News From ACFAS

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Space is still available in our August, October and November Arthroscopy of the Foot and Ankle courses held at the nationally recognized Orthopaedic Learning Center in Rosemont, Illinois. Learn from thought leaders in the profession while working with the same state-of-the-art surgical and audiovisual equipment used by the Arthroscopy Association of North America.

Register now at acfas.org/skills and look forward to:

• More than nine hours of hands-on laboratory time
• The chance to practice advanced arthroscopic techniques on fresh cadaver specimens
• Video-enhanced lectures featuring actual arthroscopy cases
• A fireside chat the first night of the course with the opportunity to share your most challenging cases

Arthroscopy of the Foot and Ankle is worth 16 continuing education contact hours and fulfills privileging requirements. Visit acfas.org/skills to secure your spot today! Wish you could get a clear picture of how well your current coding and billing procedures are performing? Then come to Coding & Billing for the Foot & Ankle Surgeon, July 26–27 in Dallas or September 20–21 in Teaneck, New Jersey, and learn how just a few simple changes can save you time and improve your reimbursement.

Work together with your fellow attendees to accurately code and bill for a week’s worth of clinics, surgeries, calls, office procedures and complex cases. Also get tips for using modifiers to avoid denials and win appeals.

This seminar is worth 12 continuing education contact hours and closes with a breakout session focused on private and multispecialty practices. Reserve your spot now at acfas.org/practicemanagement. See photos and recaps from last month’s record-breaking ACFAS 2019 in ACFAS Update, on its way to your inbox and mailbox soon!

Read all about the conference’s events and activities, including Residents’ Day and the Residency Directors Forum, and find out who won this year’s manuscript and poster competitions. Also read new ACFAS President Christopher L. Reeves’, MS, DPM, FACFAS first column on how to keep perspective in the face of adversity.

View this latest issue on acfas.org now, but keep an eye on your email and postal mail for your personal ACFAS Update delivery!

Foot and Ankle Surgery

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A preliminary study was conducted to explore the potential of having a braceable foot through a proposed accelerated Ponseti method by which manipulations, five castings and Achilles tendon tenotomy are implemented in a week. Included were 11 patients with 16 severe congenital idiopathic clubfeet treated by an accelerated Ponseti method. Five patients exhibited bilateral club foot deformity, and average age at treatment was 54.8 days.

All patients, who had severe congenital idiopathic club feet with a Pirani score of 6, received the accelerated Ponseti method. The method involves manipulation of the deformed foot and first casting in one day, with the second, third, fourth and fifth castings in the fourth, fifth, sixth and seventh day post manipulation. After the fourth cast removal, Achilles tenotomy was performed with subsequent three-week casting for all patients.


A retrospective analysis of patients newly scheduled for bunion correction surgery and completing patient-reported outcomes between October 2013 and January 2018 was conducted to calculate minimally important differences for the domains of the Foot and Ankle Outcome Score (FAOS) for hallux valgus surgery. Using anchor- and distribution-based strategies, the minimally important difference for the pain domain ranged from 5.8 to 10.2, from 0.3 to 6.9 for the symptoms domain, 8.3 to 10.3 for the activities of daily living domain, 7.4 to 11.1 for the quality of life domain and from 7.0 to 15.7 for the sports and recreation domain.

Small differences in the activities of daily living domain may have greater clinical significance for patients with better function. Generally, the most minimally important difference values for the domains of FAOS ranged from above 4 to below 16.


A study was conducted to determine if antirheumatic medications raised the risk of both soft-tissue and osseous postoperative complications in patients with rheumatoid arthritis (RA) who underwent foot and ankle surgery. Of the final 110 subjects meeting inclusion criteria, 31 experienced a postoperative complication, and no statistically significant association was observed between taking antirheumatic medications in the perioperative period and postoperative complications. Longer surgery duration and peripheral neuropathy were associated with a statistically significant increase in postoperative complications. Every 15 minutes of increased surgery time correlated with a 1.2-fold increase in complication risk.

Nonelective procedures had a higher risk of soft-tissue complications compared to elective procedures. Although no statistically significant association existed between the specific medication and complications, some medications trended toward statistical significance.

Practice Management

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Naming a medical practice can take considerable effort, and it should be easy to say, hear, spell and remember, as well as appealing and resonant with the target patient base. One common naming strategy is to use part or all of the physician's name, but this is appropriate only for solo practices. Using a localized or geographic name makes it easier for the target audience to find the practice and its specialization, although these types of names may become outdated over time or restrict the practice's scope if additional services are provided.

A third strategy is to select a name at random, provided it is unique and memorable. It could have an abstract relationship to the practice or practitioner, or it could make an analogy between the practice and the patients or their desired state.


A 2018 study from medical employment firm CompHealth cited ways young physicians find their first positions, what they want in a job and why they depart. Although compensation is important, facilities should know young physicians also want to work in a place with an outstanding culture and a good work/life balance. Younger physicians care about their patients and career, but they also want time for family, friends and interests outside of medicine, so many healthcare facilities have modified their recruiting approach to meet all their staffs' needs.

Experts say physicians in their first job are seeking to build upon the clinical expertise they have been cultivating in their residency or fellowship. Also vital are opportunities for better financial stability, such as loan forgiveness, net income guarantees or a signing bonus, because new physicians often have accrued significant educational debt. CompHealth found 40 percent of placements stem from referrals and networking, while only 12 percent of young doctors use social media to find work.


Primary care doctors and specialists are increasingly using electronic consultations (eConsults) to communicate with each other securely, and they can help patients avoid additional visits and free up capacity in crowded health systems, reducing waiting times for others. More than 40 percent of specialist referrals are unnecessary in some cases, according to research. One study determined about 33 percent of specialists are unwilling to make appointments with new Medicaid patients, while delays in getting the right advice from a specialist can be harmful. EConsults can save considerable time, expense and aggravation for patients who would need to travel far to see specialists.

“A safety net system can't afford to hire enough specialists to meet demand—eConsults get around that problem by increasing access through enhancing efficiency,” says NYC Health & Hospitals President Mitchell Katz.

Health Policy and Reimbursement

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Insurers selling health plans on the Affordable Care Act marketplace are fighting lawsuits from consumers in four states—Texas, Washington, Georgia and Ohio—who claim they were misled about which health providers were covered under their plan. The lawsuits allege that the consumers did not learn their doctor or hospital was outside its network until after purchasing the plan.


Some 96 percent of hospitals nationwide have adopted electronic health records (EHRs), up from just 9 percent in 2008. However, many physicians say the systems are cumbersome and unintuitive, and the number of hours spent clicking and typing on EHRs exceed their hours spent with patients. Meanwhile, an investigation by Kaiser Health News and Fortune reveals that the federal government's EHR initiative has spurred numerous patient safety risks stemming from software glitches, user errors and other flaws. Reports of these instances have been accumulating in various government-funded and private repositories yet remain largely unseen.


Contracts with noncompete clauses are now common in medicine, although some states limit their use. The clauses aim to stop physicians and other healthcare professionals from taking patients with them if they move to a competing practice nearby or start their own. Whether they are binding, especially when patient care is disrupted, is a point legal scholars debate. In general, to be enforceable, the agreements must be reasonable and narrowly drawn so that they protect an employer's legitimate business interest but do not unduly restrict a doctor's ability to make a living.

Courts may weigh whether enforcing a noncompete clause would create a physician shortage in a particular region or specialty. The guiding principle is generally patient choice. A recent report by the Trump administration evaluating how to promote choice and competition in healthcare recommended that states examine the clauses for their effect on patients' access to care and the supply of providers.

Medicine, Drugs and Devices

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A new report from the U.S. Centers for Disease Control and Prevention has found that one third of uninsured U.S. citizens did not take their medicine as prescribed to try to lower their costs. In 2017, nearly 60 percent of adults aged 18–64 years reported being prescribed drugs over the past 12 months, according to the study. People with private insurance were better able to afford their drugs, with only 8.4 percent not taking the medication as prescribed. Approximately 12.5 percent of Medicaid enrollees resorted to this step.


A traffic, content and network analysis scrutinized 24 leading medicine-related mobile apps among users in the United States, Canada, the United Kingdom and Australia. Researchers were interested in whether and how user data is shared by the interactive apps—which cover drug information, dispensing, administration, prescribing and/or use. They also wanted to get an idea of the privacy risks to the physicians and consumers who use the technology. Investigators found that the vast majority of apps analyzed, 79 percent, shared user data.


Rebates and other concessions attached to the Medicare Part D program undermine the value of generic medications by steering health plans toward higher-cost brand drugs that may yield bigger price breaks. Investigators from Johns Hopkins scrutinized the 57 preferred drug lists offered across Part D's 750 standalone prescription plans in November 2016. They identified 935 multisource drugs—for which both generic and branded products were available—12.8 percent of which did not appear as a generic on any formulary. Nearly three-quarters of the formularies, meanwhile, placed one or more brand-name drugs in a lower cost-sharing tier than their generic versions; and 30 percent placed fewer utilization controls, such as prior authorization or step therapy, on the branded product for at least one medication.

For the 222 multisource drugs that were found on all formularies and had both branded and generic versions covered on at least one list, only 5 percent had a lower cost-sharing tier, and about 30 percent boasted fewer utilization controls on the branded options. The investigators note that the price of brand-name medications was $3.90 vs. $1 for generics, underscoring how favorable placement of branded products on preferred drug lists fosters use of more expensive medications. In turn, out-of-pocket costs for beneficiaries go up, along with what the Part D program pays for prescription drugs.