News From ACFAS

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With over 1,800 foot and ankle surgeons in attendance and a sold-out Exhibit Hall, another outstanding Annual Scientific Conference is in the books for ACFAS! Thank you to all who joined us in San Antonio to make the premier event in the profession another huge success!

It was an action-packed week in San Antonio, kicking off with an inspiring keynote address from NY Times Bestselling Author Ben Nemtin on the Ripple Effect of Healthcare and the installation of Scott Nelson, DPM, FACFAS as the 69th President of the College. We also celebrated the tenure of retiring College Executive Director Chris Mahaffey, MS, CAE, FASAE and welcomed new Executive Director Patrick (PJ) Andrus, CAE. This year’s meeting included a full lineup of interactive labs, sessions and workshops ending with a Texas-style Wrap Party at the Buckhorn Saloon to make for another successful Annual Scientific Conference.

Full conference coverage and photos will be featured in the April issue of ACFAS Update. The fun might be over for now, but your luck hasn’t run out—we’ll be back in Las Vegas for the 79^th Annual Scientific Conference February 25-28, 2021! Let your patients know you attended last week’s Annual Scientific Conference in San Antonio—download the free fill-in-the-blank press release from the ACFAS Marketing Toolbox.

Once you complete the press release with your information, you can distribute it to your local media, include it in your office newsletter or post it on your practice website and social media accounts.

For other free resources to help promote your practice, educate patients and increase office referrals, visit the Marketing Toolbox at acfas.org/marketing. If you missed Coding & Billing for the Foot and Ankle Surgeon last week in San Antonio, you’re in luck! You have two more opportunities this summer to attend this seminar and ensure your practice is properly reimbursed for the care you provide. Join us for one of the two Coding and Billing for the Foot and Ankle Surgeon Seminars.

July 31-August 1
(Friday/Saturday)
Disney Swan & Dolphin Hotel
Orlando, FL

September 11-12
(Friday/Saturday)
Palmer House Hilton
Chicago, IL

This seminar is worth 12 continuing education contact hours. Register now at acfas.org/practicemanagement.

Foot and Ankle Surgery

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Researchers investigated whether the takedown of a painful ankle arthrodesis to total ankle arthroplasty can restore some sagittal plane motion and improve functional scores. A retrospective analysis was performed on 77 patients who underwent a conversion of a painful ankle arthrodesis to a total ankle arthroplasty between Feb. 2003 and Dec. 2016, with an implant retention rate of 88 percent and a mean follow-up of 8.3 years. Eight of the 11 failures were revised to a total ankle replacement, two underwent revision arthrodesis and one elected for below-the-knee amputation. The mean American Orthopaedic Foot and Ankle Society ankle-hindfoot, Buechel-Pappas and visual analog pain scale scores improved from preoperative values, with less satisfaction noted in those who needed revision surgery. Researchers conclude that converting a painful ankle arthrodesis to a total ankle implant is a viable way to obtain range of motion and improved patient satisfaction scores similar to primary total ankle replacement.


Researchers carried out a retrospective analysis in 31 cases (39 feet) of patients with intractable plantar fasciitis. In the enrolled 26 cases, 16 patients (19 feet) received open plantar fascia release, and the other 15 patients (20 feet) received percutaneous radiofrequency ablation. The surgical results were assessed by visual analog scale (VAS) and American Orthopaedic Foot and Ankle Society Ankle-Hindfoot Scale (AOFAS-AH) before and after surgery in all patients. There were no differences in demographics and characteristics information between the two patient groups. The open plantar fascia release had a longer average operative time and a longer recovery time to normal activity than the percutaneous radiofrequency ablation. There were no differences of postoperative VAS scores and the AOFAS-AH scores between the two groups, and all patients reported satisfaction after either operation.


The purpose of this study was to determine the incidence of tibial stress fracture after ankle arthrodesis, highlight any related risk factors, and identify the effectiveness and healing potential of treatment strategies. Researchers performed a retrospective chart review at two large academic medical centers to identify patients who had developed a stress fracture of the tibia after undergoing ankle arthrodesis. Fifteen out of 1046 ankle fusion patients developed a tibial stress fracture at a mean time of 42 months following the index procedure. Stress fracture location was found at the level of the fibular osteotomy in two patients and at the proximal end of an implant in nine. Fourteen of the 15 patients had a nondisplaced stress fracture and were treated with immobilization and activity modification. Of these, three failed to improve with nonoperative treatment and subsequently underwent operative fixation. Only one of the 15 patients presented with a displaced fracture and underwent immediate plate fixation.

Practice Management

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In order to grow your medical practice, you must have mechanisms to monitor and assess the current state of your business. Use these metrics to form realistic expectations, framing one-year, three-year and five-year goals. Identify the financing options that work best for your practice, taking into consideration interest rates, account fees, premiums, and closing costs as well as the term of your loan. Cash-flow is extremely important, and doing a quick payoff can create a cash-flow crunch. SBA loans can be especially helpful for doctors who are looking to open, acquire, or expand a practice because of a federal guarantee of up to 85 percent, meaning less risk for the lender and easier access for the borrower. Set up a business plan, including financial goals and parameters that weigh profit against your interests and passions as a physician. Be careful in building your team, because human capital is the most important growth area and main investment for a medical practice. Resist the temptation to hire quickly because of immediate demands or pressures, and focus instead on curating a high-quality staff for sustainable growth.


A recent Medscape report finds that 42 percent of physicians surveyed feel the effects of burnout. Physician burnout affects all ages and specialties, and much of the dissatisfaction has to do with restrictions on patient-doctor time. A Medical Economics Physician Report found that nearly 80 percent of doctors cite administrative burdens as the top challenge they experience in practice, draining their time to the point that one study estimates that doctors today spend just 27 percent of their time interacting with patients. In recent years, the healthcare industry has become increasingly controlled by systems that place quantity of visits over quality. Telemedicine, the use of video conferencing to communicate with patients, can allow physicians to add value to both see more patients and spend more time with the patients they see. Televisits provide continuity of care by keeping patients connected with their doctors and maximize billable time through a built-in mechanism that monetizes after-hours care and communications like callbacks and follow-ups.


The federal government recently won a $145 million civil and criminal settlement against Practice Fusion, a San Francisco-based electronic health record company. Practice Fusion admitted to taking payments from a major drug company in exchange for dropdown menus that encouraged physicians to prescribe opioids to their patients. The company internally estimated that the drug company could gain nearly 3,000 new customers and increase opioid sales to more than $11 million by implementing the change. Between 2016 and 2017, more than 700,000 unique "pain care plans" were started because of the alert and 20 percent to 33 percent of them involved opioids.

The case highlights how health electronic prescribing is intended to make prescribing safer, but unintended harms may occur without adequate oversight, say Jason N. Doctor and Liisa T. Laine of the Schaeffer Center for Health Policy & Economics at the University of Southern California. They and their research team analyzed the effects of e-prescribing in Finland, where a nationwide e-prescribing system was rolled out across several municipalities over four years starting in 2010. They found that e-prescribing increased the potentially harmful dispensing of benzodiazepines among younger patients because it facilitated prescription refills. "We believe the federal government should require electronic prescribing safeguards that leverage scientific insights about how prescribers make choices to ensure that these systems improve health, not harm it," the authors assert.

Health Policy and Reimbursement

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The physician-staffing firm that runs Nashville General Hospital sued 700 people in Davidson County in 2019. The hospital is a publicly-funded safety net facility that is meant to be the best place in the city for patients without insurance, but its emergency room is run by a company called Southeastern Emergency Physicians. Although Nashville General has stopped suing patients for hospital fees in the past few years, Southeastern has gone the opposite direction, filing more lawsuits against patients than ever in 2019. Robert Goff, a retired hospital executive and board member of nonprofit RIP Medical Debt, says hospital leaders usually say they cannot do anything in these cases. The practice of suing patients is not new for Southeastern or its parent company, TeamHealth, but such lawsuits have picked up in recent years even as the company has stopped balance billing patients.


A new eHealth survey finds that nearly two-thirds of Medicare enrollees are worried about receiving surprise medical bills. Medicare beneficiaries said surprise bills were their top concern when receiving medical care, ahead of other concerns like copays and deductible payments. Almost 40 percent of enrollees said having an in-network provider was their top concern when receiving medical care. Almost 33 percent of survey respondents said out-of-pocket costs were their main concern when selecting a plan, while 31 percent said it was having coverage for preferred providers and 21 percent said it was paying monthly premiums. The survey comes a few weeks after the House Ways & Means Committee released a proposal that would, among other measures, establish an independent mediated negotiation process for billing disagreements.


A new survey by Politico and Harvard's T.H. Chan School of Public Health finds that the vast majority of Americans put cutting health care and prescription costs as their top priorities heading into election season, regardless of party affiliation. Eighty percent of those surveyed put "taking steps to lower the cost of health care" as "extremely" or "very" important, including 89 percent of Democrats and 76 percent of Republicans. By contrast, implementing a Medicare buy-in program or enacting Medicare for All ranked sixth and tenth, respectively, among the 22 issues survey respondents were asked to prioritize. The focus on health care costs is consistent with polling over the past two years and has driven congressional Democrats' emphasis on passing legislation meant to lower drug prices and reinforce the Affordable Care Act (ACA).

The Trump administration has also touted efforts on drug pricing, though it has made little headway on the issue. The current Democratic front-runner for president, Sen. Bernie Sanders (I-Vt.), has vowed to pass Medicare for All as part of an ambitious platform. Republicans have little interest in a major health care overhaul after the GOP's failed attempt to repeal and replace the ACA in 2017, with just 37 percent saying this is important to them, even lower than the 43 percent of GOP respondents who ranked a Medicare buy-in as extremely or very important. The poll surveyed 1,011 US adults between Jan. 21 and Jan. 26 and had an overall margin of error of 3.5 percentage points.


Eight million Americans have started crowdfunding campaigns through websites like GoFundMe to pay for medical expenses for themselves or someone in their households, according to a NORC at the University of Chicago survey. Another 12 million Americans said they have started a campaign for someone else, and 20 percent of Americans said they donated to such campaigns. The proliferation of these online fundraisers to pay for medical bills is a symptom of the increasing costs of health care, even for those who have insurance. The NORC survey found 85 percent of respondents thought the government should be responsible for providing help when medical care is unaffordable.

Medicine, Drugs and Devices

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A new report released by US Food and Drug Administration (FDA) describes scientific research conducted and funded by the agency in fiscal year 2019 to support the development of generic drugs under the Generic Drug User Fee Amendments (GDUFA II). The report covers 13 research areas within FDA's four scientific priorities the agency set for FY2019, including complex drug-device combination products and methodologies for bioequivalence and substitutability evaluation. The research addresses ways to strengthen FDA's assessment of abuse-deterrent formulations, generic dry powder inhalers and handling the complexity of long-acting injectables and implants, among other areas.


A report released last year by the US Centers for Disease Control and Prevention estimated that nearly 3 million Americans annually contract antibiotic-resistant infections, resulting in the deaths of more than 35,000 people. However a major hurdle to a robust antibiotic ecosystem is low expected revenue and limited market opportunities for the drugs despite the potential for substantial public health benefits. Several antibiotic companies filed for bankruptcy over the past year. The Duke-Margolis Center for Health Policy and other stakeholders have called for alternative value-based payment reforms that coordinate and strengthen incentives for the development, availability and appropriate use of priority antibiotics. Scott Gottlieb, former commissioner of the US Food and Drug Administration, and other public officials have called for the development of "subscription," population-based payments or licensing models for priority antibiotics.

In the United Kingdom, an experimental subscription payment arrangement is being used as a set fee paid to manufacturers based on the availability of a drug to safeguard a population and not the volume of the drug actually used. This subscription payment strategy may better reflect the value of the antibiotic to the population being covered, in particular Medicare beneficiaries who do not have to face the risk of a resistant infection because an effective alternative is available to prevent its spread.