News From ACFAS

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Our education committees are actively seeking new instructors and faculty members to meet the needs and high standards of our surgical skills courses, regional programs, enduring education materials, e-Learning offerings and Annual Scientific Conference. Sharing your experience and expertise with your colleagues not only helps perpetuate the profession, it helps us provide best-quality educational opportunities that challenge and inspire.

If you are an active Fellow member and have attended our educational programs within the past three years, complete an Education Program Faculty Application for consideration and fax it to the ACFAS Education Department at (800) 382-8270 or email it to Mary Meyers, ACFAS director of Education Curriculum and Alliances.
In February 2016, the Centers for Medicare and Medicaid Services (CMS) finalized its 60-day repayment rule, which states you have 60 days to pay back CMS for an overpayment.

Overpayment means you have received a payment in excess of amounts properly payable under Medicare statutes and regulations. The clock begins ticking once an overpayment is identified and quantified. According to CMS, an overpayment is identified when you determine, through the exercise of reasonable diligence, that you have received an overpayment and quantify its amount. You then have 60 days to refund CMS for overpayments dating back six years. Note that this may open you up to additional liability under the False Claims Act.

Direct questions to your Medicare administrative contractor or to Sarah Nichelson, ACFAS director of Health Policy, Practice Management and Research.
They say that in tumultuous times, you should focus on those who are helping to make a positive difference in the world. ACFAS, in honor of National Volunteer Week, thanks you, our many volunteer members, for giving your time and expertise to the profession and for upholding the College’s mission.

You bring passion and light to everything you do for the College, and you are the reason why ACFAS has existed for nearly 75 years. Thank you for your continued commitment, dedication and service to your colleagues and patients!

Foot and Ankle Surgery

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Multiple factors can lead to nonunion following revision arthrodesis in the foot and ankle. Depending on certain factors, current literature pegs nonunion rates for these procedures between zero and 47 percent. To determine the clinical and operative factors related to successful revision arthrodesis, researchers reviewed the case logs of three foot and ankle surgeons. Successful revision was defined as radiographic union on the final radiograph during follow-up. Out of 82 identified cases, 23 percent had nonunion. Neuropathy and prior attempts at revision were identified as significant risks for persistent nonunion. Researchers said it is important to identify neuropathy as a possible risk even in patients without diabetes. In addition, while initial revisions were successful 77 percent of the time, a three-fold increase in persistent nonunion occurred with each additional attempt at revision.


A recent study was conducted to determine the differences in early weightbearing and range of motion (ROM), compared with non-weightbearing and immobilization in a cast, in patients who underwent a procedure for an unstable ankle fracture. The study analyzed 110 patients who underwent open reduction and internal fixation. The main outcome measure was time to return to work (RTW). Patients were divided into two groups: early weightbearing (at two weeks) and late weightbearing (at six weeks). There was no difference in RTW postoperatively. The early group showed significantly improved ROM (41 degrees vs 29 degrees), as well as better Olerud/Molander ankle function scores (42 vs 30) and physical and mental SF-36 scores (51 vs 42 and 66 vs 54, respectively). There were no differences in wound complications or infections. Researchers recommended early postoperative weightbearing and ROM.

Practice Management

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Last week's cyberattack on Washington, D.C.'s MedStar Health garnered plenty of headlines, but it is far from the first hospital to experience such a fate. Hackers are targeting the healthcare industry more than ever due to the high value of sensitive health information, and the breaches will likely continue. According to experts, one reason these hacks continue to land blows is that cybersecurity within the healthcare industry is lagging behind that of other industries. If you steal a credit card, someone will notice very quickly, and the hacker's window of opportunity rapidly closes. But healthcare data is "pervasive through an individual's life," according to Kelsey Farbotko, an attorney with Williams Mullen. This makes it easier to target. The U.S. Department of Health and Human Services has regulations that healthcare companies must follow to keep patient information safe under HIPAA, but these regulations are difficult to follow. In addition, human error is nearly impossible to guard against. Fortunately, some companies are trying to develop technologies that could mitigate various healthcare data insecurities. One company, for example, is developing a platform that uses blockchain technology so that a data log cannot be changed, deleted, transposed or forged.


The Merit-Based Incentive Payment System (MIPS) could have many unintended consequences that physicians may not be aware of. Here are four possible consequences:

1. Physician practice consolidation and acquisitions will continue. Being able to perform well under MACRA will be difficult for private practices. It will require a lot of resources that many doctors simply do not have. Since there appears to be a trend toward outcome measures, this will result in more collaboration and integrated delivery systems. To fulfill all of these requirements, consolidations and acquisitions will continue.
2. Understanding the relationship between Medicare Parts A and B will become more complicated. It will be very important to figure out how performance under Medicare Part B will affect reimbursement under Medicare Part A. Many organizations may struggle to figure out how the two relate, especially because sophisticated analytics likely must be done to determine the difference.
3. Physician compensation and service agreements will need to evolve. Practices will need to plan more efficiently and to examine their care processes in light of MIPS's focus on outcome-oriented measures. This includes areas such as discharge planning, care coordination and making clinical data available across various settings.
4. Commercial contracts will need to be amended. The language of certain contracts will change and must be decoded to completely understand. If, for example, Blue Cross pays you 150 percent of Medicare, it will be up to you to determine all of the details involved, including timeframe and reimbursements.

Offering a highly individualized patient experience can increase revenue by 16 percent, according to new research from Oracle. The report said health organizations can use tools to promote patient self-service from a variety of devices. Oracle found that the top opportunities to individualize services are 1) giving providers point-of-care data to influence interventions; 2) providing patients feedback to inform chronic condition treatment regimens; and 3) enabling precision medicine tactics by running analytics. Unfortunately, the obstacles in the way of implementing these strategies include budget constraints, regulatory frameworks, information security, an inability to analyze information and a lack of interoperability. In addition, 93 percent of respondents in Oracle's survey admitted they believe they are leaving money on the table by not implementing more flexible operations.

Health Policy and Reimbursement

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The Merit-Based Incentive Payment System (MIPS) will revamp Medicare's fee-for-service payment system. Medicare professionals need not get too concerned. Those who receive a certain part of their revenue through alternative payment models (APMs) are exempt from MIPS requirements. These include accountable care organizations, episode-based payments and patient-centered medical homes. The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) will make these designations somewhat difficult to follow, but clearing up APMs is a stated priority. MACRA is also geared toward encouraging providers to participate in APMs, which can result in initial bonus payments. During the first five years of implementation (2019-2024), qualifying participants are encouraged to participate in APMs through a 5 percent annual “bonus” if they receive a “significant share” of revenue through eligible APMs. The physician community has raised its collective voice as the MIPS regulations have been put in place, and many are interested in participating in APMs. Many still have concerns, though, particularly the potential for MACRA APMs to hold them accountable for costs outside their control. Finding a balance between innovation in cost control and quality improvement while creating a space for provider participation and success remains a large task.


The U.S. Centers for Medicare and Medicaid Services have launched a program to slash costs for joint replacement surgeries. The 800-hospital program places the financial responsibility for joint replacement success in the hands of the individual hospital, up to 90 days post-discharge. Where old models provided a fee-for-service setup, this new program will give each hospital a single payment to perform the surgery. Medicare spends about $7 billion a year on joint replacement, and many facilities are not well-equipped to perform the surgery. The new model serves to cut costs, mortality rates and the rate of complications to support both industry financial health and patient health. It is unclear how the program will address the large increase in joint replacement surgeries, which have increased by 50 percent in less than a decade.


The cloud and big data are set to revolutionize patient data access, according to Karen DeSalvo, the U.S. Department of Health and Human Services’ (HHS) acting assistant secretary. DeSalvo's goal is to oversee a system where health data is focused on people, not records. This approach could help stymie for-profit "blocking" of patient data. She wants to usher in payment reform, crafting a incentive package to spur the movement of data and data systems connections. Then, a more interoperable system would be installed to allow technology to speak the same "language." The next problem to fix is the "blocking" issue. DeSalvo said in an interview that as of February, many major vendors have agreed not to block data. These vendors supply electronic health records for 90 percent of inpatient beds, and the move is essential because it was not considered possible a year ago. DeSalvo is also overseeing a shift to cloud-based data and more secure data connections in the name of patients around the country. The healthcare sector still has much to do to catch up with other industries, she said, but the correct steps are being taken to revolutionize data access.


Federal investigators have found critical cybersecurity vulnerabilities in the health insurance websites of three states that would allow hackers to access sensitive personal information. The sites for California, Kentucky and Vermont were cited as having flaws that are not yet fixed and pose a dangerous threat to hundreds of thousands of people. The Government Accountability Office (GAO) also noted that if the vulnerabilities were any indication, other state-run health insurance sites are almost certainly compromised as well. In its report, GAO said one state did not encrypt passwords, another did not properly use a filter to block hostile attempts to visit the site and one did not use proper encryption on its servers, making it easier for hackers to get in.

Medicine, Drugs and Devices

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Sen. Lamar Alexander said the 21st Century Cures Act could reach the Senate floor soon. The bill intends to speed up the U.S. Food and Drug Administration's approval of new drugs and devices while boosting funding for medical research. Negotiators are still working out the details and the bill is already months behind schedule, but the Health, Education, Labor and Pensions Committee will have its last series of markups and will decide on the bill's future. The National Institutes of Health funding could be set at around $9 billion over five years, although not all legislators are on board with the mandatory funding. Alexander has said he wants to simply put the bill on the floor and give it a vote as a way of settling these disputes.


Independent cybersecurity researchers Mike Ahmadi and Billy Rios identified multiple security vulnerabilities in several medical devices and are now calling on the U.S. Food and Drug Administration (FDA) to act. The researchers claimed FDA needs to "buckle down" and regulate medical device cybersecurity more seriously. The warning came amid an announcement from the Department of Homeland Security revealing that more than 1,400 cybersecurity vulnerabilities can affect certain versions of an automated supply cabinet used in hospitals and other health facilities to dispense medical supplies. "What will you do when all of a sudden you're hit with 1,400 vulnerabilities for one product?" Ahmadi asked. One of the biggest issues is vulnerability disclosure. When working with a vulnerability detection tool called AppCheck, he and Rios discovered that device manufacturers are reluctant to discuss vulnerabilities with researchers. When Ahmadi and Rios reported vulnerabilities to the manufacturer of the Pyxis Supply Station, though, they were surprised by the company's compliance. It signaled to them a positive step in the right direction for vulnerability disclosure. Ahmadi ultimately believes that FDA should require manufacturers to actively participate in fixing vulnerabilities.


A new report from the planning board for a national medical device evaluation system (NMDES) details how the U.S. can implement a coordinated network of partners to improve evidence on the safety and effectiveness of medical devices. The report discusses establishing a framework by partnering with the U.S. Food and Drug Administration and other public agencies, patient communities, provider systems, medical device manufacturers, academic institutions, health payers and others. NMDES could develop into a network of these voluntary partners to generate higher-quality data at lower costs while developing and improving resources and device safety updates. The first demonstration projects might include improving and expanding an existing medical device registry by linking with other data sources and data types or by creating a new virtual registry using electronic health records and claims data on a higher-risk device with potentially serious but rare adverse events.