News From ACFAS

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If you missed the new Coding Fundamentals course at ACFAS 2022, you’re in luck! The recording is available on ACFAS OnDemand from May 2-June 7—just in time for you to brush up on the basics before the next Coding and Billing for the Foot and Ankle Surgeon virtual course set for June 9-10.

Register now to access the pre-recorded course for one month and get a background in coding and billing led by faculty members Danielle Butto, DPM, FACFAS and Sean Grambart, DPM, FACFAS. Walk away with the tools to understand the use of Evaluation and Management (E&M) and Current Procedural Terminology (CPT) codes in your practice, recognize the most common modifiers and their use in your practice, and understand how to code minor in-office procedures.

Visit acfas.org/practicemanagement to register and for more information on this and other Coding courses for 2022. We have a full line up of ACFAS’ popular Arthroscopy of the Foot and Ankle Surgical Skills Course in 2022! Join us at one of these upcoming courses and get the latest techniques, didactic lectures and surgical demonstrations at the Orthopaedic Learning Center (OLC) in Chicago.

May 21-22, 2022 (Sold Out)
July 9-10, 2022
October 1-2, 2022
November 12-13, 2022
December 10-11, 2022

These two-day, interactive courses led by skilled arthroscopy surgeons will give you the opportunity to learn and practice established and cutting-edge techniques in foot and ankle surgery with 9+ hours of hands-on lab time with the latest equipment and techniques. The lecture presentations will include videos of actual arthroscopy cases with ample time for faculty interaction.

Visit acfas.org/skills for more information and to secure your spot at one of these upcoming highly interactive course dates. ACFAS is proud to be the home of over 7,800 diverse and unique foot and ankle surgeons. We know you are working tirelessly to advance the profession and improve patient care. We want to learn more about your accomplishments and how you are making a difference!

We are looking to feature members to get to know our membership in a different way. All you have to do is answer a few casual questions and submit a picture of yourself and we’ll feature you in an upcoming post on ACFAS social media accounts. If you are interested in being featured, please email erin.morrison@acfas.org.

Foot and Ankle Surgery

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A retrospective review of the Trauma Quality Programs data from the American College of Surgeons including 70,525 patients who sustained a fracture of the foot from 2015 to 2018 was held to find predictors of acute compartment syndrome of the foot. Fasciotomies were conducted in 0.7 percent of all foot fractures. Open fractures, crush injuries and multiple foot fractures were the strongest fasciotomy predictors, with odds ratios of 2.38, 2.38 and 2.33 respectively. Being male was linked to a higher probability of fasciotomies of 64 percent, and a dislocation in the foot increased likelihood of fasciotomies by 48 percent. Level III trauma centers saw a higher rate of fasciotomy than tertiary trauma centers. Multiple other factors were covered while controlling for cofounders.


A study sought to measure the normal thickness and magnetic resonance imaging (MRI) appearance of the tibialis posterior tendon near the navicular insertion in normal volunteers. The researchers imaged 41 ankles with a 3T MRI system, and proton density weighted images with fat saturation were obtained in the three orthogonal planes. Twenty-one volunteers (eight men and 13 women) age range 19-43 years were included. At measurement point-1 on the coronal images, observer-1 and observer-2 assessed hyperintensity (mostly minimal) in 90.5 percent and 95.3 percent of tendons, respectively, with a Cohen's kappa coefficient of 0.701 (moderate agreement) for the right foot and in 60 percent and 70 percent of tendons with a Cohen's kappa coefficient of 0.624 (moderate agreement) for the left. In the axial images, both observers evaluated hyperintensity in 100 percent of the tendons with a coefficient of 0.763 (moderate agreement) for the right foot,and in 95 percent of tendons with a coefficient of 0.839 (strong agreement) for the left foot.

At measurement point-2 on coronal images, both observers rated any degree of hyperintensity in 33.3 percent of tendons with a coefficient of 1.00 (perfect agreement) for the right foot, in 38.9 percent of tendons with a coefficient of 0.766 (moderate agreement) for the left. On axial images both observers assessed hyperintensity (mostly minimal) in 100 percent of tendons with a kappa coefficient of 0.702 (moderate agreement) for the right foot, in 95 percent of tendons with a coefficient of 0.790 (moderate- to strong agreement) for the left.


Researchers reviewed the short- to midterm outcomes of 24 patients (16 males and eight females) who were treated with osteochondral autologous transplantation harvesting from ipsilateral talar articular facets for osteochondral lesions of the talus. The American Orthopaedic Foot & Ankle Society score improved from 61.3 ± 19.0 pre-operatively to 84.9 ± 9.2 post-operatively while the visual analogue scale score improved from 6.1 ± 2.3 to 2.0 ± 1.4 at the last follow-up. Twenty-one patients (87.5 percent) were satisfied with their clinical outcomes. By the final follow-up computed tomography scan, there was bone cyst formation at the donor sites in three patients, at the recipient sites in five patients and at both sites in five patients. Two patients (8.3 percent) underwent re-operation with arthroscopic debridement due to medial gutter hypertrophic soft tissue impingement.

Practice Management

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US doctors do not like the amount of documentation time electronic heath records (EHRs) require for billing purposes, according to an analysis of responses to the 2019 National Electronic Health Records survey from 1,524 office-based physicians in primary care, surgical and medical specialties published in JAMA Internal Medicine. Generally, 64 percent of respondents expressed satisfaction with their EHR, while 28 percent were dissatisfied and 8 percent were neutral. However, 58 percent felt EHR documentation is too lengthy and reduces the amount of time they can spend with patients. Respondents also agreed that documentation done solely for billing increases their total documentation time. Respondents spent an average of 1.77 hours per day outside of office hours completing EHR documentation, but almost 33 percent said they spent at least two non-office hours per day, including 35 percent of primary care specialists, 32 percent of medical specialists and 28.6 percent of surgical specialists. Physicians were estimated to have spent a total 125 million hours documenting outside of office hours during the year. Moreover, participants in a pay-for-performance program or accountable care organization spent an average of two hours daily on documentation, versus 1.58 hours among non-participants.


The Medical Group Management Association's Ron Holder recommends using benchmarking data to assess a practice's progress toward productivity goals. Among the metrics he cites as helpful in this regard is prior-year performance on both the practice and provider levels, budget, benchmarks and new versus follow-up patients. Holder writes that by analyzing multiple data points, "you'll have a macro perspective of your practice's health and a better understanding of its operational and financial wellbeing. Plus, you'll be able to hit the ground running with specific strategies for success. Key components of building an effective strategy are knowing where you are, how you are doing and where you could (and want) to go."

Health Policy and Reimbursement

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The United States can expect health spending to expand by a little more than 5 percent per year through 2030, when the figure will approach $6.8 trillion, a new analysis from the US Centers for Medicare and Medicaid Services' Office of the Actuary estimates. Trends in health spending and insurance takeup will be shaped by the ongoing COVID-19 pandemic over the next few years, according to the National Health Expenditure report. For the latter part of the projection period, traditional economic, demographic, and health-driven factors will be the driving force behind activity.

The share of the US population who is insured is pegged at 91.1 percent for 2021 and 2022, mostly due to COVID-related enrollment gains in Medicaid, but the proportion is likely to drop back below 90 percent by 2030 as the pandemic effect wears off. Medicaid and Medicare spending are slated to grow during 2021–30, at an average pace of 5.6 percent and 7.2 percent, respectively, while private health insurance spending is predicted to expand about 5.7 percent. The report also anticipates average per-year growth of 5 percent for spending on retail prescriptions drugs. The biggest surge is likely to come during the second half of the decade, in response to new drug approvals in the first half. Additionally, hospital spending growth is forecast to average 5.7 percent, and spending for physician and clinical services is projected to increase 5.6 percent per year over 2021-30.


The end of the COVID-19 pandemic could disrupt a US healthcare system made more generous, flexible and up-to-date thanks to temporary emergency measures. Phasing them out could force an estimated 15 million Medicaid beneficiaries to find new sources of coverage, require congressional maneuvering to retain broad telehealth access for Medicare enrollees and muddle special COVID-19 rules and payment policies for hospitals, doctors and insurers. Although virtually all of those losing Medicaid should qualify for some other source of coverage, either through employers, the Affordable Care Act or the Children's Health Insurance Program, Urban Institute researcher Matthew Buettgens said this transition will not be automatic. The Centers for Medicare and Medicaid Services is recommending states take a gradual approach and tie these recipients to other potential coverage. The status of tests, treatments and vaccines covered under emergency use authorization from the Food and Drug Administration is an especially hazy area.


Under President Biden's budget proposal, the US Food and Drug Administration's (FDA's) budget would grow by nearly 34 percent compared with the current fiscal year, with much of the $2.1 billion increase intended to prepare for future pandemics. FDA also would strengthen the accelerated approval program for certain drugs. This program has been criticized for approving drugs and letting them stay on the market before their effect is proven or the drug is withdrawn. The proposal says it would accelerate the follow-up study process, ensure high-quality results and make technical changes to allow FDA to withdraw drugs that do not show a benefit. FDA specified that $1.6 billion of the increase would be used to support the US Department of Health and Human Services' pandemic preparedness plan, help FDA evaluate vaccines, accelerate the rapid development of tests and reinforce the supply chain for personal protective gear. FDA's overall budget would rise to $8.4 billion under the budget plan.

Medicine, Drugs and Devices

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US pharmacists are expanding their responsibilities, in a trend that started before the COVID-19 pandemic and has continued to gain traction. The National Alliance of State Pharmacy Associations estimates that more than dozen states have empowered pharmacists to not only screen but to treat customers for some common ailments. While this authority typically is conferred via statewide protocols or under collaborative practice agreements with physicians, a few states are bestowing direct prescribing authority to pharmacists so they can independently prescribe drugs for a broad range of conditions that can be diagnosed with rapid tests at the point of care.


The US Department of Health and Human Services' (HHS') Health Resources and Services Administration (HRSA) is planning to take action against Boehringer Ingelheim for reducing discounts to the 340B federal drug discount program, which provides medicines at reduced cost to hospitals and clinics serving low-income populations. The program requires drug companies to offer discounts that are typically between 25 percent and 50 percent on outpatient drugs to participating hospitals and clinics, which are estimated to number 12,400. In 2020, several drugmakers began eliminating some discounts when hospitals or clinics purchased medicines and shipped them to contracted community or specialty pharmacies for patients to pick up or for delivery in place of using their own in-house pharmacies. The drug companies asserted that using contract pharmacies led to such issues as duplicate billings, ineligible rebates and product diversions. Some drugmakers want hospitals and clinics to provide patient claims data beyond what is already shared regarding Medicaid recipients. HHS issued an advisory opinion in 2020 stating that drug companies are obligated to provide discounts even if hospitals and clinics use contract pharmacies to deliver drugs. The agency noted that some hospitals and clinics must use contract pharmacies for distribution if patients live in more remote areas. HRSA has referred Boehringer to the HHS' Office of the Inspector General for penalties.


Lawmakers in the House have passed legislation that would cap the cost of insulin at $35 per month for most patients who depend on the lifesaving medication. Nearly 30 million Americans have diabetes, and some patients who use insulin are forced to ration doses or abandon treatment completely because of the escalating price. A Kaiser Family Foundation analysis estimates that one in five insulin users in the country would save money under the proposal, which moved through the lower chamber with bipartisan support. While the bill is appealing because so many Americans are affected by diabetes, some perceive it as a distraction from pledges to crack down on exorbitant prescription drug prices across the board. A more sweeping proposal included in a $2.2 trillion social spending and climate bill addresses the broader problem by allowing Medicare to negotiate drug prices, but that measure has lost momentum.


A new analysis by research firm SSR Health reveals that brand-name drugmakers increased their wholesale prices by 4.4 percent in the last quarter of 2021, compared with a 3.8 percent increase a year earlier. When accounting for inflation, however, wholesale prices declined by 2.3 percent. Net prices that health plans paid for medicines, after subtracting fees, rebates, and discounts, fell by 0.7 percent. After taking inflation into account, net prices decreased by 5.4 percent. In both instances, these changes reflected the largest quarterly declines in real terms in 15 years, according to SSR Health. The report also found that 92 percent of publicly traded brand-name drug companies experienced declines in wholesale prices in real terms, with an "unprecedented" 88 percent of brand-name medicines affected. The gross-to-net bubble — which measures the difference between gross sales at list prices and net prices after rebates – increased slightly to 47.5 percent, continuing an upward trend over the past six years.


Researchers at the University of Texas at Arlington (UTA) have developed responsive footwear that relieves pressure on areas of the feet that undergo high strain during walking and other activities. The dual-layer insole apparatus for diabetic foot lesion prevention, which UTA designed in partnership with the University of North Texas Health Science Center, has been granted a patent from the US Patent and Trademark Office. The removable insole eases stress by periodically regulating and redistributing pressure across all areas of the foot. The apparatus uses fluid-filled cells to add variability to a person's foot-loading patterns and lower prolonged pressure to any given area. In addition, the insole can also replace a total contact cast during the healing of a foot ulcer, and supply gait and ground force analysis. The UTA team is collaborating with the University of Texas Southwestern Medical Center on a pilot study funded by the National Institutes of Health to assess initial prototypes.