News From ACFAS

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ACFAS is successful, growing and stronger than ever before. We are financially sound, have industry-leading membership renewal rates and run the best CME in the profession. We have achieved much of what our founders dreamed of more than 75 years ago in the early days of this College.

So what is next on the to-do list? Should we sit back and enjoy the hard-earned prosperity? Should we get lazy and bask in the sunshine at the top? Obviously not. We all know how that type of overconfidence and comfort-in-the-moment ends up…and we are not going down that road. ACFAS will remain a nimble and highly results-oriented association thanks to our organizational structure and our firm reliance on membership survey data to direct our efforts.

As I prepare to turn over the gavel to incoming president Chris Reeves, DPM, MS, FACFAS, I am filled with confidence and pride in where we are going and who will help lead us there. We are fortunate to have a wealth of volunteer leaders who rise to the challenge of taking us higher up the hill. In the coming months and years, you will see this College take significant steps in key areas of outcomes research, professional relations and surgical education. Much of this work has already begun, and we have allocated the resources to make sure that these prioritized efforts do not slow in their progress.

One key element I value about ACFAS is that we do NOT try to be everything to everybody. We are a special interest group that prioritizes the surgical aspect of your practice. We have positioned this College to advocate for your surgical interests in the most efficient and effective manner. This means a consistent focus on research, education and advocacy so that you can better use your skillset to help patients.

We are proud to partner with APMA in advocating for our profession, especially in recent efforts with AOFAS and AAOS. We work regularly with APMA leadership to assure that our efforts are well aligned. Most of you are members of both ACFAS and APMA, so we are moving forward together.

I would like to thank all the Board of Directors and staff members I have had the pleasure of working with for so many years. In particular, I would like to thank Chris Reeves and our executive director, Chris Mahaffey. ACFAS will be in great hands with all of these leaders, and I am confident they will both continue to make you even more proud of your decision to be a member of the American College of Foot and Ankle Surgeons.

John S. Steinberg, DPM, FACFAS
ACFAS President Before you leave for ACFAS 2019 in New Orleans, be sure to download our free ACFAS 2019 mobile app to keep all conference events and activities right at your fingertips.

The ACFAS 2019 app gives you instant access to exhibitors, your preselected sessions, convention center maps, shuttle bus routes and times, live social media feeds and more. Also receive up-to-the-minute alerts and reminders through the app and use it to rate and comment on the sessions you attend.

Search your app store for ACFAS 2019 (iOS and Android) or visit https://www.core-apps.com/dl/acfas2019 to download the app now. App login credentials plus instructions for adding your personal schedule and contact info were sent to all attendees on Monday. No matter if you’re an early bird or a night owl, ACFAS 2019 in New Orleans will have plenty of opportunities for you to get a firsthand look at industry’s latest surgical technologies. Choose from any of these morning or evening events:

Wednesday, February 13
Treace Medical Concepts, Inc.
Lapiplasty^® Cadaveric Symposium
6–8pm
Ernest N. Morial Convention Center
Room 393-394
RSVP

Zimmer Biomet
6:15–8:15pm
Solutions to Common Problems in the Foot & Ankle
Ernest N. Morial Convention Center
Room 388-389
RSVP

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

Organogenesis
Regenerative Medicine in Foot & Ankle Surgery
6:30–7:30am
Ernest N. Morial Convention Center
Room 388-389
RSVP

DePuy Synthes
Flatfoot Reconstruction Lab
6:15–7:45pm
Ernest N. Morial Convention Center
Room 391-392

Treace Medical Concepts, Inc.
Lapiplasty^® Cadaveric Symposium
6:15–8pm
Ernest N. Morial Convention Center
Room 393-394
RSVP

Zimmer Biomet
6:15–8:15pm
InCore^™ Lapidus Cadaveric Lab
Ernest N. Morial Convention Center
Room 388-389
RSVP

Visit acfas.org/neworleans for details on presentations and speakers. Want to find out about ACFAS activities close to home? Attend your ACFAS Region meeting during ACFAS 2019, February 14–16 at the Ernest N. Morial Convention Center in New Orleans!

Your ACFAS Regions will hold membership meetings in New Orleans and will discuss their 2019 plans for educational events and support of local schools, residencies and fellowships. Attend your meeting to hear all about it and offer your opinions!

Region meetings are scheduled during conference lunch breaks at reserved tables in the Exhibit Hall. A complete schedule of meetings will be listed in your onsite conference brochure, on the conference mobile app and on signage at the conference.

Attending your meeting will also put you in a drawing for one of nine $100 Amazon gift cards! You must be present to win, so don’t miss out! All meetings will take place at reserved tables in the Exhibit Hall. Take advantage of free, one-on-one professional media training during ACFAS 2019 in New Orleans. Learn the same PR strategies the pros use and make them work for you and your practice.

Time slots are filling quickly, but a few openings are still available on Saturday, February 16. Reserve your session now by contacting Melissa Matusek, CAE, ACFAS director of Marketing and Communications, at melissa.matusek@acfas.org.

Foot and Ankle Surgery

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A comparatively large set of treatment options for Achilles tendon ruptures exist, including surgical and nonsurgical approaches. The purpose of this case report is to demonstrate a new technique for a specific subgroup of Achilles tendon ruptures that present with a large tendinous gap. Researchers used a two-step procedure designed to provide additional stability through an autograft from the anterior rectus sheath of the patient. Two patients were treated after suffering traumatic Achilles tendon ruptures on the left side with a gap of >3.5 cm and a high demand in daily activities. The reconstruction was performed using an upper-quadrant recuts sheath as a WRAP-augmentation. After securing the transplant tissue, the abdominal wall was reconstructed using a Vicryl™-Prolene™ mesh. Afterward, a standard approach to the Achilles tendon was performed with a Kirchmayr-Kessler suture. The end result was then stabilized with a rectus sheath WRAP over a length of 14 to 15 cm. For the cases reported here, multiple clinical follow-ups were performed over a five-year period. The researchers reported highly satisfying results, with a return to sports activity after six months and no complications. As such, they believe the rectus sheath autograft is an effective solution for Achilles tendon ruptures with large gaps in healthy patients that demonstrate a high demand in daily activities.


A study was conducted to evaluate stiffness and range of motion (ROM) following minimally invasive surgery. Fifty patients received open scarf-Akin surgery, and 48 received minimally invasive Chevron Akin (MICA) surgery between January 2014 and December 2015. Moderate stiffness occurred in three cases in both groups. In MICA, extension was raised by 10 degrees and remained unchanged in scarf. Both cohorts showed similar improvements in American Orthopaedic Foot and Ankle Society score, pain and subjective foot value. Radiographic evidence of correction was comparable, apart from an increased shortening of the first metatarsal by 3 mm in MICA. The scars were smaller in MICA compared to scarf. Wound complications included delayed healing in 10 percent in scarf and wound infections in 4 percent in MICA. Recurrence rate and other complications were comparable, except for reoperations, which were higher in MICA than in scarf. In MICA, 14 percent were intraoperatively converted to open surgery.


A study was conducted to test the hypothesis that calcaneal reconstruction can alleviate chronic pain due to calcaneal malunion. The researchers reviewed the records of 10 male patients who received calcaneal reconstruction for calcaneal malunion between January 2009 and July 2014 at the mid-term follow-up. Talocalcaneal height and angle, calcaneal pitch, calcaneal width, Böhler angle, Stephens classification and Zwipp classification were assessed by three orthopaedic doctors at each visit. The average follow-up period was 67.1 months, while the sites of pain prior to reconstruction were lateral aspect in four patients, plantar aspect in three, diffuse pain in two and anterior aspect in one. A significant difference in talocalcaneal height, talocalcaneal angle, calcaneal pitch, calcaneal width and Böhler angle was observed before and after reconstruction, while none was noted between reconstruction and the last follow-up. Radiological measurement agreement was calculated to be moderate to strong, and the average American Orthopaedic Foot and Ankle Society Ankle and Hindfoot score improved from 66.50 plus or minus 9.37 pre-reconstruction to 80.30 plus or minus 8.52 at the last follow-up. The mean visual analog scale score improved from 8.60 plus or minus 1.43 before reconstruction to 3.40 plus of minus 0.84 at the last follow-up, and most patients were satisfied with the results postoperatively.

Practice Management

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As physicians seek new ways to increase productivity, they might consider the benefits of hiring physician assistants (PAs) and nurse practitioners (NPs). Research shows these types of advanced practice providers (APPs) are filling gaps in patient care and helping to extend the doctor's reach. NPs and PAs can work with varying degrees of autonomy, increasing access and freeing up the doctor's schedule for more complex patients; spend extra time with patients, improving satisfaction scores; monitor wellness, improving the practice's quality metrics and provide billable services, boosting practice revenue.

By taking on a variety of care delivery tasks, APPs can also help reduce physician burnout, experts say. However, it is recommended that practices allow at least a month's time for integration, during which APPs should shadow the doctor and become familiar with the practice, workflow and patient population. In states where NPs can practice independently, the physician would not have liability for the NP's actions. However, PAs ­require supervision established through "collaborative agreements" with physicians—written documents that define the practice's model for care delivery and how or when the physician should be involved in the patient's care.


A simulation study suggests shared decision-making can significantly lower the odds that patients will file lawsuits and complaints against a medical practice. Among the benefits associated with shared decision-making is facilitating patient-centered care and mitigating overuse of lab tests as informed patients skip invasive exams. Through use of a Web-based recruitment platform, the researchers enlisted 800 participants. Upon completion of decision-making vignettes for an appendicitis scenario, a survey showed that participants who engaged in brief or thorough shared decision-making were 80 percent less likely to desire an attorney than those who did not engage in shared decision-making. Primary barriers to shared decision-making identified by the study include clinicians' notion that it wastes time and that it is inappropriate because the options are not equally recommended. In addition, many clinicians assume that certain patients do not want to engage in shared decision-making, but patients do want to be involved in decisions when they understand the consequences.


An important habit for doctors to prioritize this year is punctuality. Take advantage of your smartphone's reminder and calendar alert functions, or get someone on your team to keep you moving from patient to patient in a timely manner. In addition, communicate clearly. Bulleted lists are easily digestible for email communication, and if texting, clarity is key. For face-to-face communication, ask questions to make sure people understand you; do not assume that they do because they are nodding their heads. Furthermore, establish boundaries and be protective of your personal time. Make rest and recovery a priority. In addition, learn from residents: they might have some insights on the latest modalities that have not yet made their way to you. By asking them to educate you, you are helping to cultivate the next generation of doctors. Finally, spend five minutes every morning thinking about the day's most important question (MIQ). Your MIQ can be any issue that is occupying your mental bandwidth, whether that is the best way to handle a multidrug-resistant infection or a problem at home. At the end of your day, spend another five minutes revisiting your MIQ and considering what insights and solutions you came up with.

Health Policy and Reimbursement

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The U.S. Department of Health and Human Services (HHS) has proposed a rule that would reduce prescription drug prices and out-of-pocket costs by calling on manufacturers to pass discounts directly on to patients and increasing transparency to prescription drug markets. "Every day, Americans—particularly our seniors—pay more than they need to for their prescription drugs because of a hidden system of kickbacks to middlemen," said HHS Secretary Alex Azar. "President Trump is proposing to end this era of backdoor deals in the drug industry, bring real transparency to drug markets and deliver savings directly to patients when they walk into the pharmacy."

The proposed rule would specifically exclude from safe harbor protection under the Anti-Kickback Statute rebates on prescriptions paid by manufacturers to pharmacy benefit managers (PBMs), Part D plans and Medicaid managed care organizations. The rule would establish a new safe harbor for prescription drug discounts provided directly to patients, as well as fixed-fee service arrangements between drug companies and PBMs. According to HHS, "By encouraging negotiated discounts that are reflected in cost-sharing methods like co-insurance, used for many expensive drugs in Medicare Part D, the proposal is projected to provide the greatest benefits to seniors with high drug costs." The proposal also addresses the pressure drug makers cite to provide increasingly larger rebates, providing instead a clear pathway for drug companies to compete to have the lower price and out-of-pocket cost to the patient.


The Trump administration has proposed new steps to discourage opioid abuse in Medicare Advantage and Part D, including extra surveillance and expanded use of nonopioid pain treatments. As part of its 2020 draft call letter, the U.S. Centers for Medicare and Medicaid Services (CMS) encouraged private Medicare plans to adapt benefit designs to promote nonopioid therapies and treatments, such as peer support services, cognitive behavioral therapy and therapeutic massage, if recommended by a physician. The agency is also urging Part D sponsors to supply overdose treatments, including at a lower cost-sharing rate to encourage access.

Furthermore, CMS advises coprescribing naloxone with opioids to persons deemed high-risk, and has requested comments on how to feasibly implement coprescribing. CMS vowed that it would not approve benefit designs that discouraged enrollment by beneficiaries who require medication-assisted treatment for their addiction. Star Ratings for Medicare Advantage sponsors will also have more varied language on potential opioid misuse. Ratings currently featuring a measure for high-dosage opioids use from multiple providers would be divided into two separate measures and would be capable of flagging concurrent use of opioids and benzodiazepines. Over the coming months, CMS's National Committee for Quality Assurance will discuss nonopioid chronic pain options with plans and providers to potentially develop new measures for therapy rollout in 2021.


The Trump administration is striving to cut Medicaid spending via block grants, a strategy that hinges on coaxing states to accept fewer federal dollars than they currently receive. A small unit within the U.S. Centers for Medicare and Medicaid Services (CMS) is developing a plan to allow states to request consent for federal Medicaid funding delivered in a single lump sum rather than as a percentage of states' total costs. CMS leaders are remaining low-key on this initiative, given political fallout from past Republican efforts to rein in Medicare spending. Healthcare providers, especially those serving low-income beneficiaries, are not enthused by the prospect of block grants, since Medicaid already compensates them at significantly lower rates than Medicare or private insurers, and block-granting the program could prompt states to further slash Medicaid enrollment or reduce payments.

American Hospital Association President Rick Pollack says his organization questions whether CMS is legally authorized to allocate Medicaid finding through block grants. "We have long voiced concerns about how block-granting Medicaid could ultimately result in losses of coverage and could negatively affect access to quality care," he notes. However, CMS has wide latitude to permit states to experiment with Medicaid programs and the marketplaces by applying for waivers, with CMS Administrator Seema Verma passing work requirements in multiple states and soliciting states to seek ways of bypassing certain Affordable Care Act coverage mandates.

Medicine, Drugs and Devices

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As investigations into drug prices kicked off in both houses of Congress, lawmakers criticized pharmaceutical executives for declining to testify. Sen. Chuck Grassley of Iowa, the Republican chair of the Senate Committee on Finance, indicated he could compel drugmakers to appear before the committee, expressing disappointment that only two companies have agreed to testify at a later date. Sen. Ron Wyden of Oregon, the committee's top Democrat, agreed with Grassley, suggesting the parties are united in their determination to address skyrocketing drug costs. Both Grassley and Cummings have the power to subpoena witnesses—such as drug company executives—to appear before Congress, although Grassley said he was not yet prepared to invoke that option.

The House Committee on Oversight and Reform also held the first hearing in its own investigation into drug prices. While lawmakers noted that both hearings were only the first of many, an early consensus emerged that something must be done about drug rebates, which provide discounts to middlemen in the supply chain but often push patients toward pricier brand-name drugs. Senators also targeted drug discount coupons, which lower the price for patients at the cash register but do not address the larger struggle between manufacturers and insurance companies. Given the influence of the drug industry, however, it could be an uphill battle to hold pharmaceutical companies accountable.


House Democrats are investigating the three main insulin manufacturers in the United States over "skyrocketing costs." Eli Lilly, Novo Nordisk and Sanofi received questions about their pricing strategies from Rep. Frank Pallone Jr. (D-N.J.), chair of the Energy and Commerce Committee, and Rep. Diana DeGette (D-Colo.), chair of the Energy and Commerce Subcommittee on Oversight and Investigations. The lawmakers said they worry about patients living with diabetes rationing their insulin because they cannot afford to purchase more. "When patients go without insulin—or ration their doses—there can be tragic consequences," they wrote in a letter to the drug manufacturers. "As one of the few manufacturers of insulin in the United States, your company is well-suited to shed light on these issues and offer potential solutions."

The lawmakers are requesting a range of documents and information from the companies, including their average price for insulin products for the past decade and explanations for increases, the net profits of the companies' insulin products for the past 10 years and a list of changes made to their insulin products. Pallone and DeGette say the price of insulin tripled between 2002 and 2013, and nearly doubled between 2012 and 2016, despite the lack of significant advances in the formula. They are also questioning whether the companies have entered into any agreements in the last 10 years that delay, limit or prevent the availability of generic insulin on the market.


A government-backed coalition of hospitals and medical device manufacturers have issued a joint cybersecurity plan outlining safeguards both manufacturers and hospitals should insist upon. According to Healthcare Sector Coordinating Council Executive Director Greg Garcia, the plan shows that both device makers and hospitals are eager to cooperate on addressing insecurity and to take initiative, amid congressional inaction. Although the plan will not eliminate security problems immediately, it advises manufacturers to explain to hospitals how they will look for new cyber weaknesses in their devices, how they will fix them and when. Manufacturers should also inform hospitals about how long they will support devices by patching newly discovered vulnerabilities and when hospitals should plan for those devices to reach the end of their usability. Among the reasons why medical device cybersecurity is lagging is that hospital machines are built to last 10 years or more, so they must deal with a new generation of cyberthreats at the end of their usable lifetimes. Hospitals also often lack the financial resources and manpower to correct device vulnerabilities themselves.