News From ACFAS

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Flip through the final ACFAS 2019 program online and see what’s in store for you in New Orleans!

View complete listings of sessions, exhibitors, speakers and posters, get a feel for the layout of the convention center and Exhibit Hall with color-coded maps and take note of the daily shuttle bus schedule.

ACFAS 2019 is just two weeks away—we can’t wait to let the good times roll with you! Nourish your mind and body at one of two satellite breakfasts scheduled for Friday, February 15 during ACFAS 2019 in New Orleans. Learn the latest in regenerative healing and medicine while enjoying a delicious meal to fortify you for the day ahead.

Amniox Satellite Breakfast
Orchestrating Regenerative Healing in Podiatric Surgery
Friday, February 15
6:30–7:30am
Ernest N. Morial Convention Center
Room 391–392

Organogenesis Satellite Breakfast
Regenerative Medicine in Foot and Ankle Surgery
Friday, February 15
6:30–7:30am
Ernest N. Morial Convention Center
Room 388–389
RSVP

For details on these breakfast programs and other industry events, visit acfas.org/neworleans. Stop by the sixth annual ACFAS Job Fair (Booth No. 232) in the ACFAS 2019 Exhibit Hall in New Orleans to post your CV or open position!

Hosted by PodiatryCareers.org, the Job Fair invites available candidates to post their CVs on the Job Fair bulletin boards and employers to post descriptions of open jobs.

Be sure to dress your best and also visit the Headshot booth (Booth No. 751) in the Exhibit Hall on Friday and Saturday to have your picture taken for free by a professional photographer. Your photo session will include a brief meet and greet with a makeup artist, and you will receive both hardcopy and digital versions of your headshot. Use FootHealthFacts.org, the College’s patient education website, to attract new patients and referrals to your office and also enhance your practice website—for free! You can:

• Add a link to FootHealthFacts.org on your website’s homepage and direct patients there for foot and ankle health information
• Link to specific articles, condition pages and videos featured on FootHealthFacts.org
• Encourage patients to use the Where Do You Hurt? interactive foot diagram
• Remind patients to follow FootHealthFacts.org on Twitter, Facebook and Instagram

FootHealthFacts.org is free to use and continually updated with new content. If you have any questions about how to use the free resources on FootHealthFacts.org, contact Jolinda Cappello, ACFAS communications manager, at (773) 444-1320.

Foot and Ankle Surgery

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A study was conducted to compare gait in terms of foot loading and temporal variables after the extended lateral approach (ELA) and sinus tarsi approach. Twenty-two patients presenting with an intra-articular calcaneal fracture underwent plantar pressure distribution measurements six months post surgery. Measurements were performed while patients walked on the pedobarography platform, and values of dynamic variables were significantly lower on the operated limb in the ELA.

In the sinus tarsi approach, no differences were seen between the operated and uninjured limbs (UIN) at peak pressure and at maximal vertical force. Values of temporal variables between the operated and UIN differed in the ELA. The theory that differences in foot load between the operated and UIN will be more significant in the ELA was validated, and differences in loading and temporal variables between the operated and the UIN persisted six months after surgery in both methods. The operated limb was less loaded, with the tendency to shift the load toward the midfoot and forefoot. Following the sinus tarsi approach, the dynamic and temporal variables on the operated limb were nearly the same as those on the healthy one.


This study sought to determine whether treatment of isolated stable Weber B type ankle fractures with a cast or a simple orthotic device for three weeks produces noninferior outcomes compared with conventional immobilization in a cast for six weeks. The study included 247 skeletally mature patients aged 16 years or older with an isolated Weber B type fibula fracture and congruent ankle mortise in static ankle radiographs. Participants were randomly allocated to conventional six-week cast immobilization or three-week treatment either in a cast or in a simple orthosis. All subjects were weightbearing immediately upon casting or orthotic application.

At 52-week follow-up, the mean Olerud-Molander Ankle Score (OMAS) was 87.6 (SD 18.3) in the six-week cast group, 91.7 (SD 12.9) in the three-week cast group and 89.8 (SD 18.4) in the three-week orthosis group. The between group difference at 52 weeks for the three-week cast versus six-week cast was 3.6 points and for the three-week orthosis versus six-week cast was 1.7 points. The only statistically significant between group differences observed in the secondary outcomes and harms in the two primary comparisons were slight improvement in ankle plantar flexion and incidence of deep vein thrombosis, both in the three-week orthosis group versus six-week cast group.

The researchers concluded that immobilization for three weeks with a cast or orthosis was noninferior to conventional cast immobilization for six weeks in the treatment of an isolated stable Weber B type fracture.


The purpose of this study was to assess the effects of medical comorbidities on the incidence of surgical site infection following primary Achilles tendon repair. A secondary aim was to assess the effects of specific medical comorbidities on the cost and extent of healthcare utilization related to surgical site infection following primary Achilles tendon repair.

Nearly 25,000 patients undergoing primary Achilles tendon repair between 2005 and 2012 were examined. Patients with one or more preexisting medical comorbidities at the time of surgery had a higher rate of surgical site infection compared to those without. Diabetes and vascular complications were associated with the highest surgical site infection rates. The rate of surgical incision and drainage was higher in patients with cardiac arrhythmias and uncomplicated hypertension. The presence of a medical comorbidity significantly increased the cost and duration of surgical site infection treatment.

The researchers concluded that medical comorbidities can complicate the postoperative course for patients undergoing Achilles tendon repair, which increases the cost of care and duration of treatment. A better understanding of the relationship between each medical comorbidity and surgical site infections following Achilles tendon repair may be ascertained with additional prospective studies, allowing for a more accurate evaluation and stratification of surgical candidates to improve patient outcomes.

Practice Management

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Physicians who want to adequately fund their retirement should consider a cash balance plan. In essence, a cash balance plan is a type of qualified retirement plan that usually is layered on top of a combination 401(k)/Profit Sharing Plan. It is a defined benefit pension plan similar in certain respects to a defined contribution plan. For instance, like a 401(k) plan, the cash balance plan's participant views his or her own individual account balance and can use a portable account balance, so upon exit from the practice, the holder may roll over the balance into another qualified plan, such as an Individual Retirement Account (IRA). Cash balance plans can multiply retirement savings and also carry benefits in terms of tax deductions and deferrals. Furthermore, they can be used to attract and retain employees, offer protection from creditors and provide timely and comfortable retirement.


Physicians who believe in their clinic's capacity to address patients' social needs may be less likely to report burnout, according to a study published in the Journal of the American Board of Family Medicine. Researchers conducted a cross-sectional analysis of 1,298 family physicians who completed a certification practice demographic questionnaire in order to apply to continue certification with the American Board of Family Medicine in 2016. The researchers found that 27 percent of physicians reported burnout and that those who had a high perception of their clinic's ability to address patients' social needs were less likely to report burnout. Furthermore, physicians who reported high clinic capacity to address patients' social needs were more likely to have a social worker or pharmacist on their care team and to work in a patient-centered medical home.

"The association between lower burnout and physician perception of their clinic's ability to address patients' social needs held even when we controlled for other factors previously shown to be associated with burnout, such as physician control of their workload and time spent on electronic health records at home," said Emilia De Marchis, MD, primary care research fellow and clinical instructor at the University of California, San Francisco. "This work suggests that a new strategy to reduce physician burnout may be to increase a clinic's ability to address patients' social needs."


One of the most powerful and predictable layers of defense every physician can implement is a complete liability insurance program. As with all asset protection planning, insurance must be implemented in advance of a problem, so it is important to get adequately insured sooner rather than later. In addition, physicians should work with an expert and buy until it hurts. Nothing is more effective than insurance when it comes to addressing many specific, predictable risks. Erring on the side of caution and buying at the top of your budget in terms of the actual coverage limits is the best money you can spend on protecting your wealth and the practice that generates it. This means working with an experienced, multiline insurance broker who has access to all the top insurance carriers, will understand your business and actively make suggestions about the types of coverage you need and the appropriate limits.

Although some cost-sensitive physicians consider it an unnecessary expense, many people overlook the fact that years of disciplined spending and savings can be wiped out instantly for those who are inadequately insured. It is important to note that a personal liability "umbrella" policy of at least $1 million is mandatory protection for all physicians and especially for those who have a home or car. In addition, you cannot rely on a personal liability umbrella policy to protect you from almost any professional liability; those require separate insurance of multiple kinds, not just malpractice insurance. You also must actively protect assets that may be exposed beyond your coverage limits and limit your target value to your insurance coverage now, while you can legally do so.

Health Policy and Reimbursement

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The U.S. Centers for Medicare and Medicaid Services' (CMS) Center for Medicare and Medicaid Innovation has announced a new payment model and updates to an existing model, designed to enable Medicare Advantage and Part D plans to better serve patients and help them achieve good health. "The models being announced today create new incentives for plans, patients and providers to choose drugs with lower list prices, and new ways to meet the unique healthcare needs of specific populations, prevent disease and expand the use of telehealth," said U.S. Department of Health and Human Services Secretary Alex Azar.

The model for Medicare Advantage plans is an update to the Medicare Advantage Value-Based Insurance Design or "VBID" model that CMS first launched in 2017. The model for Part D plans is called the Part D Payment Modernization model. The models will be closely monitored, and if they clear certain thresholds for impact on quality, costs and access to benefits, the models can be expanded in scope. Plans participating in the VBID program will be offered along with traditional Medicare Advantage plans. CMS will monitor whether plans that take up these more tailored coverage options are able to reduce costs and increase quality.


President Donald Trump has directed administration officials to investigate how to prevent surprise medical bills, widening his focus on drug prices to include other issues of price transparency in healthcare. Trump tasked his health secretary, Alex Azar, and labor secretary, Alex Acosta, with working on a solution, according to attendees. "The pricing is hurting patients, and we’ve stopped a lot of it, but we’re going to stop all of it," Trump said during a roundtable discussion.

Surprise billing, or the practice of charging patients for care that is more expensive than anticipated or not covered by their insurance, has received a flood of attention in the past year, particularly as news organizations have undertaken investigations into patients’ most outrageous medical bills. Trump, Azar and Acosta said efforts to control costs in healthcare were yielding positive results, discussing in particular the expansion of association health plans and the new requirement that hospitals post their list prices online. The president also took credit for the recent increase in generic drug approvals, which he said would help lower drug prices.


The U.S. Senate has approved legislation to extend certain Medicaid policies following House approval. Included in the bill is a nearly three-month extension of spousal impoverishment rules to allow married couples to guard certain assets while seeking coverage for home- and community-based services. It also features $112 million for an approximately three-month extension of the Money Follows the Person demonstration that helps state Medicaid programs switch older adults and people with chronic illnesses back into their communities. Both the House and Senate had passed the extensions in the last session, but in different proposals that were never reconciled or signed into law. Last month, the Senate folded the extenders into the continuing resolution, but the partial government shutdown over border wall funding delayed the vote.

Medicine, Drugs and Devices

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Growing evidence suggests back-door arrangements that drug manufacturers make with insurers and pharmacy benefit managers, known as "rebate traps," are skewing the prescription drug market and taking low-cost medications off the table for some customers. Pharma companies offer volume-based discounts to these middlemen, which then inflate the price of competing generic drugs or omit them from their formularies. The only way that some customers can procure the cheaper option is by accepting a larger copay or purchasing the medications without using prescription benefits.

One example is Sanofi's insulin product Lantus, the price of which has nearly quadrupled over a decade. Although Eli Lilly's more affordable Basaglar is essentially the same, unpublished research shows that only 17 percent of Medicare plans for older adults covered the biosimilar as of early 2018, while virtually all of them covered Lantus. This may be just one of many examples of effective, less costly alternatives not being offered on formularies, investigators say.

A forthcoming Johns Hopkins study based on 2018 Medicare coverage, meanwhile, shows that almost every plan included one or more branded drug better positioned in the formulary than the corresponding generic. Additional research from Avalere finds that only 19 percent of generics covered by Medicare were in preferred formulary tiers with the lowest out-of-pocket expenses last year versus 71 percent in 2011. Despite mounting outrage over secret rebates, Congress so far has done little to address the issue.


The government shutdown is creating a backlog of hundreds of medical device applications awaiting review at the U.S. Food and Drug Administration (FDA), triggering a wave of delays for new medical technology to reach patients, according to the medical device industry. Because of the shutdown, FDA cannot collect and process new applications for medical devices nor their associated user fees under existing law. That is creating a delay of hundreds of submissions to FDA for review, the medical device industry said.

"We worry about the long-term impact," said Scott Whitaker, CEO of the Advanced Medical Technology Association (AdvaMed), which represents the world's largest medical device makers. Thousands of FDA employees are furloughed by the shutdown, bringing to a halt the previously routine regulatory and compliance activities of the agency. FDA typically receives 300 submissions a month from medical device and technology companies, AdvaMed said, so a long-term backlog of applications is cause for alarm. FDA has said "carryover" user fee money that is collected from companies under the Medical Device User Fee Act still exists, but that is not expected to last much longer. AdvaMed is proposing legislation "to ensure FDA continues to have access to funds to conduct medical device reviews during a lapse in appropriations." Hope exists that legislation could emerge to at least allow more parts of the government to reopen, with device makers saying FDA is an agency critical to patient safety.


Although use of insulin by patients living with type 1 diabetes has not changed much in recent years, the cost has gone up markedly, according to a new analysis from the Health Care Cost Institute (HCCI). The nonprofit reports that daily insulin consumption in this patient population inched up 3 percent from 2012 to 2016, yet its cost nearly doubled during that same time frame. The annual amount split by patients and their insurers, before rebates, jumped from an average of $2,864 to $5,705 over the study period. "It's not that individuals are using more insulin or that new products are particularly innovative or provide immense benefits," notes HCCI senior researcher Jeannie Fuglesten Biniek, who co-authored the paper. "Use is pretty flat, and the price changes are occurring in both older and newer products. ... The exact same products are costing double." The findings, based on a review of commercial claims data for an estimated 15,000 patients, come on the heels of mounting anecdotal evidence that high costs are driving insulin users to take potentially harmful steps, such as rationing their supplies.