News From ACFAS

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Considering a fellowship post-residency, but missed the first Fellowship Zoom Room last evening? Don’t worry, you have two more opportunities to join us and get your questions answered with the College’s newest online event.

This series of Zoom Meetings brings together a list of specific fellowship programs for short presentations, to meet prospective future fellows and to answer any burning questions you may have. Mark your calendars: the next two Zoom Rooms are coming up Tuesday, April 26 and Thursday, April 28 at 7:30pm CT and you won’t want to miss them!

Visit acfas.org/fellowshipzoomrooms to see the full schedule, a listing of participating programs in each Zoom Room, and to register. Looking to build your coding and billing foundation? The Coding Fundamentals course from ACFAS 2022 is available through ACFAS OnDemand from May 2-June 7. This is the perfect time to get an intro on the essentials before the next Coding and Billing for the Foot and Ankle Surgeon virtual course on 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 learn more about all upcoming Coding courses in 2022. The newest two-part podcast Show Me the Money: Understanding the Physician Pay Structures and Contract Negotiations is now available on ACFAS OnDemand.

Log in now to join as moderator Hendrik Ryan Tan, DPM and panelists D. Zack Dawson, DPM, AACFAS; Christopher R. Hood, DPM, FACFAS; Steve W. Jasonowicz, DPM, FACFAS; and Michael R. Zimmerman, DPM, FACFAS have an engaging and frank conversation intended to help young attendings understand and navigate practice finances.

Check out the newest podcast now at acfas.org/OnDemand.

Foot and Ankle Surgery

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A study investigated the association of clinical outcomes with radiological changes and cartilage regeneration shown on arthroscopy before and after supramalleolar osteotomy (SMO) in patients with intermediate-stage varus ankle osteoarthritis (OA). The researchers reviewed 26 cases with intermediate-stage varus ankle OA who received SMO with at least 12 months of postoperative follow-up. Significant changes in the tibial ankle surface angle (TAS), talar tilt (TT) and heel alignment ratio (HR) were observed, although no significant changes in the tibial lateral surface angle (TLS) were seen at the final follow-up versus its preoperative value. Postoperative TAS changes and the degree of cartilage regeneration in the talar dome significantly impacted the final follow-up American Orthopaedic Foot and Ankle Society ankle-hindfoot score. Changes in the TAS angle and the degree of post-SMO cartilage regeneration predicted clinical outcomes after SMO, with greater changes in the TAS angle corresponding to better outcomes.


A study was held to review the results of more than 20 years' follow-up of metatarsal neck shortening oblique osteotomy (SOO) for forefoot deformity in patients with rheumatoid arthritis (RA). Metatarsal neck SOO was conducted on 163 feet in 108 patients between January 1985 and December 1996, while a retrospective cohort study was performed on 36 feet in 22 patients, all female, and the mean age at surgery was 45.6 years. The follow-up period was 25.1 years, and the presence of painful callosities in the surgically treated feet without revised surgeries fell from 32 feet to four feet at the last follow-up, with mild pain that did not inhibit footwear. Re-osteotomy at the metatarsal of the lessor toe was undertaken on four feet in two patients. Radiologically, among 128 toes without revised surgeries, 85 percent were able to have the joint space preserved, and 89 percent maintained a pain-free condition without deformity recurrence. The mean total Japanese Society for Surgery for the Foot RA foot and ankle score was 64.0/100, and the visual analogue scale of overall satisfaction was 62. The overall satisfaction correlated positively with calcaneal pitch and negatively with joint space narrowing at the talocrural joint.


Estimating the incidence of chondral or osteochondral lesions (O)CLs in patients with chronic lateral ankle instability (CLAI) was the purpose of a systematic review and meta-analysis of 12 studies with 2,145 patients and 2,170 CLAI-exhibiting ankles from the PubMed, Embase and Cochrane databases. The pooled occurrence of (O)CLs in ankles with CLAI was 32.2 percent, and 43 percent of all legions were chondral and 57 percent were osteochondral. Among all (O)CLs, 85 percent were sited on the talus and 17 percent on the distal tibia. Of the talar (O)CLs, 68 percent were medial and 32 percent were lateral. These findings should help physicians in the early recognition and treatment of ankle (O)CLs in the context of CLAI.

Practice Management

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The Health Resources & Service Administration is granting a reporting extension to physicians who received Provider Relief Funds (PRF) and faced extenuating circumstances. It applies to physicians who were required to report in an applicable reporting period, but extenuating circumstances prevented them from doing so by the required deadline. If the request is approved, the physician will be allowed to complete their report in the PRF Reporting Portal, but if denied the physician must return all unreported funds. Requests can be made in the event of severe illness or death, natural disaster, lack of receipt of reporting communications, failure to click "Submit" in the PRF Reporting Portal prior to deadline, internal miscommunication or error or incomplete Targeted Distribution payments.


Health systems can immediately implement five actions highlighted in the 2022 Healthcare Workforce Rescue Package to improve physicians' well-being, especially through a peer-support program. The first step is to adjust expectations in recognition that these are abnormal times, and the second involves the elimination of mindless processes. The third step is to turbocharge staffing, while the fourth is to delegate well-being to an executive. The fifth step is to acknowledge that employee-assistance programs are insufficient, about which ChristianaCare's Heather Farley is particularly adamant. The package's developers recommend that health systems provide quality mental health services; lower the barriers to soliciting help, like erecting a peer-support program and supply psychological first aid training for leaders.


Alternative small business funding may be the fastest and easiest option for medical practices looking to expand. Because medical equipment and technology can be prohibitively expensive to buy upfront, alternative medical practice funding can help the practice acquire the newest tech now and grow service offerings faster, without having to save up for months or years. Real estate purchases also align well with alternative financing, which can also expedite the acquisition of an existing practice. Moreover, medical practice funding can help cover the costs of hiring new staff until the practice starts generating more revenue from the increased patient load. Advertising and marketing can additionally benefit from the working capital provided by alternative small business funding. Finally, such arrangements can enhance patient services and keep the practice competitive.

Health Policy and Reimbursement

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Sen. Charles E. Grassley (R-Iowa) stated at a town hall in Waukon, Iowa, this week that Republicans will not try to repeal the Affordable Care Act (ACA) if they retake the Senate in November. Repeated Republican attempts to rescind the law have ended in failure. Nevertheless, some Republicans have suggested that the GOP should continue to try to repeal the ACA if both the House and the Senate fall back under its control this year. Sen. Ron Johnson (R-Wis.) expressed a desire for a repeal during a radio interview in March.


Vice President Kamala Harris has unveiled the Biden administration’s four-step plan to strengthen consumer protections in relation to health care costs. The plan calls for holding medical providers and debt collectors "accountable for harmful practices," downgrade the role medical debt plays in determining whether Americans can access credit, forgiving medical debt for more than 500,000 low-income veterans, and informing consumers of their rights. A February 2022 report from the Consumer Financial Protection Bureau (CFPB) estimated that U.S. consumers held $88 billion in debt as of June 2021. Black and Hispanic individuals were found to be more likely to have medical debt, along with young adults and low-income individuals, according to the study. Soon after the CFPB findings were released, credit unions Equifax, Experian, and TransUnion announced that starting on July 1, they will no longer include medical debt in collections on credit reports after it is paid off. Jenifer Bosco, a staff attorney at the National Consumer Law Center, says, "a continued push to make sure more consumers have good health insurance and expanding Medicaid in the remaining states would help prevent medical debt from building up in the first place. Better access to hospital financial assistance, which is often required by law, can prevent catastrophic medical debts."


Surprise billing dispute arbiters will need to consider information in addition to median contracted rates for billed items or services, the U.S. Centers for Medicare and Medicaid Services said in revised guidance. Providers and health insurers can submit certain types of information to influence arbiters' decisions on qualifying payment amounts, including the training, experience, and quality level of providers or facilities. Other information that can be submitted include the regional market share of providers or facilities; the acuity of the patients who received the services; and efforts—or lack thereof—to enter into network agreements or contracted rates from the previous four years, if applicable.

The CMS guidance, dated April 12, also says arbiters are not responsible for deciding whether median contracted rates are correct. If an arbiter questions a rate's accuracy, the federal government should be consulted, the guidance says. The updated guidance comes in response to a federal judge vacating part of the dispute resolution process laid out in the interim final rule implementing the surprise billing ban. That regulation required independent dispute arbiters to begin with the assumption that the median contracted rate is the appropriate out-of-network amount to pay the items or services in question.


The Biden administration wants to communicate to rural Americans that it will boost its health care budget in rural areas as part of a midterm election campaign. Agriculture Secretary Tom Vilsack said the Agriculture Department has allocated $43 million in grants to 93 rural health care providers and community groups in 22 states. Biden administration Cabinet members are also aggressively promoting the benefits of the $1.9 trillion American Rescue Plan Act (ARPA) and a $1.2 trillion infrastructure package to rural Americans. The grants represent the first phase of apportionments from $475 million reserved for rural health care organizations via ARPA. The grants' utilization will vary among grantees.


The Urban Institute reports that the average benchmark premium on Affordable Care Act exchanges declined for the third straight year, falling 1.8 percent in 2022. More insurers joined the exchanges if the state opened up Medicaid or had a state-run exchange, with 14.5 million enrollments this year mainly due to enhanced subsidies that reduced insurance costs. The average premium declined 1.7 percent in 2021 and 3.2 percent the year before, while analysis indicated that "premiums for employer-sponsored increased by 3.9 percent in 2020 and 3.6 percent in 2021." Urban also observed that 11 states had benchmark premiums exceeding $500 a month for a 40-year-old nonsmoker, while six states had premiums of less than $365 a month.

The insurers participating in a rating region was a key determinant of premiums' variation. For example, Blue Cross Blue Shield, national or regional insurers and provider-sponsored payers corresponded with "greater than average benchmark premiums," while a Medicaid insurer in the rating region drove lower benchmark premiums. Analysis of insurers across 58 regions observed 288 plan issuers this year versus 198 in 2020. "The most striking development was the substantial premium increases by national commercial insurers UnitedHealthcare and Cigna, and Aetna," Urban noted.

Medicine, Drugs and Devices

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Researchers have developed a method for identifying counterfeit pharmaceuticals using edible tags that can be read by a smartphone app to verify the source and quality of the medication. The researchers genetically modified silkworms to produce edible silk proteins with an attached cyan, green, or red fluorescent protein. Tags containing these fluorescent silk proteins, which are broken down by gastrointestinal enzymes, can be applied onto pills or added to liquid medicine. The researchers also developed a smartphone app that scans the fluorescent pattern, uses a deep learning algorithm to decode the digitized key, and takes users to a webpage featuring information about the medication's source and authenticity.