News From ACFAS

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Your valuable expertise as a foot and ankle surgeon received national coverage! Pain Medicine News recently spotlighted ACFAS’ and the American Association of Nurse Practitioners’ new joint Clinical Consensus Statement (CCS) on gouty arthritis of the foot and ankle.

In the article, lead CCS author Roya Mirmiran, DPM, FACFAS discusses why and how the CCS was developed, and two physicians, ACFAS member Brett Sachs, DPM, FACFAS and Laurel Short, MSN, FNP-C, also share their views on the CCS and how they use it in their practice.

Pain Medicine News reaches 47,475 pain-treating physicians in the United States as well as 46,761 pain-treating nurse practitioners and physician assistants. Read the article now and be sure to share it through your own social media channels. Work one-on-one with a professional media trainer at ACFAS 2019 in New Orleans and gain valuable PR tips and tools to help you publicize your practice and also speak on the College's behalf. Learn how to be a more confident public speaker, both on and off camera, and see how just a few simple strategies can increase your outreach to your patients, peers and community.

Reserve your free, personalized one-hour session now by contacting Melissa Matusek, CAE, ACFAS director of Marketing and Communications, at melissa.matusek@acfas.org. January 28 is the last day to register to attend the 2019 Residency Directors Forum! This event for residency directors and faculty is scheduled in advance of ACFAS 2019 in New Orleans on Wednesday, February 13 from 1:30–5:30pm and is cohosted by the Council of Teaching Hospitals (COTH).

This year’s program focuses on best practices in residency training. There will also be time for open Q&A with all of the residency-related organizations, including AACPM, PRR, COTH, CPME, ABFAS, ABPM and ACFAS. Attendees can also earn up to 2.5 CME hours.

Forum sessions will include:

• CPME and ACGME: Sharing Best Practices in Resident Education
• Slaying the Three-Headed Monster: Patient Safety, Physician Well-Being and Resident Remediation
• Research: The Next Frontier
• Get on Board! Preparing Your Residents for In-Training Exams and How This Correlates with ABFAS Board Qualification Rates
• Mix It Up Like Jambalaya: Organizational Oversight Updates

Residency program directors, codirectors and faculty are invited to attend, with up to two attendees per program. School deans are also invited.

Visit acfas.org for further details and to register. Did you know falls are the leading cause of injuries and death from injury among older Americans? Use our latest infographic, Prevent Trips, Slips & Falls, to show your senior patients how healthy feet and ankles can help reduce their risk of dangerous falls.

Log into the ACFAS Marketing Toolbox to download this new infographic then:

• Print and display it in your office
• Distribute copies to your patients and referring physicians
• Share it on your social media sites

The infographic also includes an editable box in the lower righthand corner for your office’s contact information.

Visit acfas.org/marketing for more free infographics, PowerPoint presentations, healthcare provider marketing tools and other products to educate your patients and the public while also promoting your practice.

Foot and Ankle Surgery

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A study assessed a novel modification to conventional partial calcanectomy to address certain issues. The vertical contour calcanectomy method incorporates improvements to an already accepted limb salvage technique, and the researchers sought to classify the indications, contraindications, intraoperative technique and postoperative management of the vertical contour calcanectomy for patients presenting with heel ulcers. Conventional partial calcanectomy cannot ensure complete soft-tissue closure, as closure under tension is needed for primary closure of the soft-tissue deficit or the wound must be closed by secondary intention. Closure under tension heightens the possibility of dehiscence and subsequent postoperative surgical site complications that lead to the same risks for major amputation as the index heel ulcer.


This study sought to examine the effects of suture-tape augmentation on functional ankle instability (FAI). A total of 24 patients who underwent suture-tape augmentation were followed for more than two years postoperatively. Functional outcomes were evaluated with the Cumberland Ankle Instability Tool (CAIT) and the Foot and Ankle Ability Measure (FAAM). Changes of peroneal strength, proprioception and postural control were analyzed with an isokinetic dynamometer and a modified Romberg test.

CAIT and FAAM significantly improved to average 27.2 points and 86.7 points, respectively, at final follow-up. Peak torque for eversion in 60 degrees angular velocity significantly improved to 10.6 Nm at final follow-up. Deficit ratio of peak torque for eversion significantly improved from mean 39.5 percent to 20.9 percent, and significant side-to-side difference was revealed. No significant differences were observed in joint position sense. A significant improvement in balance retention time was revealed at final follow-up, and the relative deficit ratio compared to the unaffected side was 30.9 percent.

The researchers concluded that patient-reported functional outcomes significantly improved after lateral ligament augmentation using suture tape. Although this procedure demonstrated significant effects on FAI based on improvement of isokinetic peroneal strength and postural control, recovery rates compared to the unaffected side were not significant at the intermediate-term follow-up. In addition, no positive effect was seen on proprioception of the ankle.


A study was held to compare ultrasound and standard X-ray images values in ankle sprain-related fracture diagnoses in 52 patients with ankle torque-related fractures. Echography was shown to be at least as good as standard radiographs on the screening of ankle torque-related fractures. Almost 8 percent of fractures were misdiagnosed with plain radiographies, which agrees with the lower limit found in the bibliography. All false negatives on radiographs were true positives in the first ultrasound evaluation, and the average time for the ultrasound protocol was 42 seconds. An ultrasound was determined to be at least as effective as conventional X-ray images when used in diagnosing ankle sprain-related fractures, irrespective of age or gender. Echography could lower the number of radiographies conducted when diagnosing these kinds of fractures, thus reducing the amount of radiation exposure and accelerating the diagnostic process and in situ diagnosis.

Practice Management

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Healthcare organizations are increasingly searching for solutions to combat physician burnout, but simply implementing a program to improve well-being without defining the goals, objectives and what determines success is not enough. Leaders at Tacoma, Washington-based nonprofit MultiCare Health System explained the lessons they have learned in creating a successful physician well-being program.

One misconception is that the program can be run by a single person. Instead, ensure that the right people are at the table. MultiCare's physician well-being program began as a small grassroots effort with multiple levels of leadership, as well as the operational and clinical side, but it eventually evolved into a cross-functional team. In addition, preparation is vital to obtaining your health system's leadership support. Furthermore, it is important to spread the word across various channels. Explain why the program exists, how it can help and what it can do.

Finally, measurement and feedback are key. Measurement will show what kind of progress you are making or are failing to make. At MultiCare, a physician well-being index survey is distributed to physicians, nurse practitioners and physician assistants. The provider efficiency profile (PEP), a report from Epic, is also used to validate what physicians are feeling. In addition, MultiCare has a wellness advisory group of 20 physicians from across the organization help the team focus on areas that need attention.


Acquisitions of physician practices by private equity firms are on the rise, although the effects on patients and physicians remain unknown, according to a new Weill Cornell Medicine study published in the Annals of Internal Medicine. The report found that private equity firms purchased 102 physician practices in 2017. Dr. Lawrence P. Casalino, chief author of the study, said he expects the trend to accelerate over the next few years.

Private equity firms typically purchase between 60 percent to 80 percent ownership of a physician practice with the anticipation of recouping an average annual return of 20 percent or more. The study found that these companies typically pay between $1–2 million per physician and provide "market rate salaries" to the physician owners but stand to reap all or most additional revenues. Physicians are also drawn to selling their practices because of the push toward value-based purchasing, the study argues, since smaller practices lack the resources to meet the requirements of value-based programs. Additionally, receiving a large stake from a private equity group assists physician practices in recruiting new talent that may not have been readily available had they remained an independent operation, according to the study.

While this dynamic has proven fruitful for both private equity firms and some physician practices, critics worry that it places profitability over patient care. Casalino said that while the impact on patients remains to be seen, physicians will continue to do business with private equity firms for the forseeable future.


The decision to buy, sell or merge a medical practice is more complicated than ever. As such, physician owners must have a clear understanding of the three main legal structures: asset purchase, stock purchase or merger. In an asset purchase, the buyer purchases specific assets of the target practice that are listed within the transaction documents. Buyers may prefer an asset purchase because they can avoid buying unneeded or unwanted assets and liabilities. Meanwhile, sellers generally disfavor asset transactions because the seller is left with potential liabilities without significant assets it could otherwise use to satisfy those liabilities. Also, the tax treatment of an asset sale is generally less favorable to sellers than a stock sale.

In a stock purchase, the buyer purchases the stock of the target practice directly from the target's shareholders. A stock purchase may be preferred if the buyer wishes to continue operating the target practice after the purchase. However, the buyer may be exposed to unknown risks by buying the entire practice, assets and liabilities.

In a merger, two separate legal entities become one surviving entity. Under state law, the assets and liabilities of each are then owned by the new surviving legal entity. In terms of required corporate approvals, mergers generally require approval only of the seller's board of directors and a majority of its shareholders. This lower threshold is particularly appealing when a target practice has multiple shareholders. However, shareholders who vote against the merger will generally have appraisal rights under state law. These allow dissenting shareholders to petition a court to obtain the fair market value of their shares, which can complicate transactions and increase the buyer's costs.

Health Policy and Reimbursement

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Sen. Chuck Grassley (R-IA), the new chair of the Senate Finance Committee, has attached his name to a trio of bills meant to lower drug costs, many of which have stalled in past sessions but that now enjoy renewed enthusiasm. One is a Grassley proposal with Sen. Amy Klobuchar (D-MN) that would allow Americans to import drugs from Canada for personal use. Grassley said he would bring back two other bills on the topic with Democrats: the CREATES Act, which aims to crack down on anticompetitive behavior from brand-name manufacturers, and a bill to ban the practice of "pay-for-delay," when companies pay generic manufacturers to delay production of off-patent drugs, as two other top priorities.

Meanwhile, Sen. Bernie Sanders (I-VT) is set to unveil his own drug pricing proposals, one of which is conceptually similar to a Trump administration international reference pricing proposal. Sanders' version includes a provision that could strip drug companies of exclusive licenses if negotiations stall. In a Republican-controlled Senate, many of the more ambitious pieces of legislation are unlikely to become law, but as the White House continues to agitate on drug costs and with Democrats in control of the House of Representatives, many on Capitol Hill believe both parties have incentive to pass legislation in the next two years.


Sen. Bernie Sanders and Rep. Elijah Cummings have introduced legislation aimed at lowering the cost of prescription drugs for U.S. consumers. The proposed legislation, which has several co-sponsors among Democrats in the House of Representatives and in the Republican-led Senate, is three-pronged. First, it would match U.S. prescription drug prices to the median price from five countries—Canada, Britain, France, Germany and Japan—where drug costs are typically significantly lower because of government price controls. That is similar to a proposal the Trump administration said it plans to put forth in the coming months that would create an "international pricing index" to help the cost of prescription drugs to Medicare more closely align with other countries.

The Sanders-Cummings bill would also allow the U.S. Secretary of Health and Human Services (HHS) to negotiate prices in Medicare Part D, a program that helps Medicare beneficiaries pay for self-administered medicines like those purchased at drugstores. Furthermore, the proposal would end a ban that keeps Americans from buying medicines at lower prices from Canada and other countries.


A $100 billion GOP healthcare spending package up for reintroduction in Congress is designed to encourage Americans to exercise more and to get more control over their finances, but it would mandate that people reorganize their lives in response to modest financial incentives. The measure would consider gym memberships tax-deductible medical expenses and would help cover out-of-pocket costs for high-deductible health plans by permitting beneficiaries to put more money in tax-shielded health savings accounts. Usage of flexible spending accounts and health savings accounts to buy sports equipment would also be allowed.

Although the policy mandates opting in, experts believe that various forms of scarcity experienced by consumers will discourage this. They call scarcity a "cognitive tax" that makes it difficult for people to live healthy lives and to make health-promoting choices, especially for those who may have a busy professional or family life. Evidence suggests that passive public health policies are more effective at spurring action on healthcare, such as public health initiatives for water fluoridation and air quality improvement.

Medicine, Drugs and Devices

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The U.S. Food and Drug Administration's (FDA) Center for Drug Evaluation and Research (CDER) approved 59 new drugs in 2018, including 19 first-in-class agents, 34 novel drugs for rare diseases and seven biosimilars. Forty-three of these newly approved drugs had priority review, 24 were fast tracked and 14 were designated as breakthrough therapies.

The first drug derived from marijuana to be cleared by FDA was a purified formulation of cannabidiol (Epidiolex—GW Pharmaceuticals) for the treatment of seizures related to two rare forms of epilepsy for patients older than two years. FDA also approved a second new medication for Dravet syndrome: stiripentol (Diacomit—Biocodex). Another drug approval for rare or orphan diseases was migalastat (Galafold—Amicus Therapeutics) for Fabry disease.

Meanwhile, FDA approved a new antiviral influenza treatment featuring a novel mechanism of action. Baloxavir marboxil (Xofluza—Shionogi) is approved for the treatment of acute uncomplicated influenza in people aged 12 years and older who have been symptomatic for no more than 48 hours. In the oncology/hematology field, approvals include duvelisib (Copiktra—Verstem Oncology) for relapsed or refractory chronic lymphocytic leukemia/small lymphocytic lymphoma and glasdegib (Daurismo—Pfizer) for newly diagnosed acute myeloid leukemia in patients aged 75 years or older or those who have comorbidities that disallow use of intensive chemotherapy.


U.S. Centers for Medicare and Medicaid Services (CMS) Administrator Seema Verma announced that a rule requiring hospitals to post their standard charges online is only the first step CMS is considering in price transparency. She said CMS wants to make the rule actionable so that consumers and physicians can use pricing to make decisions. This would also create competition in the healthcare market, which would drive down prices. Currently, a 50 percent to 75 percent price discrepancy exists in certain prices between hospitals in the same region, Verma said.

The new rule, which went into effect on January 1, mandates hospitals post their prices online in a machine-readable format so that consumers can import the information into other documents. This also sets the stage for third parties to develop applications for consumer use, she said. Feedback about the rule has been both positive and negative, with some saying it is only confusing consumers and that the chargemaster price is not an indication of what a patient will actually pay. Verma said the price transparency approach helps the uninsured to know what price they will be charged, but it does not reveal the cost after additional insurance discounts for those who are insured. She said they are working through these challenges and that it is nevertheless an important first step in making healthcare more affordable.


A study published in Health Affairs shows soaring U.S. prescription drug costs are mostly due to year-over-year price hikes by the manufacturers, not innovative therapies or enhancements to existing medications. The cost of brand-name oral prescription drugs climbed more than 9 percent annually from 2008 and 2016, while the yearly cost of injectable drugs rose more than 15 percent. Brand-name drugs comprise an average 44 percent of total prescription drug spending, and this portion is shrinking as drugmakers devote more attention to developing high-priced specialty medications, according to University of Pittsburgh Medical Center Professor Immaculata Hernandez.

Also seen was a 4 percent annual spike in cost for oral generics, although Hernandez attributes it to a "patent cliff" that hit the drug market during the study period, in which several blockbuster medications became generics. "Research and development is only about 17 percent of total spending in most large drug companies," says Johns Hopkins University Professor Gerard Anderson. "Once a drug has been approved by the U.S. Food and Drug Administration, there are minimal additional research and development costs, so drug companies cannot justify price increases by claiming research and development costs."