News From ACFAS

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A proposed local carrier determination (LCD) issued by the Durable Medical Equipment Medicare Administrative Contractors (DME MAC) limiting DPMs’ ability to prescribe pneumatic compression devices/therapy (PCDs) had its day in the sun Tuesday, as over 12 stakeholder groups and individuals provided comments at the DME MAC hearing. ACFAS and its members are gravely concerned about attempts to limit DPMs’ scope of practice and testified Aug. 30 in support of allowing DPMs to prescribe PCDs. Many other stakeholders’ testimonies supported the ACFAS comments, and those included manufacturers, legal experts, suppliers and allopathic physicians, all of whom supported DPMs’ prescribing. One group specifically noted the importance of this and agreed with ACFAS that DPMs are key to the healthcare team, in this case to deliver wound care. There was no testimony presented that supported limiting DPMs’ prescribing authority for PCDs, and there was no evidence given to support this recommendation either.

The proposed regulation states: “Prescriptions for PCDs used to treat lymphedema or chronic venous insufficiency with ulceration (E0650-E0652) are limited to MDs, DOs, NPs, CNSs and PAs enrolled in Medicare and authorized by Medicare to prescribe as physicians. Podiatrists and other providers are excluded from the regulations because management of the systemic intravascular changes and fluid shifts that may be caused by the use of a PCD is beyond their scope of practice.”

ACFAS stressed that it is within the DPM’s scope of practice to treat lymphedema or chronic venous insufficiency with ulceration (E0650-E0652). Noting that DPMs are recognized by Medicare as physicians, ACFAS stated that a properly conducted review comparing the training, education, and experience of DPMs to NPs, CNSs and PAs would clearly confirm that prescribing these PCDs for lymphedema or chronic venous insufficiency with ulceration by DPMs is appropriate and permissible. Visit acfas.org/hpa for a complete copy of the comments ACFAS plans to submit to CMS. Have you ever been an expert witness, or are you thinking of it in the future? Are you committed to the highest degree of professional ethics? The ACFAS Expert Witness Testimony standards were developed to aid members who may testify as expert medical witnesses in court proceedings. Over 1,000 members have signed and returned the Expert Witness Affirmation Statement to the ACFAS office to reinforce their personal commitment to these standards. You should too! For more information and to complete the statement, visit the ACFAS website. Visit the Journal of Foot & Ankle Surgery online today to check out the latest new feature — video add-ons. The September 2011 issue offers two: one from Rigby et al. illustrating the need for axial loading cross screw fixation for the Austin bunionectomy; the second from Saxena et al. showing the use of an anti-gravity treadmill in post-op rehabilitation of the Achilles tendon. You can also listen in to two new audio add-ons as the editor and authors discuss some of the more complex points of research on surgical resident workload, and on post-treatment leukocytosis in patients with diabetic foot infections.

Use your free member access to be one of the first to utilize these concise online enhancements, and 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 when prompted with your ACFAS member information.

Check back often for more new content at the online home of JFAS!

Futurescan™

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Healthcare, especially healthcare financing, is changing day by day. To help provide some basic education on current trends in the U.S. healthcare industry, ACFAS is sharing abstracted articles from the American Hospital Association's publication, Futurescan™ 2011: Healthcare Trends and Implications 2011–2016, in this special eight-week section.

Medicare, Medicaid, and private payers are expected to undergo major payment changes over the next five years under the Patient Protection and Affordable Care Act, writes Paul B. Ginsburg, president of the Center for Studying Health System Change. The law grants the secretary of Health and Human Services the authority to devise and deploy new payment techniques, such as shared savings arrangements with accountable care organizations, and to pilot other methods such as bundled payment.

An important unknown element is whether provider leverage with private payers will climb, stay flat, or shrink, and Ginsburg thinks that "hospital leverage will remain strong for some time, until enough insured people are either in narrow-network plans ... or in plans with tiered designs that give patients incentives to choose hospitals on the basis of value." He notes that "continued weakness in the economy could accelerate the development of such plans, and more sophisticated Medicare tools to measure quality and efficiency will make them an easier sell." Ginsburg anticipates a significant ramp-up in the expansion of network and tiered health plans around 2018, when the "Cadillac tax" on high-cost health plans in the Affordable Care Act is enacted, among other things.

Foot and Ankle Surgery

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Researchers assessed whether the central incision technique would be an effective, well-tolerated surgical incision for the surgical treatment of insertional Achilles tendinopathy with minimal to no loss of plantarflexion strength. A review was made of a single surgeon’s experience with 27 patients (29 surgical procedures). The mean followup time was four years. An additional telephone assessment was performed at a mean followup time of seven years. The average recovery time was 5.7 months. There was no significant difference in plantarflexion strength between the operative and nonoperative sides. At the four-year mark, 15 patients had an AOFAS hindfoot score of 100; the average AOFAS hindfoot score was 96. At seven years, 22 patients (including two bilateral cases) reported pain scores of 0 and they had no strength deficits. Overall, there was a 96 percent (22 of 23) satisfaction rate.


Researchers assessed the safety, efficacy and effectiveness of growth factors alone or in combination with other technologies in the treatment of diabetic foot ulcers by systematically searching relevant data bases limited to English and German language and publications since 1990. Twenty-five studies were identified, comparing becaplermin, rhEGF, bFGF and the metabolically active skin grafts Dermagraft and Apligraf with standard wound care (SWC) alone or extracellular wound matrix. Treatment with becaplermin, rhEGF, Dermagraft and Apligraf resulted in a higher incidence of complete wound closure and shorter time to complete wound healing with statistically significant differences. There was no difference in the proportion of adverse events between treatment groups. Economic evaluations showed becaplermin to be cost-effective.


A retrospective study was conducted to assess the effectiveness of intramedullarly nailing and blocking screws for distal tibial fractures. The research involved 21 patients in whom adequate reduction could not be accomplished with distal tibial intramedullary nailing alone. Eighteen patients had blocking screws inserted from the medial side, one patient had the screws inserted in the medial and anterior side, and two patients underwent insertion in the posterior side. All patients achieved neutral alignment with union in both coronal and sagittal plane, and no infections were observed. The sole complication of the blocking screws was fissure in a single patient at the site of the screw during surgery, while nonunion developed with 8 degree flexion angle in another patient. Union was reached in this patient at nine months with autologous bone grafting.

Practice Management

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A typical practice setting brings together a variety of expertise and personalities. When they work in unison, it can result in a thriving healthcare delivery business, but occasional discord can be costly. In order to harmonize a practice, it is important to identify any misconceptions employees may have about the worth of their roles. Talking with the individuals involved is an important first step, before calling a group meeting to discuss problematic issues. If disagreements that become a recurring dispute, help from a consultant may be needed. Another resource are human resource tools administered internally, such as Bloomington Hospital's use of the Predictive Index, a simple questionnaire that provides insight into a person's workplace behaviors and motivations. Hiring also plays an important role. When a practice sees frequent turnover resulting from staff disruptions, reactive hiring procedures and policies may be the cause.


The economic downturn is in many instances dashing physicians' retirement hopes, according to a Jackson & Coker survey of 522 doctors issued Aug. 2. More than half of the respondents had revised their retirement plans since the 2007-2009 recession; some 70 percent of that group said they will work longer until retirement because personal savings had been eviscerated or had not grown as rapidly as expected. Still, some physicians said they were exiting medicine earlier than intended, including moving to part-time positions, partly on account of economic changes in practice life, such as uncertainties surrounding health system reform, an erosion of pleasure from work, and the rising cost of doing business.


AltaMed Health Services of Los Angeles is the first organization in the country to earn the new Primary Care Medical Home (PCMH) designation for Joint Commission accredited ambulatory care organizations. The PCMH option, which was launched in July 2011, focuses on how effectively the primary care clinician and the interdisciplinary team work in partnership with the patient. It complements the Ambulatory Care Accreditation Program.

Health Policy and Reimbursement

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The Centers for Medicare and Medicaid Services (CMS) is launching a program that would bundle insurance payments for multiple procedures in an attempt to improve patient care while also boosting cost efficiency. The purpose of the program is to spur hospitals, doctors, and other specialists to coordinate in treating a patient's specific ailment during a single hospital stay and recovery. CMS has invited providers to help design four payment bundling models that grant providers flexibility on how they get paid and for which services, as well as provide incentives to avoid needless or duplicative procedures.


The vast majority of physicians in the United States will face a malpractice claim during their career, according research published in the August 18 issue of the New England Journal of Medicine. The researchers analyzed malpractice data over a 14-year period for all physicians covered by a large malpractice insurance provider. They estimated more than 75 percent of doctors in specialties with a low risk of malpractice and 99 percent of doctors in high-risk practices will be sued. The study also found that while the risk of a malpractice claim is high, about 80 percent of claims never result in any payment to plaintiffs.

Medicine, Drugs and Devices

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The National Institutes of Health has released a final rule on financial conflicts of interest. The new rule lowers the minimum threshold for what investigators must disclose from $10,000 to $5,000, and increases the types of interest that must be disclosed, but at the same time softens a public reporting requirement from the proposed version to allow the option of written responses instead of maintaining a website. The final rule can be found here.


AstraZeneca has started to disclose payments and other “transfers of value” made to physicians and healthcare organizations in the United States through a searchable database. The pharmaceutical company is disclosing consulting and speaker fees, meals and travel, educational items, pre-clinical or clinical research payments, royalties, license fees, and ownership or investments interests. Also listed will be payments paid to physicians through third parties and payments made to medical and research institutions, hospitals, clinics and group practices. Rival Eli Lilly launched a physician payment registry in July.


A list of 56 common medical tests and procedures and the price associated with each could change how doctors deliver care at Beth Israel Deaconess Medical Center in Boston. Many doctors have no idea what patients are spending on prescribed treatments. Neel Shah, who directs costsofcare.org, which aims to help doctors understand how their decisions affect what patients pay for care, says considering costs and deciding what is worth the money is not part of most medical school programs. Some doctors say considering the cost of care is unethical, but Shah says such a belief is fading as doctors increasingly realize that medical bills are the leading cause of personal bankruptcy.