News From ACFAS

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Every three years, ACFAS conducts comprehensive surveys that help guide the College’s governance, programs, services and policies. You will soon receive one of two randomly selected surveys:

• College Priorities and Member Needs Survey
• Practice Economics & Physician Compensation Survey

Your individual responses will not be seen by any ACFAS member or staff member and will only be reported in the aggregate. To add a little incentive for your participation, for each survey, one respondent will receive an iPhone X, and three respondents will receive Bose noise-cancelling earphones.

Responses are due June 15. You can stop and restart your responses if necessary. If you have any questions, please contact mahaffey@acfas.org. Thank you for participating! On May 10, 2018, the South Carolina legislature approved changes to the podiatric scope of practice that will allow DPMs with three-year residencies and RRA certification to perform most ankle surgeries. All DPMs will gain greater amputation privileges as well. The governor is expected to sign the legislation soon.

In addition to the tireless efforts of ACFAS past president Michelle Butterworth, DPM, FACFAS and many other ACFAS members, ACFAS would also like to recognize the effort of allopathic physicians who supported this effort as well. This scope of practice victory was achieved through extensive grassroots efforts and will help offer the citizens of South Carolina increased availability of expert foot and ankle care.

Now only three states remain: Massachusetts, Alabama and Mississippi. Massachusetts DPMs are engaged in similar efforts right now and prospects look good, but nothing is a certainty in legislative politics. There is no DPM scope legislation pending in Alabama or Mississippi. ACFAS welcomes our nine new Student Club presidents for the 2018–2019 school year:

AzPod: Kyleigh Pierson, Class of 2021
Barry: Misha Tavaf, Class of 2020
CSPM: Varsha Sulunkhe, Class of 2020
DMU: Robert Clements, Class of 2020
Kent State: Natasha Bhagat, Class of 2020
NYCPM: Jonathan Shalot, Class of 2020
Scholl: Sherjeel Hassan, Class of 2021
Temple: Stephanie Golding, Class of 2020
Western U: Byron Lemon, Class of 2021

ACFAS Student Clubs are located on all nine podiatric medical school campuses and provide Student Club members access to ACFAS scholarships, local ACFAS Region funding and onsite visits from members of the Board of Directors. The clubs regularly invite ACFAS members to speak on surgical techniques and help enhance students' academic curriculum. It always feels good to get a positive online review from a patient. Under the right circumstances, a healthy collection of positive reviews can be an asset to your practice.

According to ACFAS Member Benefit Partner Officite, the more positive reviews you have online, the more appealing your practice will be to prospective patients. Good reviews can also help improve your SEO ranking by inching your website closer to the front page of major search engines without any additional work on your part.

Officite offers the following tips for obtaining favorable online reviews:

1. Direct patients to your listings.
   Being direct is often the best approach. If a patient expresses satisfaction, you can simply ask him or her to leave a review.
   
2. Give patients some direction.
   Patients may forget some of the details about your request or forget your request altogether. They will be more likely to act if you give them a small handout that clearly lists the URLs of your review listings and social media channels.
   
3. Consider reputation management software.
   Reputation management software can help you:
   
   • See where you are being reviewed
   • Evaluate how positive the feedback is
   • Track your long-term progress
     
   More positive reviews mean more SEO traffic, which ideally means more appointments scheduled.
   
4. Make your review requests in person, not online.
   A personal touch from you can help you earn their trust. Also be sure to make the review process as convenient as possible before you ask your patients to do anything.

Foot and Ankle Surgery

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Researchers conducted a systematic review to evaluate current studies on arthroscopic lateral ankle ligament repair for chronic lateral ankle instability. A systematic search of MEDLINE, EMBASE and Cochrane Library databases was performed during August 2017, and eight studies for a total of 269 ankles were included; 87.5 percent of studies were LOE III or IV, and the QOE in all studies was of poor or fair quality. Preoperative American Orthopaedic Foot and Ankle Society (AOFAS) scores ranged from 41.2 to 69.9, and postoperative AOFAS scores ranged from 90.2 to 98.

All studies using AOFAS scores showed an increase in postoperative outcome score of 22.8 to 54.2 at a mean follow-up of 17.1 months. Five studies used Karlsson-Peterson scores with a mean postoperative score of 88.5 (range, 76.2-93.6) at a mean follow-up of 21.2 months. The comparative studies showed similar clinical outcomes between arthroscopic and open procedures. The overall complication rate was 11.6 percent in the included studies. The overall rate of return to sport was 100 percent.

The systematic review demonstrated that arthroscopic lateral ankle ligament repair yields favorable clinical outcomes in the short term. However, no clinical evidence exists to support the advantages of the arthroscopic procedure over the open procedure, and no long-term data is currently available for the arthroscopic procedure.

A relatively high complication rate (11.6 percent) was associated with the arthroscopic procedures, although recent comparative studies demonstrated similar complication rates for both open and arthroscopic techniques.


Researchers at Wenzhou Medical University sought to discuss the effect and advantage of the improved oval forceps suture-guiding method combined with anchor nail in the treatment of acute Achilles tendon rupture.

Researchers performed the Achillon technique with the use of simple oval forceps, combined with absorbable anchor nail, to percutaneously repair the acute Achilles tendon rupture. Patients were followed up with for at least 12 months, and all patients underwent successful repair of their acute Achilles tendon rupture using the improved oval forceps suture-guiding method without any major intra- or postoperative complications. All patients returned to work with preinjury levels of activity at a mean of 12.51 ± 0.76 weeks. Mean AOFAS ankle-hindfoot scores improved from 63.95 (range, 51–78) preoperatively to 98.59 (range, 91–100) at last follow-up.

The improved oval forceps suture-guiding method could potentially allow minimally invasive repair with less complications, reduce surgical time and achieve similar functional outcomes compared with the traditional open surgery. In addition, the new technique could save the cost of surgery in comparison to the Achillon device.

For cases in which the remote broken tendon ends were within 2 cm from the calcaneal nodules, because less tendon tissue was left in the remote side, traditional percutaneous methods were incapable of ensuring the reconstruction strength. By using the anchor nail, the improved technique enables better repair capacity and expands the operation indication of the oval forceps method.


Researchers conducted a prospective, single-center study, involving a case series of 24 neuroischaemic diabetic foot ulcers (DFUs) to evaluate the clinical and microbiological effects of sequential wound debridement using an ultrasound-assisted wound debridement (UAW) device during a six-week treatment period. Soft-tissue punch biopsies were taken every other week, both before and after wound debridement sessions. Qualitative and quantitative microbiological analysis was performed, and wounds were assessed at patient admission and before and after each debridement procedure.

Wound tissue quality scores improved greatly from a mean score of 2.1 ± 1.3 points at patient inclusion to 5.3 ± 1.7 points. Mean wound sizes were 4.45 cm² (range: 2–12.25 cm²) at week zero and 2.75 cm² (range: 1.67–10.70 cm²) at week six. The mean numbers of bacterial species per culture determined at week zero and at week six was 2.53 ± 1.55 and 1.90 ± 1.16, respectively. Wound debridement resulted in significant declines in bacterial counts [1.17, 1.31 and 0.77 log units in colony forming units (CFU) for week zero, three and six, respectively]. The average bacterial load in tissue samples before and after wound debridement after the six-week treatment was Log 5.55 ± 0.91CFU/g and Log 4.59 ± 0.89CFU/g, respectively.

The results showed a substantial bacterial load reduction in DFU tissue samples as a result of UAW debridement, independent of bacterial species, some of which exhibited antibiotic-resistance. Major bacterial load reduction was correlated with improved wound conditions and significant reductions of wound size.

Practice Management

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A new study from CompHealth examines how young physicians approach employment prospects. Lisa Grabl, president of CompHealth, says facilities should be aware that in addition to ample compensation, young physicians are seeking to work in a place with a good culture and work/life balance. She asserts that the key to retention is listening to physicians to ensure their needs are being met. "That could be implementing more flexible schedules, reducing on-call requirements or bringing in locum tenens physicians to allow for vacation time or help with patient load," according to Grabl. She recommends conducting periodic interviews to monitor how the physician and his or her family are integrating into the practice and community. The survey found that 40 percent of placements are a result of referrals and networking, while only 12 percent of young doctors use social media to find work, despite spending between five and 19 hours a week online for personal use.


Due in part to declining reimbursements and other struggles, some practices are finding it difficult to hand out annual pay raises. Practices are increasingly trying to get more out of staffers despite being unable to pay them more money, but it is possible to juggle the issues of workload and pay.

First, evaluate the need for staff against existing workloads. Focusing employees' time on the most important tasks and shuffling responsibilities—either to better consolidate similar tasks or to take advantage of particular skill sets within the practice—can improve efficiency.

Second, employees are frequently willing to put in extra effort without extra pay when they see they are appreciated. Nontraditional work arrangements, such as the ability to work remotely or flexible hours, can be powerful perks. Alternate benefit strategies, including voluntary benefits or wellness programs, are also used by some practices to encourage workers to do more without increasing salaries.

Finally, practices should be honest and straightforward in compensation discussions. Physicians should begin by setting employees' expectations about salary increases from the hire date, both the timing as well as the likely amounts.

Beyond annual pay raises, practices should be thinking about compensation in all its forms throughout the year. Recognizing a job well done, ordering lunch for the office and handing out small incentives, such as gift cards, helps employees realize there are other perks of being at the practice besides the money.


A group of leading U.S. medical associations have founded the Partnership to Empower Physician-Led Care (PEPC) to promote value-based care in independent physician practices and to speak up on their behalf. Through education and advocacy, PEPC says it will urge action on four policy priorities: advancing physician-led alternative payment models, ensuring a fair policy framework that promotes choice and provider competition, creating new opportunities for physicians in commercial markets, such as Medicare Advantage, and supporting consumer-directed care.

PEPC Executive Director Kristen McGovern says independent physicians make up nearly half of the physician workforce, so it is "impossible to achieve truly value-based care without a robust independent practice community." She says, "Our goal is to ensure that independent practices are recognized as a vital part of the healthcare system and are given a clear path to continue to contribute to this transformation."

The coalition was created by Aledade Inc., the American Academy of Family Physicians, California Medical Association, Florida Medical Association, Medical Group Management Association, Texas Medical Association and PracticeEdge. McGovern says other stakeholders often do not realize that independent practices are able to take risks for their patients or that independent practices can lead alternative payment models like accountable care organizations (ACOs), often with better results. She cited a report on the Medicare Shared Savings Program, which found that 45 percent of physician-only ACOs earned savings and that they were more likely to do so than other types of ACOs.

Health Policy and Reimbursement

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The U.S. Centers for Medicare and Medicaid Services (CMS) has signed an emergency contract agreement with West Publishing Corp. to ensure its new Medicare ID cards are assigned to the right beneficiaries. CMS is mailing the cards with randomly generated beneficiary identifiers instead of Social Security numbers, and about 60 million beneficiaries will receive the new cards by next April. However, CMS learned via simulation that a data vulnerability could cause the wrong beneficiaries to receive some of the cards, as some of the address information the agency has may be inaccurate.

"To mitigate this risk, CMS requires a contractor to perform a validation of Medicare beneficiary address information in advance of the Medicare Card mailing project," says the agency. West Publishing will get $5.5 million to ensure the cards go to the right beneficiaries. "The agency's need to have a contractor perform the beneficiary address validation services is of such an unusual and compelling urgency that the government would be subject to serious financial injury if this contract was delayed and Medicare cards were mailed prior to the addresses being validated," CMS noted. West Publishing bid against two unnamed competitors, and CMS determined it had the best private-sector database to track down beneficiaries.


The U.S. Centers for Medicare and Medicaid Services (CMS) on May 7 rejected a proposal from Kansas to place a three-year lifetime cap on some adult Medicaid enrollees. This marks the first time the Trump administration rejected a state's Medicaid waiver request regarding who is eligible for the program. However, CMS Administrator Seema Verma did not reject Kansas' effort to place work requirements on some adult enrollees; that decision is still pending. Kansas and a handful of states, including Alabama and Mississippi, that did not expand Medicaid under the Affordable Care Act want to add the work requirement for some of their adult enrollees. The National Health Law Program has filed suit against CMS and Kentucky to block the work requirement from taking effect, saying it violates federal law.


The new federal budget law lets Medicare cover telemedicine services for people who have had a stroke and those who receive kidney dialysis, while also allowing Medicare Advantage plans to offer telemedicine as a covered benefit. Meanwhile, as of January 1, Medicare began permitting doctors to bill the government for monitoring certain individuals remotely using telemedicine tools. Some telehealth e-visits are covered by private health plans, Medicare, state Medicaid programs and the U.S. Department of Veterans Affairs, while more health centers and hospitals are rolling out virtual health centers, and websites offering virtual "doctor on demand" services are spreading.

However, physicians worry that they may receive less remuneration if insurance reimbursement is lower for e-visits than for in-person appointments, or that e-visits could reduce face time. In addition, health economists are concerned that e-visits could increase costs. Most telehealth e-visits are for primary care or follow-up services, although a growing number are for people with chronic conditions who are being monitored at home.

Overall, e-visits are less expensive than a trip to the doctor, but care beneficiaries may not see the difference if their insurance covers both with only a small copay or no copay. For people with large deductibles, an e-visit may mean they pay less out of pocket for that session.

Medicine, Drugs and Devices

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At a recent House committee hearing, drug distribution company executives said they support the creation of a nationwide prescription drug monitoring program (PDMP) to help curb opioid abuse. A national PMDP for tracking opioid prescriptions was proposed in President Trump's recent initiative to address the opioid epidemic. An effective implementation of a PMDP to provide "real-time red flags based on a patient's nationwide prescription history ... would require support from the Food and Drug Administration or Congress and require all pharmacies and providers to participate," said McKesson President and CEO John Hammergen. Cardinal Health Executive Chair George Barrett concurred, asserting that a national PMDP would enable improved collaboration between industry and regulators.


There were 343 medical device recalls in the first three months of 2018, marking the highest number in a single quarter since 2005, according to a report by Stericycle's Recall Index (PDF). Software was the top driver of medical device recalls in the first quarter, accounting for nearly one-fourth of all recalls.

Bethany Hills, an attorney at Mintz Levin in New York, says the rapid uptick is not surprising. Medical device software is becoming increasingly complex, with analytics that provide a higher level of clinical decision support. "The more complex the software, the more likely it is that the developers did not account for all variables in the clinical environment, increasing the risk of bugs and errors," she said.

Although it is possible the first quarter of 2018 was an anomaly, software challenges are not likely to ebb. Device manufacturers are creating more innovative devices with software that requires frequent updates and patches. Meanwhile, medical device cybersecurity has become a growing concern for industry leaders and lawmakers.

Hills anticipates the medical device recall trend will continue, especially now that the U.S. Federal Drug Administration is accepting devices with artificial intelligence and more complex clinical decision support algorithms.


President Trump is hoping to bring down drug prices in the United States by forcing higher prices in foreign countries that use their national health systems to make drugs more affordable. Foreign price controls, Trump has said, reduce the resources that U.S. drug companies have to finance research and develop new cures.

The White House Council of Economic Advisers issued a report in February criticizing the "underpricing of drugs in foreign countries." The council said that profit margins on brand-name drugs in the United States were four times as high as those in the more regulated markets of major European countries and Japan.

Alex Azar, the secretary of the U.S. Department of Health and Human Services, said the administration would focus on several problems in the new strategy to lower prescription drug prices, including high list prices set by drug makers, rising out-of-pocket costs for consumers and "foreign governments free-riding off of American investment in innovation." The United States can pressure foreign nations through diplomacy and trade negotiations.

In its annual report card on the protection of intellectual property rights around the world, the United States trade representative criticized the drug pricing and reimbursement policies of Canada, South Korea, Japan, India, Turkey, New Zealand and a number of European Union countries, saying they did not adequately recognize the value of innovative medicines.