News From ACFAS

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This Friday, voting for the 2018–2019 ACFAS Board of Directors begins. After careful review and consideration, the Nominating Committee has recommended the following Fellows for the upcoming electronic election to determine who will serve on the ACFAS Board of Directors:

• Eric A. Barp, DPM, FACFAS
• George T. Liu, DPM, FACFAS
• Roya Mirmiran, DPM, FACFAS
• Eric G. Walter, DPM, FACFAS

Two three-year terms will be filled by election. Candidate profiles and position statements are currently posted on acfas.org/nominations. Voters may cast up to two votes on their ballot. Regular member classes eligible to vote are Fellows, Associates, Emeritus (formerly Senior) and Life Members.

All eligible voters will receive an email with special ID information and a link to the election website on Friday, January 5. After logging in, members will first see the candidate biographies and position statements, followed by the actual ballot, pursuant to the bylaws. Eligible voters without a valid email address (or an email that rejected a test email from our election company) will receive paper instructions on how to log into the election website and vote. There will be no paper ballots. Don’t miss your chance to register at a discounted rate for ACFAS 2018, March 22–25 at the Gaylord Opryland Hotel in Nashville! Visit acfas.org/nashville before Monday, January 8 to save on your registration fee.

Expect the very best in clinical and surgical education plus plenty of exhibits, networking opportunities and special events to kick your career and your practice into high gear. Register now and get ready for an unforgettable conference experience! ACFAS’ latest Clinical Consensus Statement (CCS), Diagnosis and Treatment of Adult Acquired Infracalcaneal Heel Pain, is available now at jfas.org (login required to view full CCS). The CCS panel, chaired by Harry P. Schneider, DPM, FACFAS, reviewed more than 100 articles on the diagnosis and treatment of heel pain. This statement updates the 2010 Heel Pain Clinical Practice Guideline.

Says Chair Dr. Schneider, “The expert panel has dedicated significant time and effort to review current literature and to provide an updated and thoroughly vetted consensus statement. Members will easily recognize the format, which mimics the most recent CCSs provided by ACFAS.”

CCSs encourage dialogue on timely clinical topics and often represent diverse opinions, uncertainties and minority viewpoints. ACFAS’ CCS panel members have varied expertise to offer you different approaches to the same issue and to better represent your clinical concerns as a practicing surgeon. Use CCSs to supplement your work or to brainstorm new topics you feel ACFAS should pursue. ACFAS has sent letters of support for the Caring for Our Veterans Act of 2017 (S. 2193). This bill would establish that DPMs appointed to the Veterans Health Administration would be eligible for supervisory positions to the same degree as a physician. It would also allow DPMs to practice to the full extent of their education and training, thereby giving veterans full access to providers who can adequately treat their foot and ankle injuries and conditions.

Visit congress.gov for more information. ACFAS would like to know what changes you have in store for your practice this year. Let us know by voting in this month's poll at right, and be sure to visit acfas.org throughout January for up-to-the minute results.

Foot and Ankle Surgery

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Researchers determined the effectiveness of manipulation under anesthesia and local steroid injection to treat stiffness of the first metatarsophalangeal joint following surgery for hallux rigidus or hallux valgus. Thirty-five patients in this study had surgery for hallux rigidus or hallux valgus and were treated with manipulation and steroid injection for stiffness of their joint. The researchers reviewed patient records to determine the range of movement of the joint preoperatively, immediately following the procedure and at subsequent follow-up. The study found that the total range of movement of the joint improved following manipulation by an overall mean of 44.7 degrees. At subsequent follow-up, the total range of movement of the joint was still improved by 22.2 degrees overall. In conclusion, manipulation under anesthesia and local steroid injection is an effective way of treating stiffness following first ray surgery.


Researchers reviewed functional and clinical outcomes as well as complications in patients who underwent endoscopically assisted percutaneous Achilles tendon repair using a four-strand core suture configuration via a six-portal technique. The researchers reviewed data of 23 consecutive patients who underwent endoscopically assisted percutaneous Achilles tendon repair between 2008 and 2015. The study revealed that endoscopically assisted percutaneous Achilles tendon repair has significant improvement in terms of functional outcomes as measured with the Foot and Ankle Ability Measure, Short Form-36 and visual analog scale. This technique is safe and feasible with minimal postoperative pain and morbidities, early return to activities and satisfactory functional outcomes.


Researchers conducted a study to determine the prevalence of the os trigonum as a cause of posterior ankle impingement. Researchers reviewed foot and ankle computed tomography (CT) scans between January 2012 and December 2013. The study included 628 patients, of which 32.5 percent had an os trigonum present. In 14.3 percent of the patients, the os trigonum was bilateral. The analysis found that os trigonum is a common accessory bone. The bone has a 30.3 percent prevalence in a population of patients with CT imaging of both ankles and 23.7 percent prevalence in nonaffected ankles.

Practice Management

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According to the U.S. Centers for Disease Control and Prevention, more than 100 million people in the United States are living with diabetes or prediabetes. In addition, diabetes creates $245.5 billion in healthcare costs a year. And U.S. employers lost $20.4 billion to 57 million unplanned, missed workdays this year due to diabetes. Many believe people with diabetes know how to control their blood sugar and remain healthy. However, Sheila Holcomb, vice president for Sharecare Diabetes Solution, notes that only 6 percent of newly diagnosed diabetes patients receive education in the first year of diagnosis. Experts say doctors, and even employers, can limit the impacts of diabetes by having more open and honest conversations about managing the disease. Utilizing more modern and comprehensive educational tools in doctor offices can be helpful as well.


A study from Merritt Hawkins found 43 percent of all physicians are at least 55 years old, with specialists on average older than primary care doctors. "The notion that we should be training more primary care physicians while maintaining or reducing the supply of specialists is a grave miscalculation," warns Merritt Hawkins President Mark Smith. "We should be training more of both types of physicians." Seniors 65 and up constitute 14 percent of the U.S. population but account for 34 percent of inpatient procedures and 37.4 percent of diagnostic treatments and tests. "It is primarily specialists, such as cardiologists, orthopaedic surgeons, neurologists, rheumatologists, pulmonologists, vascular surgeons and many others, who care for the declining health and organ systems of [seniors]," Smith notes. "A growing number will be needed as the population ages." The study estimates that the time it takes to schedule appointments with medical specialists has risen significantly since 2014. "In certain medical specialties, vascular surgery being just one, there are only a few thousand physicians, while patients with the conditions they treat number in the tens of millions," Smith says. "The data indicates that medical specialists will be in increasingly short supply, and this should be a serious concern for healthcare policy makers and the public."


Ensuring that fee schedules are accurate is vital for a physician practice to be successful. Fee schedules will detail what is supposed to be paid based on contracts with payers. Front office personnel will also use fee schedules to calculate coinsurance and deductible amounts. Making sure fee schedules are correct requires reviewing contracts, which can be obtained a number of ways. They can be obtained directly from insurance companies or via inflow reports. Analyzing these contracts and payments will require careful scrutiny and possibly a phone call to payers. Regularly checking fee schedules will also help doctors determine if they are charging too much or too little for services.

Health Policy and Reimbursement

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The U.S. Centers for Medicare and Medicaid Services (CMS) recently issued the first part of its 2019 advance notice of changes for Medicare Advantage (MA) capitation rates and Part D payment policies. Included is a revision to the percent of encounter data used for payment. Previously, the agency has used diagnoses submitted into its risk adjustment payment system by MA organizations, and it recently started to collect encounter data that also includes diagnostic information in the method of payment. Last year, CMS combined 10 percent of the encounter data with 90 percent of the risk adjustment payment system (RAPS) risk scores; for this year and next year, CMS continued to use a combination to calculate risk scores by estimating 25 percent encounter data and 75 percent RAPS in 2017, and 15 percent encounter data and 85 percent RAPS in 2018. The agency proposes to calculate risk scores in 2019 by adding 25 percent of the risk score calculated using diagnoses from encounter data and fee-for-service diagnoses with 75 percent of the risk score calculated with diagnoses from RAPS and fee-for-service diagnoses. CMS also proposed amendments to the CMS-HCC risk adjustment model used to pay for aged and disabled beneficiaries enrolled in MA plans. This includes an assessment of adding mental health, substance use disorder and chronic renal disease conditions to the risk adjustment model and making adjustments to account for the number of conditions an individual beneficiary may have, along with various additional technical updates.


Congress recently approved short-term funding for the Children’s Health Insurance Program (CHIP), but states say the infusion of money may not be enough to save the program. At least three states have sent out warning letters that families could lose coverage for children under the program by January 31. Further, experts say the lack of stable funding could discourage enrollment in the program in the future. The recent funding approved by Congress provides $2.85 billion until March 31. However, operational issues remain a major issue with that funding. States are calling on Congress to approve a five-year extension of the CHIP.

Medicine, Drugs and Devices

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The laws of economics suggest that introducing multiple new drugs for a condition should bring prices down over time, but the experience with rheumatoid arthritis (RA) shows how that is not always the case. The cost of the first RA drug has climbed from $10,000 per year when it debuted a decade ago to more than $40,000, despite competition from a number of similar products. Price-setting practices, legal challenges and marketing strategies have worked together to keep costs high for a disease that affects some 1.5 million Americans. At the center of it all are rebates that Pharmacy Benefit Managers (PBMs) receive from manufacturers. Because the payout often is based on a percentage of the product's wholesale price, choosing more expensive options can be tempting. Although the companies insist they share the wealth with the insurers or employers that hire them, patients rarely benefit directly from rebates—which have surpassed $100 billion in value, the Berkeley Research Group reports. Rebates are attracting more scrutiny as concerns escalate over runaway U.S. prescription drug prices, with critics arguing that they can steer business away from more affordable rival products or make it more difficult for companies to break out new treatments. But the Pharmaceutical Care Management Association, the PBM industry's trade lobby, says there is no basis to complaints that rebates help inflate prices. Rather, it argues, they help save the health system millions by funneling dollars back to insurers or other clients, which can use them to keep future premium hikes to a minimum. This year, the group sponsored a study that found no association between rebates and escalating list prices for the top 200 branded drugs, suggesting that higher rebates were not necessarily responsible for higher prices.


Researchers took a fresh look at the question of whether calcium and vitamin D supplements prevent bone fractures by analyzing 33 randomized clinical trials involving a total of more than 50,000 adults over the age of 50. Each of the previous research papers involved comparing calcium, vitamin D or both with a placebo or no treatment. The analysis was focused on older adults who live in the general community and did not include those in nursing homes, hospitals and other facilities. The researchers concluded that vitamin D and calcium supplements do not seem to prevent bone breaks or hip fractures in older adults. Such supplements had no clear benefit regardless of dose, the gender of the patient, history of fractures or the amount of calcium in the diet. The study was published in the Journal of the American Medical Association.


The U.S. National Institutes of Health has given a $5.3 million grant to prosthetics researchers at the University of Pittsburgh. The scientists have been tasked with developing a lower-limb prosthesis that mimics the feeling of a leg or foot. To recreate that feeling, the researchers are testing an implant that transmits electronic signals to a simulator worn on the belt. Grant recipient Lee Fisher, an assistant professor of physical medicine and rehabilitation, says the goal is to create a device that gives a person feeling from several places on a prosthesis.


In a surprising twist, California's high court has sided with plaintiffs who sued a brand-name drugmaker for failing to warn users of a generic about the potential risks. At the center of the case is terbutaline, which could impair fetal brain development when taken during pregnancy. Novartis denied responsibility for informing generic users on the grounds that it never manufactured the copycat and had divested ownership of the original version. The state Supreme Court ruled that Novartis was indeed liable, however, because federal regulations require generics to bear the same warning label that the branded product carries. In the decision, the justices wrote that during the time that Novartis owned terbutaline, the company "did have control over the warning label and could have modified it ... Recognizing a brand-name drug manufacturer's potential responsibility for injuries proximately caused by deficiencies in its warning label—regardless of whether the injury occurred before or after divestment—provides a further incentive to the brand-name manufacturer to update the label as soon as it knows (or should have known) of the unwarned risks." The ruling comes as the U.S. Food and Drug Administration (FDA) has pushed back finalization of a contentious proposed rule from 2013 that would allow generic drugmakers to revise their product warning labels and deviate from the labeling of their brand-name counterparts. The Association of Accessible Medicines, which represents the generic drug industry, has called on FDA to pull the proposed rule permanently.