News From ACFAS

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Listen in to the top-trending discussions in the profession through the latest podcasts on ACFAS OnDemand. Whether you're using them as a teaching tool, a learning resource for yourself or just to hear what’s new, you'll be informed with new podcasts released each month.

This free resource is a great way for members and non-members to hear dialogue between subject experts with different schools of thought and discussion on new and cutting-edge themes in the profession. Podcast subjects range from dealing with second opinions, rehab for Achilles rupture, malunited ankle fracture, post-operative edema control and more!

Visit our online learning portal at acfas.org/OnDemand to access the latest podcasts and to check out other e-learning tools offered through ACFAS. If you are a fellowship program director and would like to seek ACFAS status for your program, submit your application by May 1, 2020.

The ACFAS Fellowship Committee meets late July in Chicago to review any new applications and will share new programs in August.

Contact Michelle Kennedy, ACFAS director of Membership and Post Graduate Affairs, to request an application or to learn more about the College's Recognized Fellowship Initiative.

Foot and Ankle Surgery

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This study is an independent evaluation of a new pilon fracture classification system based on CT scans, which showed almost perfect interobserver and intraobserver agreement among the authors who developed. For the present study, 71 cases of acute pilon fracture were collected and classified by six evaluators using CT scans according to the grading of the new system. Cases were presented to the same evaluators in a random sequence after a six-week interval to determine intraobserver agreement. The interobserver agreement was substantial regarding the main fracture type (I, II, III or IV) and still substantial when including the II and III subtypes. The intraobserver agreement was substantial when considering the main fracture categories, and full agreement at the type level was observed in 76 percent of evaluations. There was no notable difference in the interobserver and intraobserver agreement between the foot and ankle surgeons and orthopaedic surgery residents.


The study investigates the presence of mechanoreceptors in samples obtained from the first metatarsophalangeal joint capsules of patients with hallux valgus deformity in an effort to better understand the clinical and histopathological features of the disease. Samples were taken from the first metatarsophalangeal joint capsules of 13 cadavers with normal anatomy (controls) and 29 patients undergoing surgery for hallux valgus (cases). Orientation of collagen fibers was determined on Masson's trichrome–stained sections, and mechanoreceptors were evaluated on S-100-immunostained sections. In the sections stained with Masson's trichrome, the orientation of collagen fibers was regular in the control group, but coarse and disoriented collagen bundles were observed in the hallux valgus cases. Free nerve endings were more abundant in the hallux valgus cases than from the control group, while S-100 immunostaining was positive in the sections of both the cases and controls.


The study aimed to determine whether implanting a dehydrated human amniotic membrane (DHAM) allograft in total ankle arthroplasties (TAAs) decreased overall postoperative wound complications. One hundred seventy patients with end-stage ankle arthritis underwent TAA with a standard anterior approach by one of three foot and ankle orthopedic surgeons. Ninety-one patients underwent closure of the anterior incision with addition of DHAM, whereas 79 patients served as the control (no addition of DHAM). The researchers found no statistically significant difference in any postoperative complications between patients closed with DHAM and controls. Return to the operating room occurred in 8.9 percent of controls and 15.4 percent of the DHAM group, and there was no significant difference in postoperative plastic surgery, wound communication with the implant, implant removal, neurolysis and tendon debridement between the control and DHAM groups.

Practice Management

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In an effort to alleviate physician burnout, the US Centers for Medicare and Medicaid Services (CMS) have unveiled a new strategy for standards of care focused on efficiency and accountability. Verma pointed to CMS' Patients Over Paperwork initiative, which streamlines agency regulations and reduces process rules to save $6.6 billion and 42 million burden hours through the end of next year. CMS is also launching the Merit-based Incentive Payment System (MIPS) Value Pathways (MVP) program to make MIPS more relevant to physicians' scope of practice. This is part of its Meaningful Measures program, which aims to make reporting quality measures simple and seamless for physicians. Verma noted that much of this progress will be made through the Fast Healthcare Interoperability Resources software standard, which will let clinicians share patient data across electronic health records. CMS estimates that Meaningful Measures will save $128 million and 3.3 million burden hours by the end of the year.


When preparing to negotiate with a payer, physicians should first gather meaningful data on how the payer's rates compare to their competitors, which can serve as useful ammunition. Physicians should seek to communicate what makes their practice uniquely valuable, presenting potential weaknesses as strengths and letting the payer know about any quality initiatives in which it participates. Many physicians tend to be non-confrontational with payers, looking to "go with the flow," which is a mistake. Physicians should be forthright in asking for what they need or want while remaining open to trade-offs, understanding that time spent in additional negotiation is worthwhile.


A 2019 study by the Healthcare Information and Management Systems Society (HIMSS) found that 74 percent of healthcare organizations had experienced a significant cybesecurity incident in the last 12 months. The most common incidents involved phishing, wherein a malicious actor poses as a known entity to trick the recipient into clicking on a malicious link; spear phishing, which is a more tailored version involving specific people and content; and compromised email accounts. Practices can largely address these issues by changing the email security habits of staff, encouraging employees to treat any link from a known or unknown sender with skepticism. Practices should also prepare for the reality that at some point an incident will occur, developing the ability to respond quickly to alerts and minimize damage. A culture that encourages employees to report a possible incident that they may have created is critical to successful recovery, as time is of the essence in responding to a breach.

Health Policy and Reimbursement

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The Supreme Court will hear a third major challenge to the Affordable Care Act (ACA), granting requests from Democratic state officials and House members. Democrats had urged the justices to act quickly even though lower courts had not issued definitive rulings, looking to ensure the case was decided while justices who had rejected earlier challenges to the law remain on the court. The justices will hear a case brought by Republican state officials who argue that Congress rendered the entire law unconstitutional in 2017 when they eliminated the penalty for failing to obtain health insurance. Two lower courts agreed with this interpretation, and the Democratic states and House argue that their findings necessitate faster review by the Supreme Court. The Supreme Court has already ruled, in 2012 and 2015, to uphold the ACA in two major cases challenging core provisions of the law.


In a recent letter, Seema Verma, administrator of the US Centers for Medicare and Medicaid Services (CMS), said the agency is "currently exploring ways" to allow Medicare reimbursement for Diabetes Prevention Programs (DPPs) that use telehealth. The CMS does not currently reimburse care providers in its National Diabetes Prevention Program for using telehealth tools, which many programs want to change as they adopt telehealth to expand their reach and make the most of limited resources. CMS has said there is not enough evidence that these programs work for it to reimburse them, but Verma's letter suggests that lobbying efforts may have prompted the agency to reconsider. Including virtual care services could also help the National DPP, which few Medicare beneficiaries are accessing. In its own lobbying effort, the American Medical Association said the inclusion of virtual care services could improve access to the program for millions of underserved Americans.


The US Centers for Medicare and Medicaid Services has selected 205 applications to participate in the Emergency Triage, Treat and Transport (ET3) Model, a payment model that gives ambulance providers more flexibility in where they take Medicare beneficiaries after a call. Currently, Medicare only pays for emergency ground ambulance services when beneficiaries are transported to a hospital emergency department. Under the ET3 model, Medicare will pay participating ambulance suppliers to transport a beneficiary to an alternative destination, such as a primary care office or urgent care clinic or initiate treatment in place through telehealth. Ambulance suppliers and providers may triage Medicare beneficiaries to one of the model's interventions. The model could save Medicare nearly $560 million per year by transporting beneficiaries to physician offices rather than the hospital emergency department.

Medicine, Drugs and Devices

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While most research on prescription drug costs has centered around list prices, a new retrospective study brings manufacturer discounts into the discussion. Specifically, researchers from the University of Pittsburgh's Center for Pharmaceutical Policy and Prescribing asked how much these markdowns—which are on the rise—offset escalation in list prices. The team relied on 2007–18 pricing data for more than 600 brand medications that came to market in the United States before January 2007.

Based on their review, list prices and net prices rose 159 percent and 60 percent a year, respectively, during the study period, with multiple sclerosis therapies and cholesterol medications outpacing the rest of the field. Deeper discounts within the Medicaid system and in other payers, meanwhile, offset these substantial hikes. Discounts jumped to 76 percent from 40 percent for the former and to 51 percent from 23 percent for other payers, resulting in an overall 62 percent buffer against rising list prices.


A new study in JAMA Network Open indicates that if physicians were to prescribe short-acting medications taken twice a day instead of extended-release versions that are taken one time per day, billions in healthcare costs could be saved. Ambarish Pandey, MD, of the University of Texas Southwestern Medical Center in Dallas, said: "It's not a huge difference in terms of patient convenience, but the cost difference is remarkable." Pandey and colleagues focused on drugs whose benefits in a two times-per-day version are equivalent to those of the extended-release version. Pandey points out that some contend patients are more likely to adhere to their medication schedule if the drug is taken once a day, but that has not been proven.

To gauge costs, Pandey's team examined records for 20 drugs comprising 37 formulations—19 brand-name and 18 generic—from the Medicare Part D Prescription data set and the Medicaid Spending and Utilization Data set for 2012 through 2017. Over the entire study period, Medicare Part D spent $12 billion on extended-release formulations while Medicaid spent $5.9 billion. A switch to twice-daily versions would have saved $13.7 billion, they estimate. Pandey says insurers should require drug companies to reduce extended-release costs to the point where the price is comparable to that of the twice-a-day version.


The US Department of Health and Human Services said it plans to buy 500 million N95 respirators over the coming 1.5 years for the Strategic National Stockpile (SNS). According to the agency, "Through guaranteed orders, this acquisition encourages manufacturers to immediately increase production of N95s for use by healthcare professionals. These guaranteed orders offer reassurance to manufacturers that they will not be left with excess supplies if private sector orders are cancelled once the COVID-19 response subsides.

Manufacturers typically avoid ramping up production without such a guarantee." At present, the SNS includes millions of N95 respirators that can be used in accordance with the Strategies for Optimizing the Supply of N95 Respirators guidance released by the US Centers for Disease Control and Prevention. In an emergency, the SNS could disperse the existing products as well as any available quantity obtained through future contracts to areas in need as requested by state health officials. HHS said that no proposals have been received, nor have any contracts been executed thus far. Proposals must be received by March 18, 2020.