News From ACFAS

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Help shape the advancement of the profession and the future of the College by volunteering to serve on one of the 11 College committees for 2015-2016. Committee volunteers bring the ACFAS strategic plan to life by taking responsibility for certain tactics outlined in the plan. If you are a leader, a thinker and a dedicated worker and would like to apply to be a volunteer, please visit acfas.org/volunteer for the ACFAS Volunteer Requirements and to complete the 2015 Volunteer Application. The deadline for applications is November 14, 2014. Get a head start on learning at ACFAS 2015 in Phoenix by registering for our comprehensive pre-conference workshops scheduled for Wednesday, February 18 in Phoenix. ACFAS’ three workshops are designed to help you master your surgical technique and gain the skills needed to successfully manage your practice:

• Perfecting Your Practice: Coding/Practice Management Workshop
  (Full-Day)
• Diabetic Deformity: Master Techniques in Reconstruction
  (1/2 Day, Cadaveric)
• Master Surgical Techniques: Fine-Tuning with the Experts
  (1/2 Day, Cadaveric)

Space is limited, so reserve your spot today at acfas.org/phoenix. The Centers for Medicare & Medicaid Services (CMS) is hosting a National Provider Call on Wednesday, November 5, 2014 at 1pm (ET). During the call, CMS subject matter experts will discuss ICD-10 implementation issues, opportunities for testing and resources. A question and answer session will follow the presentation.

All physicians and their office staff are encouraged to participate to help with the transition to ICD-10, which has a compliance deadline of October 1, 2015.

For more information or to register for the free call, visit the CMS website. Correct use of modifiers is key to ensuring you receive appropriate payment for the services you provide. Make sure you’re maximizing your payments and register yourself and your office staff for the ACFAS webinar, Understanding Modifiers: Including the New Subsets for Modifier -59, set for Wednesday, November 12, 2014, from 7:30–8:30pm (CST).

Listen as presenter Jacqueline Reiss-Kravitz, CPC outlines the four new Healthcare Common Procedure Coding System modifiers that define subsets of Modifier -59 for Distinct Procedural Service, which are set to take effect January 1, 2015. Hear also the correct use of all Current Procedural Terminology modifiers for foot and ankle procedures and how to properly bill services to third-party payers, Medicare and Medicaid.

To register, visit acfas.org/practicemanagement. Has your practice changed its address, phone number or added a website? Did you change your home address? If so, don’t forget to update your ACFAS member profile by logging into your ACFAS account at acfas.org/profile.

While you’re in your member profile, be sure to:

• Update any email addresses you use (work or personal) as well as your fax number and your work, home or cell number.
• Confirm you’re receiving your Journal of Foot & Ankle Surgery and other valuable ACFAS publications at your preferred address.
• Make your contact information available to your colleagues through the College’s online membership directory by clicking “Yes” to the Members-Only Directory.
• Include yourself in the “Find an ACFAS Physician” search tool on FootHealthFacts.org. Just click “Yes” for “Consumer Physician Search.”

Throughout the year, be sure to let the College know about any appropriate updates so you can keep yourself available to peers, potential patients and ACFAS!

Foot and Ankle Surgery

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A recent study examined the functional and magnetic resonance imaging (MRI) outcomes in patients who underwent arthroscopic microfracture to treat osteochondral lesions of the distal tibial plafond, which are not as common as talar lesions. The procedure was performed on 31 ankles. After following up with patients after an average of 44 months, the study's authors found that arthroscopic microfracture brought about functional improvements. For example, significant improvements were seen in the Foot and Ankle Outcome Score (FAOS) and the Short Form-12 (SF-12) general health questionnaire. However, older patients had worse functional outcomes compared to their younger counterparts. MRI outcomes, which were assessed using the Magnetic Resonance Observation of Cartilage Repair Tissue (MOCART) score, also deteriorated with age and were negatively affected by larger lesion size. The study's authors concluded that even though arthroscopic microfracture brought about improvements in patients with osteochondral lesions of the distal tibial plafond, this procedure may not be the best treatment for this condition. In fact, the study's authors said they were uncertain what the best treatment option may be.


Juvenile idiopathic clubfoot patients who were treated at a dedicated Ponseti clinic run by a well-trained multidisciplinary team experienced better outcomes after five years than did their counterparts who were treated at a general pediatric orthopaedic clinic, a new study has found. For example, children treated at the dedicated Ponseti clinic had a lower rate of recurrent deformities and a lower rate of surgical release than those treated in a general pediatric orthopaedic clinic. Out of 100 feet treated at a general clinic, recurrent deformity occurred in 38. Sixteen of those feet required treatment using extensive surgical release, while the other 22 were treated with repeat casting and/or tenotomy and/or transfer of the tibialis anterior tendon. Of the 72 treated at the Ponseti clinic, 14 developed recurrent deformity. Only three of these feet required treatment with extensive surgical release. Treatment on the other 11 feet was performed using repeat casting and/or tenotomy and/or transfer of the tibialis anterior tendon.

Practice Management

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Meryl Luallin, a consultant who works for a company that helps physicians' practices develop strategies for assessing and improving patient satisfaction scores and maintaining service quality programs, says doctors should be aware of new regulations that will take effect in the next several years that cover the use of patient satisfaction surveys. Beginning in 2017, practices will be required to administer Consumer Assessment of Healthcare Providers and Systems — Clinician & Group Surveys (CG-CAHPS) to their patients and to report the results to the Centers for Medicare and Medicaid Services (CMS). This requirement is part of CMS' effort to move away from the fee-for-service payment model and toward a new value-based reimbursement program. Luallin says her recommendations for how practices can ensure they get the best scores possible on these surveys can be summarized in the acronym CLEAR, which stands for connect, listen, explain, ask and reconnect. Luallin elaborated on the ask component of the strategy, saying that doctors need to ask patients whether they have answered all of their questions regarding the care they provide. Luallin also notes that physicians' practices should ensure their receptionists demonstrate a willingness to help patients and that providers show they are willing to listen carefully to patients. Patients are questioned about these things on surveys, Luallin says, and their answers to these questions affect their overall satisfaction with the practice and their willingness to recommend the practice to others.


A study published in the Journal of the American Medical Association on Oct. 21 is calling into question the commonly held belief that hospital acquisitions of physicians' practices can help drive down healthcare costs. Researchers examined total medical spending for roughly 4.5 million health maintenance organization (HMO) patients in California between 2009 and 2012 and found that total spending per patient was 10.3 percent higher for hospital-owned practices than it was for practices owned by doctors. The study also found that per-patient spending at large hospital systems was 19.8 percent higher than it was at physician-owned practices. Lead author James Robinson, a professor of health economics at the University of California, Berkeley, explained the results by saying hospital acquisitions of physicians' practices give hospitals more leverage to raise prices. In addition, doctors who were previously independent but now work for hospital systems feel pressured to refer patients who need imaging and other outpatient treatments to the hospitals they work for rather than free-standing clinics that may offer these services at lower prices. Despite the results of the study, the California Hospital Association says it continues to believe that hospital acquisitions of physicians' practices can help align financial incentives among providers and deliver care more efficiently.


Physicians' practice managers should take immediate steps to deal with employees whose performance is not up to snuff since failing to do so can result in serious negative consequences such as driving away good employees, says Drew Stevens, who writes extensively on healthcare practice strategy. Addressing the problem of poorly performing employees includes using formal write-ups that document the type of problem and when it occurred. Practice managers may also want to have one-on-one conversations with problem employees to identify the reasons why their work may not be up to standards, whether it be a personal problem, conflict with colleagues or inadequate training. Practice managers should also use these meetings, which Stevens says should be held in neutral locations, to explain what the employee needs to do differently to improve his or her performance. The employee should leave the meeting understanding that the problem must be corrected immediately, Stevens says. Finally, Stevens recommends that managers develop a performance improvement plan that includes a deadline for when the employee's performance must show improvement. Failure to meet that deadline, Stevens says, should be met with appropriate consequences.

Health Policy and Reimbursement

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The American Medical Association (AMA) is lauding the Obama administration's recent announcement that it will spend $840 million over the next four years to help physicians' practices transition to business models that reward them for achieving good patient outcomes, instead of those that encourage them to see large numbers of patients. The funding, which will be provided through the Department of Health and Human Services' (HHS) Transforming Clinical Practice Initiative, will be given to networks of group practices and health systems that share their knowledge about topics, such as how to reduce hospital admissions, with other practices. Networks formed by medical associations that share information about practices and policies to help improve patient outcomes will receive funding as well. The goal of these efforts is to improve coordination between specialists and primary care doctors in caring for patients, to encourage the broader use of electronic health records, to give physicians better access to patient information and to give patients more options for communicating with their doctors. HHS believes the program will help prevent 5 million unnecessary hospital admissions over the next four years while reducing healthcare costs by $1 billion or more. AMA board of trustees Chair Dr. Barbara McAneny says her organization believes the new payment and delivery models physicians' practices will adopt as a result of the program will "lead to improvements in the quality of care for patients, control healthcare costs and enhance practice sustainability."


A new study from RAND Corp. has found that medical malpractice reforms enacted 10 years ago in three states may not have reduced the use of defensive medicine. Researchers examined data from a random sample of Medicare beneficiaries who made fee-for-service visits to emergency room departments in the three states--Texas, Georgia and South Carolina--and examined the use of computed tomography (CT) and magnetic resonance imaging (MRI) scans, in-patient numbers after emergency department visits and total charges per visit. These metrics were then compared with those for similar patients in neighboring states in the periods before the reforms were made and after. Researchers found no reduction in the rates of CT and MRI utilization following the reforms in any of the three states, while Texas and South Carolina experienced no reduction in charges as a result of the reforms. Georgia experienced a 3.6 percent reduction in per-visit emergency department charges as a result of the reforms, the study found. In a separate interview, study co-author Daniel A. Waxman, MD, said some of the care seen in the study could be considered defensive medicine, although some of it may have been provided to avoid medical mistakes rather than out of a desire to guard against lawsuits.


On Oct. 17, the Centers for Medicare and Medicaid Services (CMS) changed its Open Payments website to allow consumers and others to more easily search for payments made by drug and medical devicemakers to doctors and teaching hospitals. The new search tool, which was introduced in beta form, allows users to search for payments by entering a physician's name, location or specialty. The names of teaching hospitals and companies can also be entered to find payments. In addition, the search tool allows users to sort payments in ascending and descending order and to group them by three categories: general payments, research payments and ownership in companies. General payments can be further broken down into their type, such as food and beverage, education and consulting. The tool is seen as an improvement over the search boxes that were included in spreadsheets containing payment information. However, CMS still has not corrected all of the erroneous payment information contained in the Open Payments website. The agency says it plans to do so before the end of the year.

Medicine, Drugs and Devices

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Injection with a stromal vascular fraction (SVF) containing mesenchymal stem cells (MSCs) along with marrow stimulation may be a better treatment option for patients with osteochondral lesions of the talus (OLTs) than marrow stimulation alone, the use of which is controversial in OLT patients with poor prognostic factors, a new study has found. The study involved 50 ankles with OLTs, 26 of which were treated with marrow stimulation alone (conventional group) while the other 24 were treated with SVF injection containing MSCs (MSC group) as well as marrow stimulation. Patients in the MSC group displayed significant improvements in all clinical outcomes, including the visual analog scale (VAS) for pain, the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Scale and the Tegner activity scale, compared to patients who were treated with marrow stimulation alone. In addition, the presence of poor prognostic factors, such as patient age of 46.1 years or higher, lesions 151.2 mm2 in size or larger and subchondral cysts, were associated with a worse magnetic resonance observation of cartilage repair tissue (MOCART) score in the conventional group but not in the MSC group. The study concluded that an SVF containing MSCs should be considered as a treatment for OLTs even when these poor prognostic factors are present.


A retrospective analysis has found that canakinumab (CAN) is more effective than triamcinolone acetonide (TA) at treating gouty arthritis (GA) patients who have contraindications for or are unresponsive to or intolerant of non-steroidal anti-inflammatory drugs (NSAIDs) or colchicine. Researchers reviewed two studies that collected patient reported outcomes (PRO) and calculated a common response end-point (CRE) score to quantify overall response to treatment. CREs were based on overall changes in GA-related health outcomes from baseline to 12 weeks, including clinical markers, PROs from the Gout Impact Scale (GIS) and the Short Form-36 bodily pain scale. For each outcome measure, a 1 was added to the total score if the patient was deemed to have responded in that variable. Researchers found that the percentage of CAN responders was significantly higher than the percentage of TA responders in eight of the 12 variables examined. In addition, patients treated with CAN met an average of 65 percent of response criteria, compared to an average of 49 percent of the criteria in patients given TA. The average CRE score for CAN patients was 4.7, compared to an average score of 3.7 in the TA patients, a significant difference. Researchers concluded that the treatment differences between CAN and TA were robust, given that these differences remained even after serially removing individual responder variables and domains from the composite end-point.