News From ACFAS

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If you missed this year’s meeting in Austin, you can still take part in the ACFAS 2022 On-Demand Package! Access over 20 hours of learning recorded at this year’s Annual Scientific Conference from your computer wherever you are.

The On-Demand Package includes:

• 13 recorded ACFAS 2022 sessions totaling 23 CME hours
• Ability to view session recordings for up to one year
• Convenient 24/7 online access

Registration ends on March 31, so don’t wait to access the On-Demand Package. Visit acfas.org/Austin for more information. Join expert faculty May 12-13 in Chicago for a deep dive into podiatric internal fixation surgery. Comprehensive Fixation for the Ankle and Foot: A Resident's Course offers a small resident to faculty ratio allowing for close mentorship, and a redesigned agenda focused on shorter lectures with ample time for hands-on learning. This course offers real-life experience in:

• Major rearfoot and ankle arthrodesis techniques
• Complications that can result from internal and external fixation
• Specialty plating and external fixation techniques
• Preoperative planning
• Psycho-motor skills

Earn 17.25 CME credits as you learn about and execute the principles and techniques for stable internal fixation for fracture management, aspects of diagnosis, and treatment and subsequent management of these injuries.

Visit acfas.org/skills for more information and to register today!

Foot and Ankle Surgery

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A study probed the potential of exogenous hyaluronic acid (HA) affiliated with corticosteroid to improve pain and function in subtalar osteoarthritis, compared to isolated intra-articular corticosteroid injections. Twenty-five participants (50.16 ± 8.03 years) with a minimum follow-up of 12 months post-surgery for calcaneus fractures were enrolled. Participants were randomly assigned to two therapeutic groups, with the 12-member Corticosteroid Group undergoing isolated corticosteroid intra-articular subtalar injection, while the 13-subject HA + C Group received HA and corticosteroid. All participants had three injections with intervals of one week. The HA + C Group showed lower visual analog scale of pain (VAS) at the 12th and 24th weeks and greater American Orthopaedic Foot and Ankle Society (AOFAS) scores at the fourth, 12th and 24th week compared with the Corticosteroid Group. Although VAS improvement in the Corticosteroid Group was noted at the fourth week, it increased at the 12th and 24th weeks. VAS also improved in HA + C Group at the fourth week, with stabilization continuing until week 24. AOFAS improved at the fourth week in the Corticosteroid Group, and the levels remained stable until the 24th week. AOFAS also improved at the fourth week in the HA + C Group, with further stabilization until the 24th week. Exogenous HA + corticosteroid resulted in greater and longer analgesic effects and function improvement versus isolated intra-articular corticosteroids.


A study was held to measure the degree of variation in the dorsalis pedis artery (DPA) and the distance between the arcuate artery (AA) and the tarsometatarsal (TMT) joint in order to lower the risk of vascular complications from dorsal midfoot surgery. Researchers used 29 fresh cadaveric feet to analyze the course of the DPA and the distance between the AA and the TMT joint on computed tomography images with barium sulfate contrast. The DPA had a standard course in 11 of the 29 cases but did not induce the AA and lateral tarsal artery or branches of the plantar arterial arch supplying to the second to fourth metatarsal spaces in 10 of 29 cases. The respective mean closest distance from the TMT joint to the AA at the second, third and fourth metatarsal level in the sagittal plane was 11.4, 14.6 and 17.1 mm. Significant variation in the arterial anatomy of the DPA system was observed across the dorsal midfoot, and the surgeon's awareness of this may mitigate the risk of pseudoaneurysm and frank arterial disruption.


A study was held to characterize the optimal cut-off values for diagnosing Lisfranc instability by assessing side-to-side differences of preoperative bilateral weightbearing radiographs among patients with surgically-confirmed ligamentous Lisfranc instability. The researchers also investigated whether the midfoot measurements for detecting Lisfranc injury were usable in patients with a pre-existing bilateral Hallux Valgus (HV) deformity by evaluating whether the Lisfranc measurements could be impacted by a foot deformity as HV. Forty-seven patients were included in the Lisfranc group with a mean age of 33 (± 15) years and 25 were included in the HV group with a mean age of 51 (± 15) years. The results indicated that bilateral foot weightbearing radiographs are effective diagnostic tools for ligamentous Lisfranc instability using a standardized measurement protocol. Malalignment of the medial aspect of the second metatarsal base = 0.3 mm relative to the intermediate cuneiform yields a high sensitivity, and distance = 2.1 mm between the second metatarsal base and the medial cuneiform returns high specificity. Intermetatarsal distance between the first and second metatarsal base exhibits low sensitivity and specificity and should not be employed by itself for diagnosis.

Practice Management

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Administrative hurdles to receiving timely healthcare, also known as "sludge," can be targeted for removal via a sludge audit, and clinical leaders at private healthcare company Ascension offer four strategies that health systems can follow. The first approach is to try to eliminate any redundant steps in the existing healthcare process, instead of immediately adding a new component. A second strategy is to add a more automated digital channel as a primary option for patients when initiating the healthcare process, rather than verbal communication. Removing documents that have no bearing on the patient's medical visit is a third approach, and the fourth and final strategy is to replace processes requiring in-person visits with virtual options.


Hiring and retaining staff at medical practices requires a supportive internal culture that translates into better patient care, according to Eden Health's Heather Towery, MD. She recommends four steps, beginning with an onboarding process that is welcoming to new hires, hits the mission early and often and establishes expectations and clear objectives. The second step is to set up scheduling that offers paid time off and personal time, as well as multidisciplinary and regional team breakdowns. The third step involves a team-building meeting structure that emphasizes daily conferences, aligns incentives and provides meaningful recognition. The fourth and final step delivers a sense of purpose by giving staff opportunities to provide significant input, prioritizing fan favorite projects and developing career plans.


Family physician Carolynn S. Francavilla Brown offers tips for starting a practice that can ensure success for both doctors and patients from the outset. She says staffing is one of the biggest challenges and recommends hiring pre-health students. "They are eager to gain experience and receive mentorship for the next phase of their training, and we get motivated employees who are open to joining an established medical practice," Francavilla Brown writes. Practice management tools should also be incorporated to automate and simplify many day-to-day tasks, enabling doctors to devote more time to patient care. Networking is also essential, and Francavilla Brown suggests savvy business owners can be an outstanding source for insights and tips.


Elsevier Health's first "Clinician of the Future" global report has dire predictions for healthcare unless the industry future-proofs itself against disruptions like the COVID pandemic. The study estimated that 75 percent of healthcare workers will exit the profession by 2025. Furthermore, 71 percent of doctors and 68 percent of nurses believe their jobs have changed significantly in the past decade, with many saying they have worsened. Moreover, 56 percent of clinicians worldwide agreed patients have become more empowered to manage their own conditions over the last 10 years, while 82 percent concurred that soft skills, like listening and empathy, have become increasingly important among clinicians. Respondents also singled out priority areas requiring additional support, such as augmenting health technology skills, devoting more concentration to the patient-provider relationship and expanding the healthcare workforce.

Health Policy and Reimbursement

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The American Medical Association (AMA) reports that medical liability premium increases are rising: the percentage of premiums that decreased was 25.7 percent in 2012, versus 6.5 percent in 2021. The percentage of premiums that increased surged after 2018, when 13.7 percent of premiums expanded. In 2019, 26.5 percent of premiums spiked, while 31.1 percent did so in 2020. AMA President Gerald Harmon said the surges in medical liability premiums have compounded the financial stress that physicians have experienced during the coronavirus pandemic, and he warned that the spike "can force physicians to close their practices or drop vital services. This is detrimental to patients as higher medical costs can lead to reduced access to care."

The AMA report explains that this trend is not as severe as the last "hard market," although premiums are trending toward one. "How severe and widespread the current hard market will become—how many premiums will increase, how high they will go and whether other states will follow suit in seeing their premiums go up—is still uncertain," the study concludes.


The Medicare Payment Advisory Commission (MedPAC) warns that Medicare Advantage (MA) is driving the US government to spend billions more on seniors' medical care than necessary and needs a major overhaul. Medicare collected $12 billion in "excess payments" in 2020 over what the country would have paid to cover people who used the private plans under standard Medicare. Under MA, insurers can sell plans that provide Medicare benefits plus add-ons like dental or vision coverage, removing the need for consumers to buy supplemental insurance that picks up non-Medicare-covered costs. Yet MedPAC said rising costs could jeopardize Medicare's sustainability, and enrollment in MA plans has doubled over the past decade to cover nearly half of Medicare's 64 million beneficiaries, putting billions in big insurers' coffers. MedPAC's report said private plans are on track to cover half of all Medicare beneficiaries in 2023, and they should be pressed to trim costs. The group said MA plans "need to face appropriate financial pressure" in alignment with providers in the traditional fee-for-service Medicare plan.


When the nation's public health emergency concludes, as many as 16 million low-income people, including millions of children, are on track to be removed from Medicaid. States will be responsible for identifying who no longer qualifies for the program. Gordon Bonnyman, a staff attorney for the nonprofit Tennessee Justice Center, says: "The main concern I have is people are going to be cut off for reasons that have nothing to do with their eligibility." Under the first COVID-19 relief law in March 2020, states were offered additional funds to help pay for Medicaid if they pledged not to remove anyone from program for the duration of the emergency. Every state accepted the offer, and since the start of the COVID-19 pandemic, HHS has been renewing the public health emergency every 90 days. For several months, federal health officials have been assisting states with preparations for "unwinding" from the health emergency, including a list of recommended steps states should take and letters about federal projections. Advocates warn that if Medicaid programs move too rapidly, they will have too many incorrect addresses and call centers will be overwhelmed. Moreover, the existing computerized eligibility systems might not be able to provide accurate renewal decisions. Many states' Medicaid agencies are also short-staffed, and newly hired employees would not be experienced with handling renewals.


Physician groups are calling on Congress to ignore the Medicare Payment Advisory Commission's (MedPAC) recommendation for a flat 2023 Medicare payment calculation rate, claiming that an increase is warranted by a flawed quality-measurement framework, growing inflation and the pandemic's challenges. MedPAC advised Congress to maintain the Medicare base payment rate for physician and other healthcare professional services for 2023. The American Medical Association (AMA) and the American Academy of Family Physicians (AAFP) separately pointed out how the implementation of the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015 has negatively affected their members. Far fewer clinicians have qualified for bonus payments than expected, and many are seeing rising costs due to inflation while still contending with fallout from the pandemic. AAFP President Sterling N. Ransone Jr. said limiting Medicare pay will make it difficult for primary care physicians to make investments necessary for gaining bonuses in a MACRA-designed system. "Without a positive payment update and with continued rising costs, we risk forcing independent practices to be acquired by large health systems, further increasing healthcare costs for patients," he warned.

Meanwhile, AMA CEO James L. Madara sent a letter to Congress referring to research indicating that Medicare Merit-Based Incentive Payment (MIPS) compliance cost an average of $12,811 per physician in 2019, while MedPAC itself admitted to flaws in the MIPS framework. Moreover, the Medical Group Management Association's Anders Gilberg criticized the planned reinstatement of the 2 percent Medicare sequester penalty, which is likely to seriously impact beleaguered practices even more financially, "making MedPAC's decision even more out of touch with the reality physician practices face every day."

Medicine, Drugs and Devices

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Medicare proposed in January limiting coverage for Biogen's costly Alzheimer drug, aducanumab, prompting debate over how much Medicare can afford to pay for biotech therapies. Specifically, the US Centers for Medicare and Medicaid Services said it would only pay for beneficiaries who enroll in follow-up clinical trials, thereby excluding more than 1 million people who otherwise would have been eligible for the drug. A final determination is expected in April. Medicare currently insures 62.7 million Americans aged 65 years and older, and Alzheimer disease affects about 5.8 million mostly older adults. Alicia Munnell, director of Boston College's Center for Retirement Research, asserted: "Medicare dodged a bullet on this drug because the drug itself was controversial. But the system is set up with no guard rails and [coming medicines] could become a huge financial burden." Medicare would have to pay $28,200 yearly per patient for aducanumab. A report by researchers at Boston College pointed out that Medicare is not allowed to negotiate over how much it pays for medications. However, any rule that allows Medicare to do so would have far-ranging effects on the biopharma sector.