News From ACFAS

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Almost 5,000 nurse practitioners “took a new look at foot and ankle surgeons” last week at the American Association of Nurse Practitioners’ (AANP) 2016 National Conference in San Antonio. ACFAS President Sean T. Grambart, DPM, FACFAS and staff were on hand in the College’s booth during the conference and spoke to nurse practitioners from across the country on the value of referring patients to foot and ankle surgeons. Dr. Grambart also spoke with AANP’s Orthopaedic Group Chair Michael Zychowicz, NP, on ways for AANP and ACFAS to collaborate on future referral and educational programs.

The next stop on the campaign trail for “Take a New Look at Foot and Ankle Surgeons” is at the American Association of Diabetes Educators in San Diego in August and the American Academy of Family Physicians in September in Orlando. Visit TakeANewLook.org to see more on ACFAS’ referral campaign. The College submitted official comments to the Centers for Medicare and Medicaid Services (CMS) and the Department of Health and Human Services expressing concerns about the Medicare Access and CHIP Reauthorization Act (MACRA). The College's main concern is that the regulation will have a disproportionate impact on DPMs' payment adjustment, particularly for those DPMs in solo or small practices. This, in turn, could cause DPMs to stop seeing Medicare patients, which would affect Medicare beneficiaries' ability to see highly qualified podiatrists.

According to CMS' analysis of MACRA, 78 percent of DPMs would receive a negative payment adjustment. The only other specialties that would receive a higher negative payment adjustment are chiropractors and optometrists at 98.4 percent and 79.7 percent, respectively. CMS will release a final rule sometime this fall. If a picture is worth a thousand words, then a poster highlighting your latest research results must be priceless. Submit your poster to ACFAS 75, February 27–March 2, 2017 in Las Vegas, for an opportunity to share your discoveries with foot and ankle surgeons who want to put them into practice.

ACFAS must receive all poster abstracts by September 1, 2016 for them to be eligible for review. Notification regarding acceptance of posters will be emailed by September 30, 2016. PDFs of eligible posters are due December 1, 2016. Visit acfas.org for poster format requirements and abstract submission guidelines.

Our annual poster competition attracts some of the highest viewing traffic at the conference. Send us your abstract today so you don’t miss your chance to be part of the action! New graduates, take the next step in your career development and join ACFAS—for free! Our local Regions are proud to support first-year podiatric surgical residents with a complimentary first-year membership to the College. Receive all member benefits, including special pricing on conferences, products and services, free for one year (a $118 value).

You’ll enjoy access to acfas.org, the College’s premier website, and a subscription to the online version of The Journal of Foot & Ankle Surgery (JFAS), your source for the latest surgical techniques and research.

Join now to receive an additional three months of membership, through September 2017, and access JFAS that much sooner!

Foot and Ankle Surgery

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No studies assessing the proper course of hallux valgus pain resolution currently exist. A new study aimed to evaluate pain resolution after hallux valgus surgery and to determine predictive factors associated with residual pain six months postoperatively. Researchers analyzed 308 patients at six months and two years following the operation. Thirty-one percent had some degree of residual pain at six months. After excluding four patients, researchers found that 81 percent of patients had improved visual analog scale (VAS) scores at two years postoperatively. The median VAS jumped from 4 at six months to 0 at two years. Higher VAS scores preoperatively indicated greater risk of persistent pain at six months postsurgery. A higher preoperative Mental Component Score of SF-36 reduced this risk.


It is rarely possible to complete a perfect reconstruction of the weightbearing surface of the foot, so a team of researchers recently tested an alternative method. The method involved using the anterolateral thigh flap (ALT) in reconstruction. Twenty large defects were operated on using the tactic. Follow-up ranged from eight to 48 months, and primary outcomes included two-point discrimination and protective sensation, observation of gait and the patient's ability to return to wearing normal footwear. All flaps survived with the exception of two partial skin necroses. Surgical techniques included sensory nerve coaptation, second-stage total calcaneal reconstruction with a fibula osteocutaneous flap and a split-skin paddle method. No postoperative ulceration was recorded in any of the patients. All patients indicated they were satisfied with the procedure. The ALT reconstruction method can be used in several cases involving defects of the weightbearing sole, with excellent outcomes.

Practice Management

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At the American Medical Association's annual meeting, the acting head of the Centers for Medicare and Medicaid Services (CMS) highlighted three important Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) and Merit-Based Incentive Payment System (MIPS) factors for physicians. Andy Slavitt identified three features designed to improve care quality while emphasizing a patient-centered approach to medicine. In noting these factors, he pointed out that he understands the frustration associated with the program and how many people view it as "everything wrong with the practice of medicine." The first feature he spotlighted in an attempt to allay any fears was the Quality Payment Program, which is a streamlined version of several quality reporting programs. Slavitt said it will make it easier for physicians to report while reducing requirements, eliminating duplications and reducing the number of measures. The second highlight was the reduction of Medicare payment adjustments from nine percent to four percent across the board during the first year of MACRA implementation. Finally, Slavitt discussed electronic health records (EHRs) and the limitations of certified EHR technology. He said that as long as certified EHRs prove capable, and as long as other options exist, most types of quality reporting will be simplified for most physicians.


Some HIPAA violations are obvious, but many are more subtle and can be easily missed. Here are four violations that you may be unaware your practice is currently making:

1. Do not friend me. If you dislike comments that patients have made online, do not respond. If patients post their own health information, do not interfere. If you make any kind of response, it can cause more problems. In addition, selfies taken at work can reveal even scant amounts of information, such as an employee's name. Be sure to keep social media in check at all times.
2. Curiosity and concern. Accessing patient records without a reason is a violation. Simply looking at a patient's information to find a phone number could be a violation. Do not unnecessarily view patient information unless you have a concrete medical reason.
3. First-name basis. The waiting room can be a haven for HIPAA violations. Do not ask for any information other than the name and time of arrival or time of appointment on sign-in sheets. Do not ask for patient addresses, insurance information or reason for the visit. Do not talk to patients in any formality other than first and last name. Any important discourse should be confined to your office.
4. Fancy meeting you here. Minor HIPAA violations can even occur outside the office. If an employee meets a patient at the grocery store and answers questions, it could be a violation. Keep patient privacy in mind at all times.

A recent study indicated that medical errors are the third-leading cause of death in the U.S., with more than 25,000 casualties each year. A new blog post from Karen Wolk Feinstein, CEO of the Jewish Healthcare Foundation, highlights five actions hospitals can take to reduce medical errors:

1. Be transparent and accountable. Tracking efforts to reduce errors on a monthly basis is essential. Employees should be praised for reporting errors, and management must take a leading role in identifying problem areas.
2. Reward improvement efforts and recognize success. Rewards prompt further action, and recognizing the work of employees can improve the rate at which medical errors are reported.
3. Improve education and training. Training doctors and nurses to more clearly identify instances of medical error can give hospitals a boost. All employees should be trained, especially young professionals.
4. Learn from past successes. Building on techniques that have worked previously can be a catalyst to help lead future transformations.
5. Own the problem of medical errors. Do not shy away from mistakes. Pretending like nothing is wrong will only make the situation worse. Always employ a problem-solving protocol for situations involving medical errors.

Health Policy and Reimbursement

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The Centers for Medicare and Medicaid Services (CMS) will spend $100 million over five years to offer assistance to certain Medicare clinicians who require help achieving success under the Merit-Based Incentive Payment System. The funds will go to small practices of 15 or fewer clinicians in mostly rural areas so that the transition from fee-for-service to value-based service is easier. Under CMS’ plan, there will be no cost to physicians for the services. Organizations that offer their services will help physicians go through the steps necessary to be successful, as well as provide clinical practice improvement training to improve workflows. “Providing these tools to help physicians and other clinicians in small practices navigate new programs is key to making sure they are able to focus on what is most important: the needs of their patients,” said B. Vindell Washington, principal deputy national coordinator.


The vast majority of healthcare organizations (77 percent) plan to shift IT systems to a public cloud within the next year, according to research from HyTrust. In addition, 55 percent have already transitioned mission-critical applications to the cloud. Security concerns remain the biggest barrier to cloud migration, with 65 percent of respondents noting an increased possibility of breaches. Forty-two percent said there will be more breaches, compared to just 10 percent who believe breaches will decrease. Security concerns hamper overall adoption, but the amount of organizations physically able to adopt cloud solutions remains low for other reasons. Current vendors often have few options available, and the technology itself is still in its infancy. Around 68 percent of respondents indicated these factors as reasons cloud adoption will be difficult.


A new study by the Urban Institute indicates that the United States is on course to spend $2.6 trillion less on healthcare than initially projected over a six-year period. In 2010, the United States was projected to spend $23.7 trillion on healthcare from 2014 to 2019; the projection made in 2015 for that same period was $2.6 trillion less, at $21.1 trillion. The study indicates that healthcare spending is growing more slowly, possibly due in part to reforms under the Affordable Care Act. In particular, the study points to financial penalties for high rates of hospital readmissions.

Medicine, Drugs and Devices

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Hospitals mandate glove use to prevent patient harm and promote good hygiene, but these gloves could be a major contributor to the transmission of pathogens within hospital walls. According to a new study from the American Society for Microbiology, contaminated gloves increase the cross-transmission of healthcare-associated pathogens. An additional study recently published in JAMA Internal Medicine found that nearly 50 percent of medical workers contaminated their own skin or clothes in the process of taking off gowns or gloves. These two studies reveal a troubling picture of hospital hygiene, and providers should be careful when handling gloves so that the risk of healthcare-associated infection does not rise.


The U.S. Supreme Court recently handed down a unanimous decision in Cuozzo Speed Technologies v. Lee in a ruling that could have an effect on prescription drug costs. While the case concerned a patent for a speed limit indicator, a provision in the ruling upholds inter partes review as critical consumer protection against abusive patent activity in the prescription drug market. Prior to this decision, the pharmaceutical industry was at risk of having speculators use the review system to attack drug patents. This increases the cost of drugs and in turn increases overall healthcare costs. America's Health Insurance Plans and the Generic Pharmaceutical Association estimated that without the current inter partes process, healthcare costs would rise by at least $73 billion between 2018 and 2037.


A new study published in Pain shows that patients who take opioids prior to joint replacement surgery continue to use opioids six months postoperatively. According to study leader Jenna Goesling, researchers expected that opioid use would cease after the pain from a successful joint surgery subsided. Instead, no association between changes in pain and persistent opioid use was found. This led Goesling to conclude that patients may be taking opioids for reasons other than pain following surgery. Among patients receiving a total knee arthroplasty (TKA), 53.3 percent continued to use opioids six months postoperatively. Around 34 percent of total hip arthroplasty (THA) patients reported similar results. Among patients who were opioid-naïve prior to the procedure, 8.2 percent of patients who underwent TKA and 4.3 percent of patients who underwent THA used opioids at six months postoperatively.