News From ACFAS

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Get one step closer to ACFAS 2018 in Nashville—book your hotel room now with onPeak, the College’s official housing partner. Rooms at the Gaylord Opryland Hotel, the official conference hotel and a Marriott Rewards partner, are $229 per night.

Making your accommodations with onPeak in our hotel block ensures you receive the best rate and also protects you from poachers or unauthorized third parties claiming to be our housing partner. Rooms are first come/first serve, so head to acfas.org/nashville now to get your top pick! Register now for the new advanced Surgical Skills course, The Athlete’s Foot and Ankle: New Trends, Management and Surgical Treatments, October 8–9 in Chicago, and learn how to confidently treat athletes of all ages and fitness levels.

Two one-day tracks combine panel and cased-based discussions with cadaveric lab time to help you evaluate sports injuries and indications for surgery. Sunday evening includes dinner and a fireside chat during which you can share radiographs of your cases with your colleagues and faculty.

The 2018 dates for Surgical Skills courses will be available in the next two months. Visit acfas.org/skills for updates and to register. Proper reimbursement for the care you provide should not be complicated. Sign up for Coding and Billing for the Foot and Ankle Surgeon, October 13–14 in Phoenix, and gain real-world strategies for simplifying your coding and billing processes.

Expert faculty will use case-based and interactive procedures to show you how to code and bill for:

• multiple-procedure cases when performing forefoot, rearfoot or ankle reconstructive surgery
• open reduction and internal fixation of multiple fractures
• complex arthroscopy cases
• diabetic foot surgery

Code actual patient scenarios alongside your colleagues then apply your skills back at the office using customized checklists, handouts and forms you'll receive as an attendee.

Don’t miss this last Coding and Billing seminar of 2017—register today at acfas.org/practicemanagement. The ACFAS Fellowship Committee recently granted approved status to the following fellowship program. The program was granted Conditional Status with ACFAS since they have not yet had a fellow matriculate through:

Foot and Ankle Fellowship of the Orthopaedic Institute of Central Jersey, Wall Township, New Jersey
Program Director: Shane Hollawell, DPM, FACFAS
acfas.org/fellowshiphollawell

All Conditional Status programs are considered for Recognized Status with ACFAS after they have received status and the first fellow completes the program.

ACFAS highly recommends taking on a specialized fellowship for the continuation of foot and ankle surgical education after residency. If you are considering a fellowship, visit acfas.org/fellowshipinitiative to review a complete listing of programs and minimal requirements.

Foot and Ankle Surgery

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New research examines the relationship between smoking and the risk of nonnormal (<0.99) ankle-brachial index (ABI) at rest and after ankle plantar flexion exercise in healthy male community dwellers. Researchers performed a cross-sectional study that included 228 Japanese men aged 40 to 64 years without a history of cardiovascular diseases. The team estimated the multivariate-adjusted odds ratios (ORs) for nonnormal ABI of ex- and current smokers in relation to never smokers after adjusting for age and other confounding factors. At rest, the prevalence of nonnormal ABI was not significantly different by smoking status. After exercise, the prevalence of nonnormal ABI increased from 1.8 percent to 11.5 percent in ex-smokers and from 3.8 percent to 17 percent in current smokers, while the prevalence did not significantly change in never smokers. The multivariate-adjusted OR for nonnormal ABI after ankle plantar flexion exercise, in relation to never smokers, was 3.85 (95 percent confidence interval [CI]: 0.79-18.9) for ex-smokers and 6.97 (95 percent CI: 1.32-36.7) for current smokers. The results suggest that ABI after ankle plantar flexion exercise is useful for early detection of subclinical peripheral artery ischemia in male smokers without typical symptoms.


Harvesting of the flexor digitorum longus (FDL) or the flexor hallucis longus (FHL) is commonly used in tibialis posterior reconstruction and Achilles tendon reconstruction, but the procedure is sometimes difficult and time consuming. It is important to obtain sufficient length to make a loop around the navicular bone or anchor it in the calcaneus. Researchers describe a technique in which a loop is passed from proximal identification of the FDL or FHL through the tendon sheath, harvesting it from a minimal plantar approach. After using this technique, researchers evaluated 10 consecutive patients for neurovascular damage. They found no postoperative neurovascular injuries. The technique enables surgeons to find the FDL/FHL tendon through the medial approach and to obtain sufficient length for the procedure by cutting the distal portion of the tendon through an additional plantar incision. The technical tip for passing the loop facilitates harvest of the tendon easily and safely using the plantar approach.


New research further investigates the Low Risk Ankle Rules (LRAR) and compares them with the already validated Ottawa Ankle Rules (OAR) to potentially curb healthcare costs and decrease unnecessary radiation exposure without compromising diagnostic accuracy. Researchers conducted a retrospective chart review of 980 qualifying patients ages 12 months to 18 years presenting with ankle injury to a commonly staffed 310-bed children's hospital and auxiliary site pediatric emergency department. Twenty-eight high-risk fractures were identified. OAR had a sensitivity of 100 percent (95 percent CI 87.7–100), specificity of 33.1 percent (95 percent CI 30.1–36.2) and would have reduced the number of ankle radiographs ordered by 32.1 percent. LRAR had a sensitivity of 85.7 percent (95 percent CI 85.7–96), specificity of 64.9 percent (95 percent CI 61.8–68) and would have reduced the number of ankle radiographs ordered by 63.1 percent. The latter rule missed four high-risk fractures. LRAR may not be sensitive enough for use in Pediatric Emergency Departments, while OAR again demonstrated 100 percent sensitivity. According to the researchers, further research on ways to implement OAR and to maximize its ability to decrease wait times, healthcare costs and improve patient satisfaction is needed.

Practice Management

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New technology can allow for greater efficiency, but it also can create distraction, diverting the attention of the medical practice away from the task at hand. When implementing new technology, the medical practice should help staff balance their workload as they adapt and evolve. During times of transition, says Susan Childs, a practice management consultant with Evolution Healthcare Consulting in Rougemont, N.C., the medical practice should always clarify priorities and communicate them to their staff. The medical practice should make every effort to lighten the workload while they are in training by asking coworkers to pinch hit. Moreover, the medical practice should show staff members how to budget their time, and it may help to put a practice-wide policy in place to minimize digital distractions from social networking sites and mobile devices. Another person may need to be added to the payroll. As the office reinvents itself, one of the best ways to help the staff remain productive is to exude an aura of calm. If the team is losing focus or showing signs of fatigue, it may be because it was not given the tools to succeed.


In a new report, a National Quality Forum (NQF) committee calls for measuring telehealth quality in four broad categories, including access to care, financial impact, patient/clinician experience and efficacy of clinical and operational systems. NQF also identified six subcategories as having the highest priority for measurement in telehealth: travel, timeliness of care, actionable information, added value of telehealth to deliver evidence-based practices, patient empowerment and care coordination. NQF Telehealth Committee Co-Chair Judd Hollander notes the NQF quality measure framework is designed to inform policy across the range of payment models as telehealth proliferates. "People will get medical care, and one of the ways we'll deliver it is telemedicine," Hollander says. "But we need to know how to measure and report on quality and to figure out how we can inform reimbursement in an evidence-based manner." The committee says the report and the accompanying conceptual framework could be the platform for future initiatives by measure developers, researchers, analysts and others to push quality measurement for telehealth. The report may back the development of measures that incorporate into a telehealth environment as part of an iterative development process.


A national survey of 2,106 physicians found they consider unnecessary medical treatment to be common and mostly driven by fear of malpractice, patient demand and profit motives. Most respondents said at least 15 percent to 30 percent of medical care is not necessary. Respondents estimated 22 percent of prescription medications, 24.9 percent of medical tests, 11.1 percent of procedures and 20.6 percent of general medical care delivered to be unnecessary. The percentage for physicians who conduct unnecessary procedures for profit motive was 16.7 percent. The three leading reasons cited for overtreatment were fear of malpractice, patient pressure/request and problems accessing prior medical records. "Unnecessary medical care is a leading driver of the higher health insurance premiums affecting every American," notes Johns Hopkins University School of Medicine Professor Martin Makary. Needless treatment comprises an estimated $210 billion in excess spending each year, according to the National Academy of Medicine. In addition, overtreatment has a direct association with preventable patient harm, and Makary says nationally the issue offers a significant opportunity to improve patient safety and reduce healthcare costs.

Health Policy and Reimbursement

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The videotaped arrest of a nurse at a Utah hospital—after she notified police, correctly, that they could not draw blood from an unconscious truck driver—has been condemned by national nursing organizations, Utah officials and the local police department. The incident has brought patient-consent rules into sharp relief. The Supreme Court explicitly ruled in 2016 that blood can be drawn from drivers only for probable cause, with a warrant. The nurse and her legal representatives are using the video footage to persuade police to rethink their treatment of hospital staff. The Utah Nurses Association has encouraged as many people as possible to view the footage to understand a nurse's “ethical duty to act in the best interest of our patients at all times and in all settings.” Nurses' ethical code stipulates they must first promote a patient's rights, health and safety, according to the American Nurses Association (ANA). ANA Executive Director Debbie Hatmaker says nurses typically learn about informed consent as part of their basic training, and most hospitals have clear policies about gaining consent from patients. “You would expect law enforcement to be clear about what the law is, about consent,” Hatmaker notes. “Of course, if there's any question, they should be able to go through their chain of command, all the way up to their chief of police. The fact that it escalated as quickly as it did in that moment seemed particularly outrageous.”


California and several other U.S. states will exempt themselves this year from a new Trump administration rule halving the amount of time consumers have to purchase individual health insurance under the Affordable Care Act (ACA). Under the rule, people shopping for 2018 coverage on the federal exchange have 45 days to enroll, from November 1 through December 15. However, consumers in California, Colorado, Minnesota, Washington, Massachusetts and the District of Columbia will have more time to make such decisions. Consumers shopping for coverage in California's exchange, Covered California, will still have the full three months they have had in recent years, beginning on November 1 and ending January 31. Californians seeking individual market plans outside the exchange will have those same three months to make up their minds. “We want to make sure our consumers have the time they need to find the best plan that fits their needs,” says Covered California's James Scullary. California Assembly member Jim Wood recently introduced a bill to guarantee a three-month enrollment window for consumers seeking coverage in 2019 and subsequent years. “When the Trump administration issued its new...rules cutting the ACA's open enrollment period in half, we knew we needed to act,” Wood says. “Californians have enjoyed a three-month enrollment period for years, and this change could catch people off guard and not allow them to sign up in time.”


A coalition of influential healthcare industry and business groups has asked Congress to cover federal subsidies to insurers for at least two years, in defiance of President Trump's threats to stop the payments. The money remunerates insurance firms for cutting out-of-pocket costs for millions of lower-income customers. The Affordable Care Act stipulates those cost reductions and subsidies, but a federal judge has said Congress did not legally authorize the money. The coalition writes that "persistent uncertainty" about whether Trump will block the money "is a significant driver of current market instability." The group cites evaluations by insurance companies, nonpartisan budget analysts and others that terminating the payments would further raise premiums for millions of Americans purchasing individual policies and encourage some insurers to halt the sale of coverage. A two-year extension of the payments "would go a long way to bring much needed stability" to insurance markets, the coalition notes. Senate Health Committee Chairman Sen. Lamar Alexander (R-Tenn.) would like a one-year extension of the subsidies, while Sen. Patty Murray (D-Wash.) wants a multiyear extension.


A harsh reality of Medicare policy is that patients can be hospitalized for days, receive exams and tests and be administered drugs without ever officially being admitted to the hospital. As outpatients who are “under observation,” they can rack up substantial healthcare bills, and patients currently have no recourse for challenging observation status under Medicare. However, a federal judge's certification of a class in a class-action lawsuit in late July could change this state of affairs. The certified class includes all Medicare recipients who have been hospitalized and received observation services as outpatients since January 1, 2009. The implication is that hundreds of thousands of people will be eligible to join the suit against the U.S. Centers for Medicare and Medicaid Services, with a trial expected in 2018. A ruling in favor of the plaintiffs means they will be able to appeal their observation-outpatient stays. “People call in dire situations, and we have to tell them there's no way to challenge this,” says Alice Bers with the Center for Medicare Advocacy. “Now we can tell them, 'You're a member of the class, so stay tuned.'”

Medicine, Drugs and Devices

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Many U.S. hospitals have implemented "meds to beds" programs that seek to prevent rehospitalization by giving prescription drugs directly to patients just before they are discharged. Approximately 35 percent of U.S. hospitals offer discharge prescriptions, according to a 2016 survey by the American Society of Health-System Pharmacists. Since hospital pharmacies can bill solely for drugs used in the hospital, medications to be used at home must be issued by outpatient pharmacies. Some hospitals have recently added onsite pharmacies that all inpatients can use at discharge. Many hospitals have partnerships with Walgreens for both discharge counseling and dispensing. National Coalition on Health Care President John Rother says the recent expansion of meds-to-beds programs is attributable to a 2012 Medicare rule that imposes penalties on hospitals should patients be readmitted within 30 days of discharge. “And once Medicare acted, other insurers began levying penalties for early readmission as well,” notes Avalere's Joshua Seidman. He says to avoid fines, many hospitals rolled out "transitions of care" programs linking patients with posthospital services, such as follow-up doctor visits and drugs to be used at home. The Kaiser Family Foundation observes rehospitalizations have declined since 2012, suggesting these initiatives are having an effect.


A recent study has found that musculoskeletal extremity imaging use among Medicare patients has increased sharply over the past two decades. The study, published in the American Journal of Roentgenology, found that between 1994 and 2013, the utilization rates among fee-for-service Medicare beneficiaries increased by 43 percent for radiography, 500 percent for ultrasound, 615 percent for MRI and 758 percent for CT scan use. "The reasons for this rapid growth could be related to the various advantages of ultrasound imaging, including improved accessibility, portability and low cost," researchers reported in the study. "However, a number of studies in the podiatry literature have touted ultrasound as a mechanism to enhance practice revenue, suggesting that this could be a dominant driver of this utilization change." The study was conducted by researchers in the Department of Radiology at NYU Langone Medical Center.