the Achilles tendon Total Rupture Score, the American Orthopaedic Foot and Ankle Society Ankle-Hindfoot score or the four-point Boyden scale were not found at any time during follow-up. Rerupture occurred only in one patient from group A. No significant differences were observed between the groups regarding the isokinetic plantar flexion and dorsiflexion strength at any time or any test speed. The researchers concluded that equally favorable clinical outcomes and isokinetic muscle strength with a low complication rate were achieved with the two-stranded single Krackow technique as compared with the four-stranded double Krackow technique for acute Achilles tendon rupture repair.


Researchers conducted a study to examine the usefulness of rearfoot transcutaneous oximetry in assessing peripheral arterial disease in diabetic patients with heel ulcers. Critical limb ischemia diabetic patients with below-the-knee arterial disease were grouped according to the dorsal transcutaneous oximetry value (Group A < 30 mmHg; Group B > 30 mmHg) following a percutaneous transluminal angioplasty. Group B patients had a second rearfoot oximetry performed. In Group A, a dorsal transcutaneous oximetry of 11.8 ± 0.7 mmHg was measured, and 44.2 ± 10.1 mmHg was read for Group B. Rearfoot oximetry was 20.5 ± 5 mmHg in Group B patients. The anterior tibial artery was involved in all 151 Group A patients, and the anterior tibial artery was involved in 15 out of 40 Group B patients. The posterior tibial artery alone was involved in 20 subjects and 11 cases, and the peroneal artery alone was involved in 20 subjects and 14 cases.