News From ACFAS

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Let your voice be heard—respond to either the ACFAS Member Insights or Practice Economics Survey arriving in your inbox next week! Your feedback influences the College’s direction for the next three years. Plus, two respondents will win an Apple iPhone X, and four people will win Bose noise-canceling headphones.

Starting around May 10, via email, half of ACFAS members will receive the Practice Economics Survey, and the other half will receive the Member Insights Survey. Random sample determines which survey you will receive. All responses are anonymous and are only reported in the aggregate by a third-party survey consultant. Look for results on acfas.org in late summer.

Keep an eye out for an email from ACFASpresident@perceptionsolutions.com and respond ASAP! Streamlined coding and billing procedures and accurate reimbursement go hand in hand. Explore this connection in the popular seminar, Coding and Billing for the Foot and Ankle Surgeon, July 13–14 in Portland, Oregon or October 19–20 in Chicago, and learn how to:

• Structure your work week
• Code for amputation, forefoot, rearfoot and ankle reconstructive surgery
• Code for evaluation and management
• Use modifiers to avoid denials
• Code for diabetic foot cases, minor office procedures and complex arthroscopy cases
• Navigate new government reimbursement systems and methods

You will also code actual patient cases and scenarios for a firsthand look at each step in the coding and billing process.

This course is worth 12 continuing education contact hours (Category 1 credit). Register now at acfas.org/practicemanagement and take the first step toward maximizing reimbursement for the care you provide. Give your research global reach by publishing an Open Access article in The Journal of Foot & Ankle Surgery (JFAS).

Open Access makes your research available to millions of readers worldwide, including nonsubscribers of the Journal. Readers receive free, immediate and permanent online access to your work through ScienceDirect, and you, as the author, decide how readers can share and use your article.

ACFAS members receive a 50 percent discount on the Open Access publication fee. Visit jfas.org to learn more about Open Access publishing in the Journal or to submit your article.

Foot and Ankle Surgery

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Researchers sought to compare the treatment results of talus osteochondral lesions (OLT) with debridement and microfracture in arthroscopy-assisted surgery of acute ankle fractures. The study included 11 consecutive patients who were treated with arthroscopic acute debridement and 14 consecutive patients who were treated with arthroscopic acute microfracture in the treatment of ankle fracture. All participants were controlled clinically and radiologically in the postoperative period. Ankle pain was evaluated with the visual analog score (VAS), ankle functions were assessed with American Orthopaedic Foot and Ankle Society Ankle-Hindfoot Scale (AOFAS) and osteoarthritic changes were analyzed with Van Dijk score. The researchers found no significant difference between the groups in terms of age, gender, injury side and trauma mechanism. Mean time to surgery, fracture healing duration, time to first weightbearing and full weightbearing, follow-up period and Van Dijk score were all similar in the two groups. However, the AOFAS score and VAS activity score were statistically significantly better in the microfracture group (p = 0.044 and p = 0.001). The clinical relevance of the study is to identify the optimal acute treatment of the first osteochondral damage that occurred simultaneously with ankle fracture, to improve postoperative functional outcomes and to prevent posttraumatic osteoarthritis. The authors concluded that both debridement and microfracture yield good functional outcomes in the second year after the treatment. However, microfracture ensures significantly more successful clinical results than debridement.


Researchers conducted a study to investigate the clinical and radiographic outcomes of modified Scarf osteotomy with medial capsule interposition for rheumatoid arthritis (RA) cases, including severe destruction of the first metatarsophalangeal (MTP) joint, and to evaluate risk factors for recurrence. A retrospective observational study of 76 cases (60 patients) followed for a mean of 35.3 months (range, 24–56 months) after a modified Scarf osteotomy was performed. Scores on the Japanese Society for Surgery of the Foot (JSSF) RA foot and ankle scale, the JSSF hallux scale and a self-administered foot evaluation questionnaire (SAFE-Q) were determined, along with preoperative and postoperative radiographic parameters. There was a significant improvement, from preoperatively to final follow-up, in the mean JSSF RA foot and ankle score (from 52.2 to 76.9 points) and the mean JSSF hallux score (from 38.2 to 74.5 points). There was a recurrence in 12 feet (16 percent). The preoperative DAS28-CRP score (disease activity score [based on 28 joints in the body]-C-reactive protein score) and intermetatarsal angles between the first and second metatarsals (M1M2A) and between the first and fifth metatarsals (M1M5A) were significantly greater in the recurrence group, as were the HVA, M1M2A, M1M5A and Hardy grade at three months after surgery.


New research indicates that adding a foot examination to an annual retinal screening for adults living with diabetes may be an effective tool for the early diagnosis of peripheral neuropathy. Researchers examined 236 patients living with diabetes who attended annual retinal screenings at various centers in the United Kingdom. The assessment included an evaluation based on the Toronto Clinical Neuropathy Score, a 10-g monofilament test and two measures of neuropathy obtained using the point-of-care devices DPNCheck (Neurometrix) and Sudoscan (Impeto Medical). Forty-three percent of participants reported previously receiving basic foot care education; evidence of foot screening in the past year was documented for 18.9 percent. Among participants, 56.6 percent were found to have a moderate to high risk for foot ulcers, and 25 percent received a new diagnosis of painful distal symmetrical polyneuropathy. The one-stop screening service was well-received by the patients with 91.1 percent reporting they were "in favor" or "strongly in favor" of the service, according to the researchers.

Practice Management

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Phishing is the leading cause of data security incidents for the third year in a row, and the healthcare industry is the top target of scammers, according to a new study by law firm BakerHostetler. Hackers use phishing to obtain direct network access, convince employees to wire money, enable remote access with compromised credentials or deploy malware and ransomware, according to the report. "If you haven't been targeted, you will be," says Eric Packel, a partner in the firm. "It's not a matter of if, but when." One of the challenges for medical practices is that any employee can be victimized, and it often tends to be higher-level employees or physicians because they are so busy, according to Packel. He offers several tips to avoid being compromised. First, determine which employees are most at risk for clicking on a phishing email, such as by sending out a fake phishing email and giving additional training to those employees who respond. Second, set up a multifactor authentication process, which involves inputting an additional code beyond usernames and passwords. Third, educate about extra security. Fourth, emphasize the importance of safety, especially to higher-level staff who may push back against learning the new system. Finally, budget accordingly for installing new technology. "There's political pushback and financial and technical issues to consider, particularly with larger, more complex organizations," Packel says. "But certainly the cost of one data security incident could be more than the cost of putting multifactor authentication into place."


Many practices are implementing a new role of a patient experience officer, a designated employee responsible for making sure the entire experience is in line with patients' expectations. Research shows that a growing number of patients who leave their healthcare provider do so out of frustration with practice logistics—things like interactions with staff, scheduling hassles, wait times and communication processes. Managing the patient experience has thus become vital in retaining patients. The patient experience officer's duties typically include evaluating patient experience, establishing a patient communication plan or program, addressing patient feedback from surveys and reviews and managing online interactions with patients. One option is to invest in patient relationship management (PRM) software to make communication between patients and providers easier. The software also enables a practice to create customized surveys to gather feedback about the practice. If patients leave feedback that suggests the practice's scheduling process is difficult and time-consuming, for example, or that they would like the ability to text the practice, the patient experience officer can then research solutions and determine how processes should be changed to improve the experience. Focusing on the patient experience can produce great results for a healthcare practice. Listening to and incorporating their feedback increases patient loyalty toward the practice and in turn improves the bottom line.


Simulations using virtual patients are teaching healthcare professionals to be more empathetic and to have vital conversations on topics like mental health and substance abuse. One health simulation company, Kognito, uses gaming technology and virtual patients to create mock clinical scenarios in which practitioners test out different conversation paths to see how virtual patients respond. They then receive real-time feedback on how to have more engaging and meaningful discussions. Mental health assessment is another key area that could benefit from technology. Amid a shortage of mental health providers, patients are turning to primary care physicians, but many of these doctors lack the necessary training to comfortably diagnose mental health conditions. Kognito, however, says three-month follow-up studies of its primary care simulation showed a 51 percent increase in identifying patients with substance use or mental health disorders. Virtual humans could also help in another important area of medicine: team training. Getting a group of busy people together to practice team communication can be tough. One system integrates AI-powered virtual humans on 40-inch TV screens who represent medical professionals, such as surgeons, anesthesiologists and nurses. These avatars communicate with real-life participants to help them learn skills like administering drugs and managing conflict. A greater investment in teaching communication skills is still necessary, but there is evidence that virtual humans can play an important role in interpersonal skills training, experts say.

Health Policy and Reimbursement

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The U.S. Centers for Medicare and Medicaid Services (CMS) is encouraging community-based organizations to become service suppliers for the newly expanded Medicare diabetes prevention program model. This allows providers to bill CMS for treating Medicare patients with prediabetes and, because the service is free for qualifying beneficiaries, healthcare organizations can use it to reach individuals who might not have otherwise come in for a screening. The model is for community organizations and providers to establish structured behavior change intervention programs to curb the onset of type 2 diabetes among Medicare beneficiaries who have an indication of prediabetes. CMS said that is now enabling community-based organizations to join traditional healthcare providers in enrolling as Medicare suppliers of these health behavior change services. They may provide evidence-based diabetes prevention services after earning certification from the U.S. Centers for Disease Control and Prevention. The model is forecast to save the Medicare program more than $180 million by keeping beneficiaries healthy and avoiding new cases of diabetes. Medicare spends more than $104 billion per year treating patients with this disease, CMS said, and more than one-fourth of seniors in the United States have type 2 diabetes. This is the first preventative services test model released by the CMS Innovation Center to expand nationally.


A recent HealthView Services analysis found that as of this year, there is a transition in the income brackets used to determine how much older Americans will pay for their Medicare Part B and Part D coverage. The highest earners may wind up paying 200 percent higher premiums for Parts B and D compared to someone in the first bracket. Drivers of this trend include the Medicare Access and CHIP Reauthorization Act, which reduced the ranges for the third, fourth and fifth income brackets, pushing some retirees into the next bracket and hiking their Medicare costs. This year, premiums for Medicare Part B are $134 monthly for singles with a modified adjusted gross income of $85,000 or less in 2016. Premiums start climbing outside of those income levels, while Part D beneficiaries also pay additional costs on top of their plan premiums if their 2016 modified adjusted gross income (MAGI) surpassed $85,000. Also affecting Medicare is the Bipartisan Budget Act of 2018, which mandates that beginning next year, individuals with incomes exceeding $500,000 will pay higher Medicare surcharges, which the Medicare Rights Center estimates will comprise 85 percent of their program costs, up from 80 percent under current statutes. Higher-income retirees can try to control Medicare premiums by planning out their income sources before applying for the program. For example, income from a Roth IRA and Roth 401(k) plan does not count toward one's MAGI and will not raise Medicare premiums.


A study from the National Council on Aging (NCOA) and the Clear Choices Campaign found Medicare's online Medicare Plan Finder tool "is overwhelming, information is poorly presented and the user design is potentially misleading—all of which confuses beneficiaries and can contribute to many making poor plan selections." NCOA also notes that among the site's biggest drawbacks "are out-of-pocket cost information is difficult to understand and provider directories are difficult to navigate." Furthermore, plan comparisons do not allow the inclusion of Medigap policies, while the site's layout and display are confusing. In addition, the language is not accessible, and the site's navigation and usability are complex and inconsistent. The unavailability of human support on the site, confusing information on health plans' quality Star Ratings, informational inaccuracy and poor customization of plan data are also cited as shortcomings. The study authors stress that although Plan Finder offers "a wealth of unbiased information on beneficiary costs" in a comprehensible manner, an overhaul of the comparison features and enrollment functions is "essential." Among their suggestions for improvement are the addition of a Web chat feature, prominent and precise display of costs, basing estimated out-of-pocket costs on more detailed personal information, a provider directory, the use of saved information about consumers' drugs, retooling the layout and display to augment usability and intuitive navigation and the replacement of insurance jargon with graphics, charts and plain language.

Medicine, Drugs and Devices

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Intel Corp., working with pharmaceutical and other healthcare companies, aims to use so-called blockchain technology to better trace drugs and potentially stem the opioid epidemic. The aim is to pinpoint where drugs leak out of the supply chain. Blockchain could also help flag "double doctoring," where an addicted patient takes out more than one prescription from multiple physicians. "It will vastly reduce the opioid epidemic," says David Houlding, director of health care privacy and security at Intel Health and Life Sciences. "I would not say this will eliminate the opioid problem, but this will help." Johnson & Johnson, McKesson Corp. and other companies will enter simulated data into new digital ledgers. The experiment will see how easy it is to track medicines as they travel from the manufacturer all the way to a patient's home. The ultimate goal is for all drug-related companies and their suppliers worldwide to be on blockchain, an online ledger that cannot be erased. Then government agencies, such as the U.S. Food and Drug Administration, could potentially plug into the blockchain and provide oversight.


After being hit by a car, Carol Harnett, president of the nonprofit Council for Disability Awareness, was unable to walk temporarily because of the severe sprain in her right ankle. But doctors told her that her insurance would likely not cover a wheelchair because she did not break a bone. Historically, durable medical equipment—such as wheelchairs, walkers or knee braces—"has always been a weak point in coverage," she said. The average employer plan covers 80 percent of the cost after the deductible is met, according to Harnett. If a patient is paying for such equipment out-of-pocket, it is worthwhile to look into coverage and figure out how to get the best deal. Patients often do not realize that insurers contract with selected medical supply companies to provide equipment, so patients who do not use an insurer's preferred provider may be charged a higher rate or have to pay the entire amount out-of-pocket. In addition, hospitals, urgent care centers and physicians may themselves negotiate with insurers or Medicare to become an approved supplier of medical equipment for their patients, or they may contract with a medical supply company to provide those items. It is key for the patient to find out whether the medical supplier is in their insurance network and how much they will owe out-of-pocket. Patients also have the unique option to buy durable medical equipment over the counter, which might prove significantly cheaper online or at the drugstore than using an insurance plan.


Video directly observed therapy (VDOT), an mHealth platform in which patients record themselves taking medications through an app, could improve adherence rates and slash costs, according to a new study published in Open Forum Infectious Diseases. Researchers at Johns Hopkins University monitored 28 tuberculosis patients managed by three Baltimore-area public health agencies between March 2016 and August 2017. They found that the app, called emocha, increased medication adherence rates to 94 percent. The study also revealed savings of nearly $1,400 in treatment costs per patient. Healthcare providers involved in the study said they could observe more doses using emocha, including those taken on weekends and holidays, thus improving adherence and potentially reducing treatment time. Providers also suggested that VDOT gave them more time to spend on other responsibilities, such as contact investigations, patient counseling and social support. The study was funded by a Small Business Innovation Research grant awarded to emocha by the U.S. National Institutes of Health. The company also plans to expand into opioid addiction treatment with a $1.7 million grant from the National Institute on Drug Abuse.