News From ACFAS

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The U.S. Centers for Medicare and Medicaid Services has released a proposed rule on prosthetics and orthotics that would require furnishers of these items to Medicare beneficiaries to be licensed or certified by a state entity or by the American Board for Certification in Orthotics, Prosthetics and Pedorthics (ABC) or the Board of Certification/Accreditation (BOC).

The College requests that CMS exempt physicians, such as foot and ankle surgeons, from the rule. Foot and ankle surgeons receive the requisite education and training during medical school and residency to be able to provide these services to patients without additional certification. Additionally, foot and ankle surgeons are unable to be licensed by ABC or BOC and would need to go through additional training, causing a lapse in continuity of care for Medicare patients. See the Federal Register for more on the proposed rule. If you are a fellowship program director and would like to seek status for your program with ACFAS, submit your application by May 1, 2017.

The ACFAS Fellowship Committee will meet in late summer in Chicago to review any new applications and will communicate their decisions later that month.

Contact Michelle Kennedy, ACFAS membership director, to request an application or to learn more about the College's Recognized Fellowship Initiative. All ACFAS members are encouraged to contact their federal representatives in support of House Bill 1058, the U.S. Department of Veterans Affairs Provider Equity Act. The bill would put DPMs on equal footing with MDs and DOs in the VA hospital system. ACFAS is writing to support this bill. For additional information, contact Sarah Nichelson, JD, ACFAS director of Health Policy, Practice Management and Research.

Foot and Ankle Surgery

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Researchers have conducted a retrospective matched pair analysis using computed tomography osteoabsorptiometry (CT-OAM) to evaluate in vivo changes of talar load distribution after lateral malleolar fractures in patients treated with open anatomic reduction and internal fixation (ORIF) compared to patients treated nonoperatively. Ten matched pairs of patients with isolated lateral malleolar fractures with a maximum fracture dislocation of 3 mm and a median follow-up of 42 months were included in the study. Patients treated with ORIF showed a significantly lower ROM compared to the uninjured contralateral ankle, and there were no differences in clinical scores of patients treated by ORIF and those treated nonoperatively. CT-OAM analysis showed symmetrical distribution of subchondral bone mineralization in comparison to the uninjured contralateral ankles for both groups of patients. The findings suggest that isolated lateral malleolar fractures with fracture gaps up to 3 mm are not associated with a change of the tibio-talar joint load distribution in vivo. Patients with isolated minimally displaced lateral malleolar fractures may achieve good clinical long-term outcomes following nonoperative treatment.


Current methods for measuring in vivo three-dimensional (3D) muscle-tendon moment arms are mainly reliant on acquisition of magnetic resonance imaging (MRI) scans at multiple joint angles. For patients with musculoskeletal pathologies, such as fixed contractures, this procedure is not always feasible. Research was conducted to develop a simple, reliable in vivo 3D Achilles tendon moment arm (ATMA) method from a single static magnetic resonance imaging (MRI) scan. The geometry of a cylinder was fit to the 3D form of the talus dome, which was used to estimate the talocrural flexion/extension axis, and a fifth-order polynomial fit to the line of action of the Achilles tendon, for nine healthy adults. The estimates achieved via this technique were compared to estimates acquired from the same subjects at the same ankle joint angles using a previously validated 3D dynamic MRI-based in vivo ATMA measurement technique. The ATMA estimates from the single scan in vivo 3D agreed closely with the validated in vivo 3D method. The data shows reliable in vivo 3D ATMA can be obtained from a single MRI scan for healthy adult populations. The single scan, in vivo 3D ATMA technique offers researchers a simple and reliable protocol for obtaining subject-specific ATMAs for musculoskeletal modeling.


New research assesses whether magnetic resonance imaging (MRI) findings can explain calf muscle strength deficits and the difference between nonsurgical and surgical treatments in restoring calf muscle strength. From 2009 to 2013, 60 patients with acute Achilles tendon rupture (ATRs) were randomized to surgery or nonsurgical treatment with an identical rehabilitation protocol. The primary outcome measure was the volume of calf muscles assessed using MRI at three and 18 months, and the secondary outcome measures included fatty degeneration of the calf muscles and length of the affected Achilles tendon. Also, isokinetic plantarflexion strength was measured in both legs. Treating ATRs nonsurgically with a functional rehabilitation protocol resulted in greater soleus muscle atrophy compared with surgical treatment. At 18 months, Achilles tendons were, on average, 19 mm longer in patients treated nonsurgically compared with patients treated surgically. These structural changes partly explained the 10 percent to 18 percent greater calf muscle strength observed in patients treated with surgery compared with those treated nonsurgically.

Practice Management

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The U.S. Centers for Medicare and Medicaid Services (CMS) has launched a national effort to make physicians aware of federal funding that could be used to compensate them for treating the sickest Medicare beneficiaries better. The agency has been paying physicians $42 per patient per month on average for consulting with specialists and coordinating chronic care services. The program could reduce expenses for treating people with chronic conditions, but physicians have not leveraged it because few know about the care management billing code, and there has been resistance from beneficiaries, who would need to pay a 20 percent copayment. According to CMS, about 35 million beneficiaries have multiple chronic conditions, which would qualify their physicians to receive compensation for chronic care services. However, chronic care claims for only 513,000 beneficiaries have been submitted as of the end of 2016.


New research into the Medicare accountable care organization (ACO) program examines whether administrative measures of wait times for specialist consults are associated with self-reported patient satisfaction. Researchers analyzed administrative and survey data from a clinically integrated healthcare system similar to an ACO. Administrative access metrics included the number of days between the creation of the consult request and first action taken on the consult, scheduling of the consult and completion of the consult. Outcome measures included general Veterans Health Administration satisfaction measures and satisfaction with timeliness of care, including wait times for specialists and treatments. Logistic regression models predicted the likelihood of patients reporting being satisfied on each outcome and were risk adjusted for demographics, self-reported health and healthcare use. Longer waits for the scheduling of consults and completed consults were found to be significantly associated with decreased patient satisfaction. Wait times are an important patient-centered access metric for ACOs, considering patients often report high levels of powerlessness and uncertainty while waiting for consultation. ACOs should have systems and tools in place to streamline the specialist consult referral process and to increase care coordination, conclude the researchers.


According to research published in 2014 in the International Journal of Medical Informatics, physicians who use a technology-centered approach have the longest patient encounter times and also have the lowest patient satisfaction scores. Patient satisfaction and engagement depend on the ability to engage in direct eye contact with the physician and screen share when he or she turns his or her attention toward the computer. However, electronic health records (EHRs) decrease satisfaction when they vie for the physician's attention. One proposed solution is to have a scribe document the patient encounter on the EHR. The physician then will be free to concentrate on patient concerns, repeat key points and explain medical results in a more simple manner. After the encounter, the physician can review the scribe's note to ensure the documentation is complete, attach orders and sign the note. When scribes are used, physicians feel more efficient, and patients believe the physician is more attentive, compassionate and courteous during their interactions, according to a 2013 study in the Journal of ClinicoEconomics and Outcomes Research. Dr. Jerry Hizon, physician-owner of Motion Sports MD in Murrieta, Calif., reports that while using a scribe, he maintained an average satisfaction rating of 4.9/5.0 and was able to spend 93.7 percent of each patient encounter directly interacting with the patient.

Health Policy and Reimbursement

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A newly released Congressional Budget Office (CBO) analysis of the House GOP's proposal to rewrite federal healthcare law predicts that approximately 24 million fewer people would have coverage a decade from now than if the Affordable Care Act remains intact. Individuals age 50 and up would face higher premiums and lower subsidies under the plan, according to the analysts. Older, lower-income people would make up a large share of those losing coverage. Uninsured people in this group would grow to about 30 percent of the total uninsured population in 2026, compared to 12 percent of the uncovered under current law. Starting in 2018, the proposal allows insurers to charge older Americans five times what the youngest ones pay, unless their individual state sets a different level, versus three times now. Also, starting in 2020, the plan would replace today’s premium tax credits, which are based on income, geography and age, with a flat amount based on age that phases out beginning at $75,000 for an individual.


The Senate confirmed Seema Verma on March 13 as director of the U.S. Centers for Medicare and Medicaid Services. Verma, who won in a largely party-line vote, is an advocate of overhauling Medicaid. She handled Indiana’s Medicaid expansion program under then-Gov. Mike Pence via a federal waiver granted by the Obama administration that allowed the state to charge Medicaid enrollees monthly premiums.


The Trump administration is opening the door for states to make changes to their health insurance programs by using a section of the 2010 Affordable Care Act (ACA) that gives them the flexibility to do so. The administration plans to replace the federal oversight on insurance plans with state control. ACA had originally laid out a roadmap for states to have more power in deciding how to implement the law as long as they met four key criteria for so-called state innovation waivers. However, in 2015, the Obama administration issued new regulatory guidance that would have tightened the use of such waivers, which were able to be used as of January 1, 2017. In a news release, the U.S. Centers for Medicare and Medicaid Services said that the "section 1332" waivers could be used to help states receive funding to help offset costs for high-risk patients and premium stabilization programs related to the individual marketplace.

Medicine, Drugs and Devices

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A new type of treatment is available for patients living with arthritis. The treatment sees damaged cartilage replaced with the same material as a contact lens. Dr. Selene Parekh, who offers the treatment at his orthopedic practice in Durham, N.C., said of the treatment, "This is a revolutionary type of product that potentially is a lifelong solution for many patients to maintain motion and decrease the pain that they're suffering from." The treatment is only being used for big toes in the United States, but European doctors are using the synthetic cartilage in knees and thumbs. Data shows 91 percent of patients who undergo the treatment experience a reduction in pain.


A new study to be presented at a Scientific Exhibit at the American Academy of Orthopaedic Surgeons 2017 Annual Meeting examines the available evidence on radiation exposure in medical imaging in pediatric orthopaedic care and offers recommendations to optimize decision-making to reduce unnecessary exposure. Analysis of peer-reviewed literature on different options in imaging technology that may be used in pediatric orthopaedic injuries, including x-rays and computed tomography (CT) scans of the spine, pelvis, hip, knees, shoulder, elbow, hand and wrist and foot and ankle, was conducted. The investigators then measured the amount of radiation in each of these scans. They discovered that pediatric patients needing surgery for hip dysplasia, scoliosis and leg length discrepancy are among those most likely to undergo imaging, such as x-rays or CT scans, and thus may be among those who are most susceptible to exposure risk. The researchers developed best practices for orthopaedic surgeons to follow, including adherence to the "as low as reasonably achievable" principle to limit exposure to parts of the body that are absolutely essential for diagnosis, removing repeated exposures resulting from technical error, restricting precise collimation to the region of interest, limiting fluoroscopy to short bursts as needed, using low-dose CT protocols adjusted for the size of the patient and limiting CTs of the spine and pelvis in pediatric patients.


The high cost of medical supplies that hospitals throw away is one reason the U.S. healthcare system costs so much. In 2012, the National Academy of Medicine estimated the U.S. healthcare system squandered $765 billion a year, more than the entire budget of the Defense Department. Dr. Mark Smith, who chaired the committee that authored the report, and colleagues blame the obvious villains—overtreatment, excess administrative costs and high prices—for most of the fat in the system, but left untallied are the waves of discards that now arrive at the warehouses of nonprofits, most of which would otherwise end up in landfills. Organizations, such as Partners for World Health, collect medical equipment and supplies from a network of hospitals and medical clinics, sort them and eventually ship containers full of them to countries like Greece, Syria and Uganda. Hospital officials sometimes say some of the waste is unavoidable, as some items must be replaced to meet infection control guidelines. Healthcare finance experts say while patients might not see the cost in their bills, the wasted supplies boost a hospital's overhead, which in turn makes everyone's costs higher. Unfortunately, quantifying what is being squandered is difficult. There is scant research on castoff medical supplies, which makes it easy for hospitals to say it does not add up to much.