News From ACFAS

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The curricula vitae and position statements of candidates for the ACFAS Board of Directors are now available for review at acfas.org/nominations. The candidates recommended by the Nominating Committee are Sean Grambart, DPM (Incumbent); Paul Dayton, DPM; and Christopher Reeves, DPM. Electronic voting will start on November 29 and end December 29. Voting instructions will be emailed to all eligible voters the morning of November 29 and mailed to those without email addresses on file. Were you board-qualified by ABPS over the summer? If so, congratulations! ACFAS would like to welcome you as an Associate Member of the College. Here’s the application form you’ll need to apply for membership to ACFAS. Once you become a member, you will have the opportunity to showcase your new board status by listing the credential “AACFAS” after your name and be eligible for the many other member benefits offered by the College.

In celebration, all newly certified board-qualified applicants who apply by December 31 will be entered into a drawing to win a new iPad!

By becoming an Associate Member of the College, your benefits begin right away with:

• Complimentary membership for the remainder of 2012. Your dues payment will cover your membership from now until the end of 2013
• Waived $95 processing fee
• If you return your application by December 31, you’ll be placed in a drawing to win an Apple iPad!

Once again, congratulations. We look forward to welcoming you to ACFAS as an Associate Member. Please contact the ACFAS Membership Department at membership@acfas.org with any questions or for more information. Tomorrow is your last day to enter into a drawing to win upgrades by simply booking your hotel room for ACFAS 2013 in Las Vegas! By booking your hotel room at Mandalay Bay by November 15, 2012, you will be entered into a drawing to win an upgraded hotel stay. Try your luck by visiting acfas.org/lasvegas to make your hotel reservation today. You could be a lucky winner! Join ACFAS for a complimentary practice management webinar, Improving Your Reputation: How to Defend against Bad Online Reviews, from our benefits partner, Officite. Register now to reserve your seat and take control of how patients view your practice online by learning how to proactively monitor your online image and encourage positive reviews from patients. Also, learn how to leverage mobile technology to acquire reviews in the office, among other techniques.

These days, patients have the ability to review your practice online in a matter of minutes. Participate in this free, 45 minute webinar on Wednesday, November 28 at 8pm CST and learn how to be one step ahead in managing your practice’s reputation. The ACFAS Fellowship Committee recently met and officially recognized its latest Foot and Ankle Surgical Fellowship Program. Details about the Philadelphia Foot and Ankle Fellowship, led by Fellowship Director Justin Fleming, DPM, FACFAS, can be found at www.acfas.org/fellowshipfleming.

ACFAS strongly encourages the continuation of foot and ankle surgical education after residency in the form of a specialized fellowship, and the College supports this endeavor for programs that meet minimal requirements and strive for official recognition by the College.

For a complete listing of programs, support by ACFAS and minimal requirements, please visit the ACFAS Fellowship Initiative page on our website.

Foot and Ankle Surgery

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A study was held to better understand the mechanism of ankle ligamentous sprain injury by presenting five cases in tennis and a comparison with four previous cases. Five sets of videos displaying ankle sprain injuries in televised tennis competition with two camera views were collected. The videos were converted, synchronized and rendered to a three-dimensional animation software, and in each case the dimensions of the tennis court were acquired to construct a virtual environment. Also, a skeleton model scaled to the injured athlete's height was employed for the skeleton matching. Foot strike was visually ascertained, and the profiles of the ankle joint kinematics were presented individually. A pattern of sudden inversion and internal rotation at the ankle joint was observed, with the peak values ranging from 48 degrees to 126 degrees and 35 degrees to 99 degrees, respectively. In the sagittal plane, the ankle joint fluctuated between plantar flexion and dorsiflexion within the first 0.50 seconds following foot strike. The peak inversion velocity ranged from 509 degrees per second to 1,488 degrees per second. It was determined that internal rotation at the ankle joint could be one of the causes of ankle inversion sprain injury, with a slightly inverted ankle joint orientation at landing as the inciting mechanism.


A study was performed to test the theory that headless compression screw fixation of proximal fifth metatarsal Jones fractures is an effective therapy, particularly in competitive athletes. Sixty athletes with fifth metatarsal Jones fractures treated with a headless compression screw were studied, with an average follow-up time of 178 weeks. Assessment of clinical and radiographic results of the procedure was carried out. All the subjects resumed full activity, and the average time to start running following surgery was 6.3 weeks while the average time to full activity was 11.2 weeks. A delayed union that healed without incident was observed in one athlete, while another suffered a nonunion and received reoperation for a screw exchange to an autogenous bone graft extracted from the iliac crest. There was no reported screw breakage, and none of the athletes suffered a refracture or discomfort in the screw insertion site.


Researchers determined risk factors for periprosthetic ankle joint infection in a matched case-control study that included 26 patients with infection and two control groups, each consisting of 52 patients. The prevalence of periprosthetic ankle joint infection within the cohort was 4.7 percent. Four infections (15 percent) had a hematogenous origin and 22 (85 percent), an exogenous origin. Staphylococcus aureus was the most common pathogen, followed by coagulase-negative staphylococci. The mean duration of the index surgery was significantly longer in the case group than in the two control groups (119 versus eighty-four and ninety-three minutes, p = 0.02). After surgery, persistent wound dehiscence (OR = 15.38, 95 percent CI = 2.91 to 81.34, p = 0.01, in comparison with both control groups) and secondary wound drainage (OR = 7.00, 95 percent CI = 1.45 to 33.70, and OR = 5.31, 95 percent CI = 1.01 to 26.78, in comparison with the two control groups, p = 0.04) were associated with the development of an infection.


Researchers investigated foot pain, functional limitation, concern about appearance and difficulty with footwear in otherwise healthy adults with hallux valgus (HV) compared to controls. Thirty volunteers with HV and 30 matched controls were recruited for this study. Self-reported measures showed that HV was associated with higher levels of foot pain and disability and significant concerns about appearance and footwear (p < 0.001). Lower pressure-pain threshold was measured at the medial first metatarsophalangeal joint in participants with HV (MD = -133.3 kPa, CI: -251.5 to -15.1). Participants with HV also showed reduced hallux plantarflexion strength (MD = -37.1 N, CI: -55.4 to -18.8) and abduction strength (MD = -9.8 N, CI: -15.6 to -4.0), and increased mediolateral sway when standing on both feet with eyes closed (MD = 0.34 cm, CI: 0.04 to 0.63).

Practice Management

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Medical practices should facilitate operations documentation in order to ensure that there is a back-up plan in place should a star employee relied on for looking up specific knowledge, such as whether a particular insurance plan is accepted by the practice, is absent, for example. The practice needs to develop a dynamic spreadsheet or binder listing accepted insurances. Likewise, a staff's over-reliance on one person for knowing this information should prompt discussion with that person over what other requests they are fielding.

The manager needs to ask specific questions, and then group them together and begin devising procedures, spreadsheets or notebooks with the answers to those questions. It needs to be ensured that everyone knows where to find these answers. This guarantees that the rest of the staff will have a reference point when the star employee is away.

In addition to according a certain autonomy to staff members, this will remove a great deal of pressure and tension from the person who has all of the answers, as constant interruptions can affect that person's work production. The manager should keep this in mind when hearing staff ask the same questions repeatedly. Furthermore, this practice restores some accountability to the other employees who think it is easier asking for the answers than looking them up. This can signal that there perhaps needs to be additional training or a better general comprehension of current policies and procedures. These situations can easily be addressed through observation, listening and dissemination of that information to the appropriate resource.


Approximately 251,000 doctors and other eligible professionals have received more than $2.6 billion in payments as part of the first phase of the Centers for Medicare & Medicaid Services' (CMS) electronic health records (EHR) incentive program. The subsequent phase calls for exchanging data with others and getting patients to look at their paperless records. CMS data reveals that goals related to those two tasks were the most frequently deferred in the first phase, which required physicians to demonstrate that they could meet at least five of 10 designated menu objectives. They were allowed to defer the remaining objectives to stage 2, when the tasks would become mandatory and carry higher thresholds for compliance in some instances.

The most frequently deferred menu objective, at 84 percent, was providing a summary of care to patients as they were transitioned to other physicians or hospitals, followed by the use of the EHR to send reminders to specific groups of patients about preventive care (80 percent). Sixty-eight percent of doctors deferred syndromic surveillance, while 66 percent deferred on being able to give patients electronic access to their records. The least-deferred items were checking drug formularies (15 percent) and generating patient lists (25 percent), both of which did not involve the external transfer of data.

To comply with second phase requirements by 2014, practices will need to ensure over the next year that vendors perform necessary upgrades, improve patient engagement and get other organizations to implement systems capable of sending and receiving data to and from their EHR systems, consultants say.


Holding recurring staff meetings is critical for modern medical practices, as such meetings enable the group to communicate about the organization as a whole. Meetings held on a consistent basis are essential to the success of the practice, and there are a number of strategies that can ensure the value of such conferences. By holding the meeting on a specific day, everyone in the organization becomes committed to the practice's success. Meetings also should be obligatory, with the presence of all practice members required, with no exceptions other than planned vacations and emergencies.

Establishing an agenda guarantees that no one misses any important items from meeting to meeting. A sample agenda would include goals, the status of goals, a training topic, current issues, current successes, upcoming events and a final thought. It also is vital to take notes. Issues, questions or other matters requiring follow-up should be taken down, and most important of all is remembering to follow through. The involvement of the organizational team is crucial, so the meeting leader should hand out assignments to the team members and rotate each member to train the rest of the team on a topic.

During the course of the meeting, the leader should ask questions and get the others engaged. The involvement of staff gives them a sense of achievement and helps to improve their confidence, which makes the meetings more interesting. The leader should prepare for meetings by designating sufficient time to practice the agenda. A lack of preparation on the part of the leader causes the agenda to lose value for the rest of the organization, and the leader also should strive to come across as energetic. Encouraging discussion among members creates an opportunity for the leader to get a handle on what is going on at the practice.


The details of how higher level evaluation and management (E/M) coding has cost the Centers for Medicare & Medicaid Services (CMS) “billions” hit the pages of the New York Times, Washington Post, and Wall Street Journal in September. The attention was on a study conducted by the Center for Public Integrity, which indicated that Medicare spent $33.5 billion on E/M coding in 2010—an increase of 48 percent over 2001 levels. The study also reported that the two highest E/M codes were on about 25 percent of physician-visit claims in 2001—and 40 percent of visit claims in 2010. Several of the articles blamed the increases in levels 4 and 5 coding on the adoption of electronic health records (EHRs) in both the office and hospital settings. EHRs, the tool that CMS is paying practices to adopt, are now cited as a principle reason for the ballooning expenditures. Worse yet, the stories detail how the click of a mouse makes it easy for a physician to document that an exam was done, whether it was or not. Additionally, cloning visit notes, auto-coders, and cut-and-paste text were mentioned as contributors to the overall increase in code levels.

EHRs make it easier to document the work performed by physicians during patient encounters, but this does not mean the higher codes are inappropriate. It is entirely possible that physicians were previously undercoding their patient encounters and that EHRs have corrected this. Nevertheless, practices should pay close attention to these recent headlines and take appropriate action. The following steps will help practices reduce their risk and keep auditors of all types out of their records: implement or develop a compliance plan, review coding for ED services, conduct an internal audit, assess documentation accuracy and compliance, assess the need for additional training, assess the coding features of the EHR, watch for action by other payers, and remember that practices that are audited for over coding will be hard pressed to mount a successful defense.

Health Policy and Reimbursement

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The latest data from the Centers for Medicare & Medicaid Services (CMS) estimates that 303,072 physicians and other eligible professionals have enrolled in the federal electronic health-record (EHR) system incentive payment programs through September, while 4,057 hospitals have signed up for the Medicare EHR incentive program, the Medicaid incentive program or both. A total of $7.7 billion has so far been paid out in an anticipated $27 billion in incentive payments through the span of the two programs, and the boost in enrolling professionals signals a 7 percent increase in total enrollment in a month for the two initiatives. CMS reports that 82,535 physicians and other qualifying professionals have thus far been paid $1.4 billion in incentives under the Medicare EHR program, while 60,208 of their counterparts have received $1.2 billion under the Medicaid EHR program. Meanwhile, the two programs have made 4,211 payments totaling almost $4.9 billion to 3,044 unique hospitals, with nearly $2.6 billion paid through Medicare and roughly $2.3 billion paid through Medicaid.


A new study from the RAND Corp. published in the November issue of Health Affairs found that physicians with less than a decade of experience practicing medicine had 13.2 higher overall costs than their more seasoned colleagues, and such findings could have repercussions as health plans "profile" physicians to bring premium hikes under control. The study comes as health insurers and the Medicare health insurance program for the elderly seek ways to cut healthcare spending. Physician profiles can be used as a basis for reducing a physician's compensation, while the researchers say the report's findings could lead to the exclusion of less experienced physicians from a health plan's networks.

"This kind of cost profiling is going to be in wide use as we move forward over the next decade," says University of Pittsburgh School of Medicine Professor Ateev Mehrotra. He also notes the possibility that one factor driving healthcare costs is newly trained physicians practicing a more expensive style of medicine. However, the researchers caution that they did not assess the quality of care provided by physicians, nor did they intend to imply that less experienced physicians provided healthcare of higher quality simply because they spent more time with patients.

Medicine, Drugs and Devices

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Some healthcare providers are raising concerns about the U.S. Food and Drug Administration's (FDA) proposed unique device identifier (UDI) regulations. For example, BayCare Health System of Florida is concerned about financial burdens that hospitals could assume in terms of data collection and disclosure mandates set by the rule, specifically in electronic health record-related infrastructure and personnel costs. Meanwhile, Premier healthcare alliance said the seven-year deployment timeframe for the proposed UDI system is too long, especially since the original authorizing legislation for it was enacted five years ago. Premier advised the FDA to complete the implementation of UDI labeling and packaging mandates for all affected devices within two years. Also voiced by providers was the worry that the proposed rule would use as a device tracking tool the Global Medical Device Nomenclature, which assesses a fee. Many commentators said they favored the use of either the ECRI Institute's Universal Medical Device Nomenclature System or the United Nations Standard Products and Services Code, both of which are available at no charge.


A study was performed to assess the clinical outcomes of a newly designed ceramic prosthesis to replace the body of the talus in patients with aseptic necrosis. Twenty-two tali in 22 patients were replaced with the prosthesis between 1999 and 2006. Eight patients were treated with the first-generation prosthesis, which incorporated a peg to fix into the retained neck and head of the talus. The other 14 patients were treated with the second-generation prosthesis, which lacked the peg. The clinical results were evaluated by the AOFAS ankle/hindfoot scale. The average follow-up was 98 months. Clinical outcomes of the first-generation prostheses were excellent in three patients, good in one, fair in three and poor in one. However, radiological indications of loosening were observed, which spurred a design change. The clinical results of the second-generation prostheses were excellent in three patients, good in five, fair in four and poor in two, with more favorable radiological presentations. Four patients, representing two from each group, required revision using a total talar implant. The total talar implant is favored over the prosthesis in terms of recommended treatment for such patients.