News From ACFAS

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The ACFAS Board of Directors election closes Friday, December 30. If you have not yet voted, a reminder email with the subject line: ACFAS Board of Directors Election—We Need Your Vote! was sent to you yesterday from acfas.ballot@intelliscaninc.net with your unique link to the election. Members without an email address or whose email system rejected our test email were sent voting instructions by U.S. mail earlier this month. If you do not see the email and did not receive a letter, check your junk mail folder. Please contact our independent election firm at kwier@intelliscan.com if you have questions about accessing the ballot site. December 31 is the final day you can pay your ACFAS membership dues. Renew your membership today at acfas.org/paymydues or via mail or fax to continue your member benefits.

All ACFAS Fellow and Associate Members should have received their 2017 ACFAS dues reminders in the mail and via email. If you have questions or need another statement, contact the Membership Department. Register now for Coding and Billing for the Foot and Ankle Surgeon, scheduled for Sunday, February 26 at The Mirage in Las Vegas, the day before the ACFAS 75^th Anniversary Scientific Conference officially begins. Learn how to get reimbursed for the care you provide and gain the tools you need to simplify your coding and reimbursement practices.

This comprehensive workshop will cover:

• 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
• and more!

Expert faculty will walk you through case-based and interactive procedures and will also give you ample opportunity to code real-time patient scenarios. Helpful handouts plus customized checklists and forms specially created for this workshop tie it all together.

Visit acfas.org/practicemanagement to register and get a head start on your conference experience! Want to get the most out of your ACFAS membership? Mark your calendar for one of two upcoming complimentary webinars:

How to Write a Good CV
January 18, 2017 at 8pm CT
30 minutes (approximate length)

Learn how to make your CV stand out from the crowd. Join Tanja Getter, lead director of Residency Education at Community Health Systems, and Russell Carlson, DPM, FACFAS, chair of the ACFAS Membership Committee, as they discuss what to include and exclude in your CV to help give you a leg up on your colleagues. Register now!

Foot and Ankle Fellowships: Taking the Next Step
February 9, 2017 at 8pm CT
30 minutes (approximate length)

Do you plan to pursue a fellowship after you complete your residency? This webinar will cover the decision-making process needed to commit to that extra year of training. Panelists include L. Marie Keplinger, DPM, FACFAS, past postgraduate fellow; J. Michael Miller, DPM, FACFAS, fellowship director of the American Health Network Foot & Ankle Reconstructive Surgery Fellowship; and Heidi Godoy, DPM, resident and member of the ACFAS Membership Committee. Topics will include:

• why fellows choose to do a fellowship
• when to start looking
• how to choose a program
• how fellowships compare to residency training
• what fellowship programs are looking for in a candidate

Link to register coming soon—save the date!

Foot and Ankle Surgery

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Most surgeons are unaware of their operating room costs, so a study attempted to determine if providing surgeons with individualized cost feedback affects their surgical supply costs. The intervention group for the Operating Room Surgical Cost Reduction project included 63 attending surgeons in orthopaedic surgery, otolaryngology-head and neck surgery and neurological surgery. Each surgeon in the intervention group received monthly scorecards showing their median surgical supply cost for each procedure compared with the institution’s baseline. All surgical departments were eligible for a financial incentive if they reduced costs by five percent. The median surgical supply direct costs per procedure decreased by 6.54 percent in the intervention group from 2014 to 2015. In the control group, the median surgical costs increased by 7.42 percent during the same time period. After controlling for surgeon, department, patient demographics and clinical indicators in a mixed-effects model, there was a 9.95 percent decrease in total surgical supply cost in the intervention group over one year. Patient outcomes were equivalent or improved in the intervention group.


Researchers investigated the effects of individual internal and external training loads and leg dominance on changes in the Achilles and patellar tendon structure. The internal structure of the Achilles and patellar tendons of 26 elite Australian athletes were assessed using ultrasound tissue characterization before and after an 18-week preseason. Small increases in the proportion of aligned and intact tendon bundles occurred in the dominant Achilles, nondominant Achilles, dominant patellar and nondominant patellar tendons. There were small positive effects on the structure of the nondominant Achilles tendon, small negative effects on the dominant Achilles tendon and no clear effects on the patellar tendons.


A study examined the effectiveness of dorsal wedge calcaneal osteotomy for the treatment of athletes with insertional Achilles pathology after failure of conservative management. Fifty-two athletes with painful Achilles tendon syndrome underwent surgery. Dorsal wedge calcaneal osteotomy was performed through a lateral approach, with two staples used for fixation. American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot and Victorian Institute of Sports of Australia-Achilles (VISA-A) scores were recorded. After a minimum follow-up of three years, AOFAS and VISA-A scores improved from 59.5 and 65.9 preoperatively to 95.7 and 90.2 postoperatively, respectively. Clinical results were considered excellent in 38 patients, good in 12 patients and fair in two patients. One patient required a revision operation.

Practice Management

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Although computers and electronic health record (EHR) systems have become more reliable in recent years, physician practices still must be prepared to continue business operations in the event of a computer system failure or outage. First, practices should devise a disaster recovery and business continuity plan and revisit it regularly to ensure it reflects the latest system updates. Emergency drills can help physicians and staff train for a real emergency and find any potential problems in the plan. Following an EHR system failure, practices must coordinate with their EHR vendor to restore a recent, uncorrupted backup. A recovery plan should also include strategies for transitioning back to restored computer systems and outline how information collected during the outage should be copied over to the EHR. Although cloud-based EHRs typically offer resilient cybersecurity protections, practices should be aware that these systems are still vulnerable to outages. Disaster recovery and continuity plans for a cloud-based EHR may include backup of patient records beyond what the cloud vendor provides.


Medical practices can apply branding strategies while keeping the waste of time, money and effort to a minimum. One strategy is to make consistency a priority across the board. When the practice's services dovetail with its messages and promotion, the two reinforce each other in patients' minds. A second strategy is to actively court honest feedback, via online patient reviews, for example. A third strategy involves refraining from tackling every single challenge. Practices should narrow down their brand messages to communicate a few key attributes that represent the service they want to provide. This will emphasize the clarity of the intended message. A final strategy is to restrategize and refresh the brand and marketing approach continuously and regularly.


A new fact sheet released by the U.S. Office of the National Coordinator for Health IT Technology (ONC) and the U.S. Health and Human Services Office for Civil Rights (OCR) outlines several situations in which sharing protected health information (PHI) is permissible. The Health Insurance Portability and Accountability Act (HIPAA) supports the electronic exchange of PHI for a variety of purposes, including contagious disease tracking, cancer registries and other public health activities. ONC and OCR review nine hypothetical scenarios that represent appropriate uses of shared PHI. For example, data may need to be exchanged in the event of a disease outbreak at a hospital or healthcare provider and disclosed to the U.S. Centers for Disease Control and Prevention. The U.S. Food and Drug Administration (FDA) also may request the PHI of patients affected by medical device recalls, as medical devices are subject to FDA jurisdiction. Physicians only need to disclose the information deemed necessary to support the recall, such as patient contact information.

Health Policy and Reimbursement

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President Obama has signed into law the 21^st Century Cures Act. The law will expand the U.S. Food and Drug Administration's (FDA's) efforts to improve patient access to treatments. The act is also expected to improve the agency's ability to hire and retain scientific experts in specific fields. The law also supports FDA's plans to upgrade clinical trial designs. Additional areas addressed by the law include a simplification of development programs for antibacterial and antifungal therapies. A new development program for regenerative medicine will also be created. Finally, the legislation addresses drug companies providing healthcare economic information to payers and formulary committees.


Republican lawmakers plan to repeal the Affordable Care Act (ACA) immediately next year, but changes to the ACA would not be implemented until a suitable replacement is found. However, health insurance consultants believe the insurance market is unlikely to remain healthy in the time between repeal and replacement. America's Health Insurance Plans warned Congress that a sudden repeal would threaten the health insurance plans for millions of Americans covered under Medicaid expansion. The American Academy of Actuaries also told lawmakers that the uncertainty following an immediate repeal would harm the long-term health of the insurance market, as companies may choose to stop selling individual policies if they believe the government will not continue to offer subsidies. "They're arguing that the thing is in death throes, that the insurance companies are losing tons of money and it's not sustainable," says Robert Laszewski, president of Health Policy and Strategy Associates. "Why do they think the insurance companies will provide the insurance policies in that scenario?"


The U.S. Centers for Medicare and Medicaid Services recently announced two new beneficiary engagement and incentives (BEI) models designed to increase patient involvement in care decisions. The BEI models aim to test different approaches to shared decision making and help beneficiaries better understand their health and treatment options. The Shared Decision Making (SDM) Model will integrate a structured four-step approach to decision making into routine clinical workflows of practitioners participating in accountable care organizations. The SDM model, which expects to engage more than 150,000 Medicare beneficiaries annually, seeks to determine if a structured process improves beneficiary outcomes while lowering Medicare spending. The second model, the Direct Decision Support (DDS) model, relies on decision support organizations to provide health management and decision support services to beneficiaries. Under this model, beneficiaries will be provided access to a website or electronic application that gives them unbiased and evidence-based information on their condition and treatment options. Beneficiaries can then use this information to discuss their options with their clinician. The DDS model expects to reach 700,000 Medicare fee-for-service beneficiaries annually.

Medicine, Drugs and Devices

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A new study compares glucose variability in patients with well-controlled type 2 diabetes using common insulin regimens: basal insulin and oral drugs (BO), basal insulin and glucagon-like peptide 1 receptor agonist (GLP-1 RA) (BGLP), premixed insulin (PM) and basal-bolus insulin (BB). A total of 160 type 2 diabetes patients aged 18 to 80 years underwent six-day masked continuous glucose monitoring. The daily glucose standard deviation was significantly lower in the BGLP group compared with the BO, PM and BB groups. The BGLP cohort also had the lowest daily hypoglycemia outcomes.


The aim of a recent study was to investigate whether glucose-lowering drugs influence the risk of hip fracture in patients with type 2 diabetes. Researchers examined data from the Danish National Patient Registry on more than 180,000 type 2 diabetes patients. Within an average of 5.5 years after diagnosis, 5,244 patients experienced hip fractures, 10,907 patients had major osteoporotic fractures and 20,557 patients sustained fractures of any type. Uses of insulin, metformin, dipeptidyl peptidase-4 inhibitors or glucagon-like peptide-1 receptor agonists were associated with a significantly reduced risk of hip fracture. Use of sulfonylureas put patients at a significantly increased risk, and glitazone use was also linked to a significantly increased risk of hip fracture. There was an increased risk of any fracture, major osteoporotic fracture, vertebral fracture and forearm fracture in users of sulfonylureas and glitazones.


President-Elect Donald Trump and Congress are likely to permanently repeal the federal tax on medical devices, which was imposed as part of the Affordable Care Act (ACA) in 2013. Republican lawmakers have vowed to repeal the ACA and cut taxes, including the one on medical devices. After receiving industry complaints, Congress last year temporarily suspended the 2.3 percent tax on the sale of nonretail medical devices, such as pacemakers, heart valves and artificial hips. The Congressional Research Service said in 2015 that the tax had a relatively minor impact on the production of devices and the industry’s employment, but lawmakers and lobbyists are seeking to link the tax cuts with job creation. OrthoPediatrics, which develops orthopaedic devices for children, saw a hiring freeze while the tax was in effect, with hiring resuming once the tax was temporarily lifted. Immediately following Trump’s election victory, lobbying group AdvaMed addressed a letter to the president-elect calling for the tax’s permanent repeal. "The medical device tax has been a significant drag on medical innovation and has resulted in the loss or deferred creation of jobs, reduced research spending and slowed capital expansion,” says AdvaMed President Scott Whitaker.