News From ACFAS

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What’s moving faster than bets at the roulette wheel? Registration and hotel rooms for ACFAS’ historic 75^th Anniversary Scientific Conference, February 27–March 2 at The Mirage in Las Vegas. At just seven weeks out until the big event, ACFAS 75 is projected to be a recordbreaker.

Register today so you don’t miss:

• Hundreds of clinical sessions covering pain and infection management, reconstruction, high-risk surgery and more
• Intensive cadaveric workshops to advance your surgical skills
• The latest industry products and services in the Exhibit Hall
• Opportunities to network, job hunt and update your professional headshot
• Special events that celebrate the College’s history and the valuable work you do

Be part of history and register now for what’s shaping up to be our biggest conference yet! Let your local primary care physicians and other healthcare providers know who you are and why they should refer their foot and ankle patients to your practice. Download ACFAS’ new healthcare provider marketing tools from the Marketing Toolbox, which highlight foot and ankle surgeons' education and qualifications, and use each in your practice to gain referrals and build relationships with your local healthcare providers.

Visit acfas.org/marketing to access the complete toolkit, which includes a "why to refer" PowerPoint presentation and script; When to Refer Guides for various types of referrals; foot and ankle surgeon fact sheets; the "Take a New Look at Foot & Ankle Surgeons" video and more. Promoting your work and the profession has never been easier! Employers and jobseekers, the fourth annual ACFAS Job Fair (sponsored by PodiatryCareers.org) will have everything you need to find the perfect candidate or position.

Come to the Job Fair anytime during the 75^th Anniversary Scientific Conference, February 27–March 2 at The Mirage in Las Vegas, to browse through resumes and job openings.

A resume expert will also be on site at the Job Fair to review your resume and offer tips for marketing your job skills and experience. (By appointment only: visit the Job Fair early to reserve your slot!)

Employers can post available positions through PodiatryCareers.org’s online career center and on bulletin boards at the Job Fair. Jobseekers should bring hardcopies of their resumes to post on the boards as well. As always, ACFAS members receive reduced rates on online job postings.

If you are not attending ACFAS 75, note that all positions and resumes received will be posted to PodiatryCareers.org after the conference. Get the most out of your ACFAS membership with two free webinars scheduled for this month and next:

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

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 show you how to make your CV stand out from the crowd. Learn what to include and exclude in your CV to give yourself a competitive advantage.

Register now!

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

Thinking about a fellowship after you complete your residency? This webinar will discuss the decisions you need to make 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 decide to pursue a fellowship
• when to start looking
• how to choose a program
• how fellowships compare to residency training
• what fellowship programs seek in a candidate

Link to register coming soon—save the date!

Foot and Ankle Surgery

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A study was conducted to investigate whether the image quality of 3D volume isotropic fast spin echo acquisition (VISTA) magnetic resonance imaging (MRI) of the calcaneofibular ligament (CFL) view is comparable to that of 2D fast spin echo T2-weighted images (2D T2 FSE) for the evaluation of CFL. The study included 76 patients undergoing ankle MRI with CFL views using 2D T2 FSE and 3D VISTA. The signal-to-noise ratio and contrast-to-noise ratio of 3D VISTA were significantly higher than those of 2D T2 FSE. The anatomical identification scores on 3D VISTA were less than those for 2D T2 FSE. There were no statistically significant differences in diagnostic performances between the two views.


Osteopontin (OPN) has been shown to correlate with interleukin-17 (IL-17) production and expression of Th17 cells in the synovial fluid of rheumatoid arthritis (RA) patients, so a new study investigated the role of OPN in monocyte migration, IL-17 production and osteoblast levels. OPN and IL-17 profiles in osteoarthritis (OA) and RA synovial fluid were determined by enzyme-linked immunosorbent assay (ELISA). The expression of miR-129-3p in osteoblasts was analyzed by real-time quantitative polymerase chain reaction, and the role of OPN in monocyte migration was assessed through the collagen-induced arthritis (CIA) mouse model. OPN and IL-17 expression were higher in RA synovial fluid compared with OA samples. OPN was found to promote IL-17 expression in osteoblasts and enhance monocyte migration. The expression of miR-129-3p was negatively regulated by OPN. Lentiviral vectors expressing short hairpin RNA inhibited OPN expression and reduced articular swelling, cartilage erosion and monocyte migration in the ankle joints of CIA mice.


A study evaluated the feasibility and safety of using the lateral calcaneal artery (LCA) as a recipient vessel for microsurgical foot reconstruction. An anatomic study was performed using CT angiography of 61 lower extremities in 31 patients. The LCA was used as the recipient artery in 17 patients. The LCA emerged roughly 31.1 mm proximal and 14.7 mm posterior to the tip of the fibula and traversed 13.9 mm posterior to the posterior margin of the lateral malleolus. The accompanying vein was used for venous outflow in five patients, and the small saphenous vein was used in the remaining patients. Emergent reoperation was performed in one case due to venous thrombosis. All flaps except for one completely survived, and only one patient was unable to wear shoes and walk at a mean follow-up of 13 months.

Practice Management

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Difficult conversations addressing patient noncompliance and distressing news can be a source of frustration and anxiety for both patients and physicians. When patients refuse important medication or do not follow dietary recommendations, there can be serious consequences for the patient’s health. Many reasons for noncompliance exist, some of which can be classified under one or more of the “three C’s”: commitment, confidence and control. Noncompliant patients often lack commitment to their doctor’s medical advice, so physicians should provide ample communication to ensure the patient understands the recommendation. The positive results of compliance should be stressed more than the consequences of noncompliance. Patients sometimes lack confidence in their ability to comply with recommendations. Physicians should gauge their patients' confidence level by asking questions and by exploring ways to help them meet health goals. Finally, a perceived loss of control over their lifestyle can cause patients to resist treatment. The patient should be given options and choices in how they implement medical advice to improve trust and commitment. When delivering bad news, such as a distressing diagnosis, physicians should recognize that the patient may not remember much of what is said beyond the diagnosis. Physicians should be honest and empathetic during the encounter and avoid giving too much detail until a follow-up appointment, unless the patient asks.


It is against the law for practices to routinely waive the deductible or coinsurance for a Medicare patient without evaluating hardship. Practices waiving coinsurance are required to pay back the claim earned where the coinsurance payment was not collected. If no attempt is made to collect the coinsurance and evaluate financial need, practices may be fined for fraudulent billing. To protect practices from these fines, practice managers should develop compliant hardship polices and educate staff and patients about the policy. Hardship forms must be included in patient charts before balances can be written off. These forms should include the patient’s number of dependents and household income, assets and essential expenses. Once the form is completed, the practice must have a process for the evaluation of the information; some practices request tax returns or documentation of Social Security payments. Next, practices should establish a percentage of the poverty level to be used as a benchmark for approving the hardship exemption. Finally, staff should be instructed to make an attempt to collect all coinsurance and deductible amounts for all patients regardless of their payment source. Patients should only be given hardship forms if they request an exemption or reduction in their balance.

Health Policy and Reimbursement

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Republicans on January 4 pushed immediately forward to repeal the Affordable Care Act as President Obama made a rare trip to Capitol Hill to defend the healthcare law. Vice President-Elect Mike Pence met with House Republicans not far from where the president gathered with Democrats, who vowed aggressive resistance to repeal efforts and said they would not participate in drawing up a replacement for the law after the swift efforts to unravel it. Republicans are using a procedural approach that will allow them to repeal substantial parts of the healthcare law without Democrats' being able to mount a filibuster in the Senate. By a vote of 51 to 48 on Wednesday, the Senate took the first step, agreeing to take up a budget resolution, or blueprint, that would clear the way for legislation repealing major provisions of the law. But even as Republicans spoke of moving quickly to repeal the law, it remained far less clear how and when they would go about replacing it. Senate debate on the budget resolution is expected to continue for several days, and the House plans to take up the measure once the Senate has approved it.


President-Elect Donald Trump and a Republican Congress are acting quickly to repeal the Affordable Care Act (ACA), but the healthcare system’s shift to value-based care and cost efficiency has a momentum that could be impossible to stop. Beyond expanding insurance coverage, the ACA has had an impact on every level of care, from what happens during checkups and surgery to how doctors and hospitals are assessed and paid. Providers have begun to move away from fee-for-service medicine, emphasizing preventative care, social work and collaboration between doctors. In 2015, the Obama administration set a goal for half of all Medicare payments to be tied to the quality, instead of quantity, of care provided by doctors and hospitals by 2018. There has been a significant cultural shift for surgeons and their patients, as providers are under pressure from Medicare and private insurers to manage and coordinate care before and after surgery while keeping costs down. In response to incentives in the ACA, smaller hospitals and physician groups have been consolidated into big provider systems. Federal money has also allowed most doctors across the U.S. to install electronic health records.


The U.S. Department of Health and Human Service’s Office of the Inspector General (OIG) has identified several obstacles that could impede success of the Quality Payment Program as part of the Medicare Access and CHIP Reauthorization Act (MACRA). OIG is calling on the U.S. Centers for Medicare and Medicaid Services (CMS) to increase guidance and technical support to ensure clinicians are prepared for the MACRA implementation period. Specifically, OIG found solo, small-practice and rural provider readiness lacking. The report recommends that CMS continue to monitor clinician preparedness as the first reporting deadline approaches in order to address any initial challenges. CMS has also been tasked with creating health information technology systems that will support data reporting, scoring and payment adjustments before 2019 Medicare payment adjustments. In 2016, CMS developed the Quality Payment Program public website, and the program's portal is expected to launch individualized accounts in January 2017. Through the accounts, CMS will be able to verify user identities, communicate payment model eligibility, provide performance feedback and gather data on a clinician's network of surrogates and vendors.

Medicine, Drugs and Devices

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A new Medicare program for joint replacements could potentially save billions without impacting patient care, according to a recent study in the Journal of the American Medical Association. Under the Comprehensive Care of Joint Replacement program, hospitals are paid a set fee for all care related to hip or knee replacement surgery, from the time of surgery until 90 days later. If the total costs are below a target set by the U.S. Centers for Medicare and Medicaid Services, the hospital gets to keep the savings. The study of 800 participating hospitals in 67 cities found that hospitals saved an average of eight percent through the program. There was some indication that quality of care may be improved under the bundled payments model, with fewer patients requiring long, extended hospital stays. Researchers estimate that widespread adoption of the model would save Medicare $2 billion annually. However, President-Elect Donald Trump’s nominee for Health and Human Services secretary, Tom Price, has vocally opposed the mandatory payment program and is likely to revoke it.


A new Vermont law aims to improve transparency in pharmaceutical pricing by requiring manufacturers to justify big price increases. State officials are instructed to identify up to 15 drugs annually with price hikes of at least 15 percent in the previous year, or 50 percent over the prior five years. Vermont’s attorney general then seeks explanations from the manufacturers and publishes a report based on the findings. The first report, released in December, identifies 10 drugs with significant price increases, including Mylan NV’s EpiPen, Sanofi SA’s Lantus insulin and AbbVie Inc.’s Humira. Although manufacturers were instructed to submit all factors that contributed to price increases, specific answers were not included in the public report because of the law’s confidentiality provision. Vermont can fine noncompliant companies $10,000, but the law does not give the state the power to cap or roll back excessive drug prices. Other states are considering similar laws, and legislation has been proposed in the Senate to require drugmakers to justify hefty price increases to the federal government.


As the price of diabetes medications continue to rise, higher insurance deductibles and changes in formularies are raising concerns among people living with diabetes. Prices for many insulin brands have increased from an average of $300 to $500 between January 2013 and October 2016, according to GoodRx. Drugmakers say price increases are necessary to fund innovation, and it is unclear what portion of the price is going to pharmacy benefit managers and wholesalers. Insurance companies have fought back against price hikes by raising deductibles and making changes in the lists of drugs they cover. CVS Caremark will no longer cover the insulin brand Lantus, which has seen a 60 percent price increase since 2013, in favor of a biosimilar version, Basaglar. Kristina Blake, a patient with type 1 diabetes, reports her deductible increasing by 400 percent, with the price of three vials of Humalog nearly quadrupling in the past four years.