News From ACFAS

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It’s a new year and ACFAS 2022 is quickly approaching! Book your hotel today to ensure you’re part of the action in Austin this year!

Hotel reservations can be made through our official housing partner, onPeak. Booking through onPeak guarantees you the lowest hotel rate and also protects you from unauthorized third-party vendors or “hotel poachers.” ACFAS will not be responsible for any room reservations or deposits made through other companies or websites, so please book through onPeak for your own safety. Hotel reservations can be made online at acfas.org/Austin, by calling (800) 950-5542 or by emailing acfas@onpeak.com.

Visit acfas.org/Austin for more information on this year’s meeting. The College has big plans for 2022! Continue to be a part of ACFAS in the new year with 12 months of learning and seminars by renewing your membership today.

You’re not going to want to miss all the perks membership has to offer, so be sure to renew your membership by the end of January or you’ll be at risk of a late fee. You can renew online, through the mail or via fax. If you have any questions about your membership, email the Membership Department at membership@acfas.org. Make plans to head to Austin a day early for Residents Day! Don't miss the chance to hear from experienced foot and ankle surgeons who will share tips from finishing residency strong to transitioning to a successful practice.

Residents Day is the place for real-world advice and wisdom to help you tackle the end of residency. You will also get an understanding of the ins and outs of CPME’s 320 Standards, skills for conflict resolution and advice on dealing with issues of harassment and give insight on how to establish work/life balance.

The program also gives you the tools to help with post-residency life such as promoting yourself properly, illustrating the importance of proper documentation and informed consent, understand the pros and cons of seeking a fellowship, and offers you advice on how to find a job.

Plus, you can make it a full day of resident learning by starting for the afternoon session – Coding Fundamentals – where you’ll learn the foundation of the coding and billing process from expert colleagues. Special bundle pricing for both programs is available. Visit acfas.org to learn more and register today! Don’t miss the Residency Directors Forum in Austin Wednesday, February 23!

This year’s forum is Co-sponsored by the Council of Teaching Hospitals (COTH) and will include various topics to assist resident educators in optimizing their resident review and oversight such as milestones, resident remediation and resident burnout. The day will continue with tips to teach the teachers, like why good documentation is important and a primer on Sim Labs and virtual education options. The day will end with a session on program mergers and acquisitions and updates from an A to Z list of resident education stakeholder organizations.

The Forum is complimentary for all residency directors, faculty and program coordinators (up to two representatives from each program), fellowship directors and school Deans. There’s still time to register now at acfas.org.

Foot and Ankle Surgery

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A cadaveric study sought to qualitatively and quantitatively define the distal and intercuneiform articulations and their clinical implications. The researchers dissected the cuneiform complex of 10 cadavers, and digitally measured the width of the complex. Further dissection revealed the distal articular surface shapes of each cuneiform were described, and the individual heights and widths were quantified. The width of the joint complex was 44.74 ± 3.40 mm and the medial cuneiform height, width, dorsal anterior and plantar protrusion distances were 32.58 ± 2.77 mm, 14.08 ± 2.26 mm, 8.51 ± 2.17 mm and 6.66 ± 1.21 mm, respectively. The respective intermediate cuneiform height and width was 23.05 ± 1.92 mm and 9.59 ± 1.85 mm. The lateral cuneiform height, width, dorsal and plantar anterior protrusion distances were 23.38 ± 2.67 mm, 10.98 ± 3.01 mm and 6.76 ± 1.43 mm and 4.19 ± 1.10 mm, respectively. The anterior surface of the medial, intermediate and lateral cuneiforms was characterized as reniform, triangular and triangular, respectively. Most intermediate cuneiforms had a common inverted L-shaped articulation with the medial cuneiform, and a B-shaped articulation with the lateral cuneiform. Understanding the dimensions of the respective surfaces allows for anatomically appropriate fixation size when correcting deformities.


Researchers used computed tomography to measure morphologic differences of the calcaneus, talus and navicular in Charcot-Marie-Tooth disease (CMT) in 21 patients (27 feet) compared with 20 healthy controls. CMT patients exhibited significantly less talar sagittal declination than controls, as well as less talar head coronal rotation. The calcaneal radius of curvature in CMT patients was much smaller than that in controls, while differences in sagittal posterior tuberosity–posterior facet angle were also significant. Surface-mesh model analysis indicated the biggest morphologic differences were at the navicular tuberosity, medial talar head, sustentaculum tali and anterior process of the calcaneus. This marks the first study to quantify morphologic distinctions in hindfoot osteology observed in CMT patients, suggesting patients identified with osseous changes of the calcaneus, especially a smaller axial radius of curvature, may benefit from a corrective three-dimensional osteotomy.


A proposed anatomical reference system (ARS) for all bones of the foot and ankle complex based on a morphological framework is designed as highly repeatable, consistent among individuals, clinically interpretable and appropriate for a sound kinematic description. The authors scanned three specimens from healthy donors and three patients with flat feet in weight-bearing computed tomography, with foot bones segmented and ARS defined based on the proposed approach. Both inter- and intra-operator intra class coefficients was 0.99, while rotational consistency was 4.7 ± 3.5 degrees and 6.2 ± 4.4 degrees for the normal and flat feet, respectively; translational consistency was 4.4 ± 4.0 mm and 5.4 ± 2.9 mm for the normal and flat feet, respectively. Curvature variation in the arches were well defined and measurements of the Djiann-Annoier angles from both normal and flat feet matched corresponding clinical observations. The angle between tibio-talar mean helical axes (MHA) and ARS mediolateral axis in the talus was 12.3 ± 6.0, while the angle between talo-calcaneal MHA and ARS anteroposterior axis in the calcaneus was 17.2 ± 5.6, indicating good capability to embody joint kinematics.

Practice Management

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A Medical Economics survey found administrative burdens to be the most-cited challenge for 2022 among physicians, with prior authorization often frustrating. Richard Bryce with the Community Health and Social Services Center in Detroit said, "The problem with a lot of insurance companies is they change what's on their formularies, and one day the insulin NovoLog is covered and then next day it changes to Humalog, and now the patient has to switch and it's very confusing. And if you want to keep them on the same one, you have to put in the prior authorization, and the insurance company wants them to try the other one first." Practices can streamline this process by assigning a staff member to each payer, who learns their specific expectations and dislikes, and should establish a basic guidebook for each payer that others can follow if necessary. Another strategy is to use technology like online forms for prior authorization, while a third involves documenting all treatment decisions and supporting them with evidence-based practices. Other tactics include prepopulating forms for each payer, and creating spreadsheets outlining what treatments and drugs for frequent diagnoses require prior authorization by payer, and what the allowed alternatives are. Gold card programs can also offer potential benefits, and a final strategy is to pursue the elimination of the prior authorization requirement.


Physicians can leverage the Internet to satisfy patients and virtually expand their practices during the pandemic, and one way to do so is by using the data they compile from website analytics programs, patient review platforms and patient intake software to find opportunities and adjustments that best configure for growth. Doctors can also provide access to online healthcare and registration, offering patients the convenience of scheduling appointments and accessing clinical information digitally. It also pays to take advantage of insights about patients to accommodate their requirements and drive growth. The pandemic has further encouraged many patients to utilize telehealth when appropriate, and offering it as a treatment option can help practices accommodate high-risk individuals, conduct visits to determine whether an in-person appointment is necessary and manage ongoing treatment, especially for patients needing chronic care. Practices should take pains to review applicable policies before deciding how to incorporate telehealth treatments into patient care plans. Marketing services to maximize telehealth and complementary treatment options also requires employing reputable email marketing programs to segment patient emails and deliver targeted messaging.


Catherine Erikson, owner/operator of Medical Interior Design and Healthcare Marketing Group, helps doctors design offices to efficiently accommodate patient flow. She says marketing and designing a practice involves factoring in "who the patients are and what type of experience they expect. We discuss how to make the best use of technology and what amenities will make their staff happy." Erikson considers population health management an important trend where doctors strive to manage patients with chronic conditions. Managing expectations is critical when working with doctors in order to maximize the use of their spaces, and Erikson says she has advised one client with limited space to purchase compact furniture, sinks and cabinetry, along with easily portable exam tables. She also advises doctors to utilize their locations creatively, which may include, for instance, setting up a mobile nurse's station, a no-wait waiting room, a floating exam zone or a dual practice with work space on one side and aesthetics on the other. Doctors can also employ electronic medical records and texting to provide mobile engagement and better manage patients' appointment times. Erikson and her team will often link interior design to the logo so the floor plan and wall color are complementary and are easily reproduced at other office branches.

Health Policy and Reimbursement

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Regular Medicaid coverage redeterminations will likely resume in 2022 if Congress passes the Build Back Better Act, so providers may see many patients lose or change coverage. While this could lead to uncertainty for providers and patients, healthcare entities can help connect patients with resources and guide them into alternate coverage and minimize disruptions in their care. "It's an important collaborative opportunity across the healthcare sector that will require the actions of the federal government, the states, health plans (and) healthcare providers to ensure that this can really be carried out in the most thoughtful and supportive way," said Alice Lam, a managing director at Manatt Health.

Fewer people with health coverage means more less utilization and more unpaid medical bills. The impact on provider reimbursement depends on how many people kicked off Medicaid actually find another source of coverage. About one-third of adults in this group should qualify for subsidized insurance from the health insurance exchanges, and many more will have access to employer-sponsored coverage, the Urban Institute predicts.


The U.S. Centers for Medicare & Medicaid Services (CMS) has released the latest 2022 enrollment data for the Affordable Care Act marketplace and the most recent 2021 public payer enrollment data for Medicare, Medicaid and Children’s Health Insurance Program (CHIP). In 2020 and 2021, public payer and Affordable Care Act marketplaces experienced major disruptions and changes that continue to have ripple effects. The year that the pandemic struck, Medicaid and CHIP enrollment escalated for the first time in two years. From 2017 to 2019, enrollment in these programs dropped 3.1 percent, according to Kaiser Family Foundation. But 2020 initiated a drastic shift that extended into 2021.

Meanwhile, the Affordable Care Act marketplaces received an injection of new enrollees in 2021 as the Biden administration opened up and prolonged a special enrollment period. Experts have projected that the influx of enrollees will create a higher demand for customer service and unanticipated shifts in risk adjustment and medical loss ratios. As 2022 approaches, public payer and Affordable Care Act marketplace enrollment trends indicate that these surges in enrollment are ongoing.


U.S. health officials on Monday cut isolation restrictions for asymptomatic Americans who catch the coronavirus from 10 to five days, and similarly shortened the time that close contacts need to quarantine. U.S. Centers for Disease Control and Prevention (CDC) officials said there is growing evidence that people with the coronavirus are most infectious in the two days before and three days after symptoms develop.

The new CDC guidance is not a mandate, but rather a recommendation to employers and state and local officials. The new guidance also was driven by a recent surge in COVID-19 cases due to the spread of the omicron variant of COVID-19.


It was difficult to predict trend lines for the payer and health insurance industry in 2021, largely because of persistent uncertainties due to the COVID-19 pandemic. One factor that has been rendered extremely unpredictable by the virus is the financial health of the nation's major insurers, which soared during the initial waves of the pandemic in 2020 but then settled back down to earth toward the end of that year. In 2021, insurers still posted mostly substantial profits, but they were far from the heights seen the previous year.

Insurers are plowing forward with digital transformation initiatives, including the expansion of telehealth and virtual health. Artificial intelligence and machine learning have worked their way into the mix and half of payers now have innovation labs in the belief that digital innovation will be the key to the future. Insurers also continued to consolidate in 2021, resulting in highly concentrated markets that have drawn the attention of the federal government, which seeks to curb consolidation in a bid to empower consumers.

Medicare Advantage, meanwhile, continues to grow; it's estimated Medicare Advantage plans will cover more people in 2022 than original Medicare. Several major insurers have taken notice, expanding their Medicare Advantage offerings in an effort to capture more of the market.


Physicians at the Surgical Specialists of Greater New York and New York-based Seckin Medical filed three lawsuits against UnitedHealth Group and CVS Health's Aetna, claiming underpayment of services performed at Northwell Health's Lenox Hill Hospital. The three surgeons cited in the lawsuits performed operations on patients in 2019 and 2020 that they deemed medically necessary, and allegedly received a fraction of what they are owed. Following the procedures, the patients' insurers were assessed more than $200,000, but the payers initially only remunerated the surgeons a few thousand dollars. The complaints say Aetna and UnitedHealth Group refused payment for certain procedure codes they categorized as inclusive of other codes, and also failed to account for the severity and complications related in the surgeries. Despite appeals, the insurers have not dispatched the remaining balance and are accused by the plaintiffs of wrongfully withholding money, with two of the surgeons seeking $277,956.37 and $218,515.92 in two lawsuits and the third suing for $280,381.98. The Surgical Specialists of Greater New York is also requesting an administrative penalty of $19,470 to UnitedHealth Group subsidiary UMR, for not providing the plaintiff's attorneys with documents they requested in June.

Medicine, Drugs and Devices

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The HHS 405(d) Task Group published a brief disclosing risks associated with the recently discovered Apache Log4j flaw that could have disastrous security implications for healthcare and other industries. Apache Log4j is a common open-source Java framework used in a various applications, including Linux and Windows operating systems, and which is universally employed by developers and vendors to facilitate logging features. A previous brief from the Health Sector Cybersecurity Coordination Center said the remote code execution bug was discovered in November, yet proof-of-concept exploit code has been spreading around social media lately. "The exploitation allows the execution of any code which could result in compromise of the server, download of malicious binaries or propagation of further attacks such as ransomware or a zero-day attack," the 405(d) brief stated. "Healthcare and Public Health (HPH) organizations are being urged to review the recently released Apache security patch with their security team and take immediate action to secure their organization and protect their patients." The Cybersecurity & Infrastructure Security Agency (CISA) has already issued a patch, but the brief said the flaw has many unknown implications, and the patch may not be a panacea for organizations with legacy systems. "It is estimated that this vulnerability could potentially affect hundreds of millions of devices, networks and/or software platforms," the brief warned. Many cloud apps used by healthcare organizations for electronic health record services and other outsourced security services use the Log4j software and may be susceptible, and the 405(d) Task Force advised healthcare organizations to work closely with third-party service providers, vendors and outsourced security services to contain the exploit.