News From ACFAS

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All ACFAS members are encouraged to contact their federal representatives in support of Senate Bill 2175, the Department of Veterans Affairs Provider Equity Act. Contacts on the Senate Committee on Veteran’s Affairs are especially important. The bill would put DPMs on equal footing with MDs and DOs in the VA hospital system.

AAOS and AOFAS recently attacked S 2175 and DPMs' qualifications, while failing to mention that 1) DPMs already provide superb care to America’s veterans in VA hospitals and 2) they have no evidence to compare the outcomes of DPMs vs. MDs or DOs.

ACFAS wrote the chair and ranking minority chair of the Senate Veteran’s Affairs Committee on May 17. For additional information, contact Sarah Nichelson, JD, ACFAS director of Health Policy, Practice Management and Research.
Bring your latest groundbreaking research to life by presenting it in poster format at our special 75^th Anniversary Scientific Conference, February 27–March 2, 2017 in Las Vegas.

Poster abstracts must be submitted to ACFAS by September 1, 2016 to be eligible for review. PDFs of eligible posters are due December 1, 2016.

Poster format requirements and abstract submission guidelines will be available on acfas.org in late June.

ACFAS’ annual poster display attracts some of the highest traffic at the conference—take advantage of this opportunity to share your newest findings with your peers and the profession!
On April 27, the Centers for Medicare & Medicaid Services (CMS) issued a notice of proposed rulemaking that outlined several important provisions of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). The proposed rule outlines the provisions of the merit-based incentive payment program system (MIPS) and alternative payment models (APMs). These two new payment programs could mean big changes for doctors who see Medicare patients.

The College is putting together reference materials that discuss how foot and ankle surgeons may be affected. Additionally, the College is writing an official comment letter to send to CMS.

Visit cms.gov for informational webinars on MACRA. Direct questions or comments about MACRA, MIPS and APMs to Sarah Nichelson, JD, ACFAS director of Health Policy, Practice Management and Research.
The U.S. Bone and Joint Initiative is seeking young investigators to apply for the young investigators grant mentoring and career development program in musculoskeletal diseases within the United States.

This workshop provides promising junior faculty, senior fellows or postdoctoral researchers who have been nominated by their department or division chairs the opportunity to receive topnotch mentorship in research, funding and academia. The deadline to apply is July 15. Visit usbji.org for more information.
ACFAS welcomes the new Student Club Presidents for the 2016–2017 school year:

• AzPod: Stephen Smith, Class of 2019
• Barry: Dylan Grau, Class of 2018
• CSPM: Brennan Menninger, Class of 2018
• DMU: Joshua Wolfe, Class of 2018
• Kent State: Emily Zulauf, Class of 2018
• NYCPM: Calvin Davis, Class of 2018
• Scholl: Austin Chinn, Class of 2019
• Temple: Brian Derner, Class of 2018
• Western U: Kale Meeks, Class of 2019

ACFAS Student Clubs are located on all nine podiatric medical school campuses and provide student club members access to ACFAS scholarships, Regional Division 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.

We wish these new ACFAS leaders great success throughout the upcoming school year!

Foot and Ankle Surgery

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Charcot osteoarthropathy (COA) can be hard to diagnose in certain situations because it can be indistinguishable from other causes of pain and swelling in the affected extremity. The presence of elevated systemic inflammatory parameters in the context of suspected infection may delay early diagnosis and treatment of COA. A new study evaluated whether these parameters are present and therefore not to be used as a diagnosis exclusion criteria. A total of 42 patients were observed. Researchers conducted plain radiographs, magnetic resonance imaging and clinical course. Inflammatory parameters included C-reactive protein level, white blood cell count and erythrocyte sedimentation rate. Statistically significant differences were found in all inflammatory parameters, showing that elevated parameters can be used to distinguish between certain stages of COA. The markers should not be considered an exclusion criterion for diagnosis.


Researchers gathered all the patient-reported outcomes and satisfaction data in the largest sample to date of patients undergoing modern fixed-bearing total ankle arthroplasty (TAA). A total of 300 patients were analyzed. All patients submitted a Veterans Rand 12-Item Health Survey (VR-12), Ankle Osteoarthritis Scale (AOS) and American Orthopaedic Foot & Ankle Society (AOFAS) Hindfoot score both preoperatively and at postoperative follow-ups. Patients also submitted satisfaction surveys at follow-up. The mean AOFAS score preoperatively was 41.1, jumping to 84.6 at latest follow-up. Mean VR-12 scores were 29.7 (Physical) and 54.1 (Mental) preoperatively and 42.7 (Physical) and 55.7 (Mental) at latest follow-up. Eighty-four percent of patients reported very good to excellent pain relief, 78 percent had improved ability to do daily tasks and 54 percent noted improvement in the ability to do heavy work or recreational activities. Only two patients underwent revision TAA, and 94 percent of patients said they would definitely have the procedure on the contralateral ankle.

Practice Management

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Electronic transactions can save the healthcare industry about $8 billion per year, according to the 2015 CAQH Index Report. The report indicates that digital processes are far more efficient than manual ones. The average cost of a claims verification performed by hand is $10.83, according to the data in the report. A digital verification is only $2.51. Digitizing the process can also save physicians time and money. A more efficient transaction system shortens the time to payment and cuts costs associated with labor. Digital processing is not yet required at practices, but health plans must offer a digital option. The practice could have many more benefits, according to analysis. The largest savings could come from eligibility and verification, which typically take a long time via phone. Revenue cycles could also be shortened. The current adoption rate for digital solutions is 60 percent, which means that 40 percent of providers still rely on manual operations. The slow move could be due to stubbornness on the part of private practices. In addition, entrenched technology at some practices may be impeding implementation because it is not able to support digital transactions.


Many healthcare organizations entrust implementation of the electronic health record (EHR) to the "physician champion," someone who has embraced technology and will help usher the organization into a more modern era. But what happens when your champion no longer wants to fulfill the role? New rules and regulations have made EHR implementation more daunting than before, and this is a completely realistic possibility. If there is no physician champion, the work will need to be done in the back office. Invest in business and practice management systems that are flexible enough to deal with constant shifts in value-based purchasing. Investigate the means to exchange medical records with other healthcare organizations. Be sure to automate medical records management workflows to save time. Create a system where it is easy to efficiently calculate and report clinical quality measures. Finally, implement a way to communicate electronically with patients. The goal is to make steady EHR progress even if you have no champion to help you through the process.


Integrating electronic health record (EHR) systems when joining with another practice can be difficult. Every office has a different workflow, and understanding those differences is key to an efficient partnership. In some cases, these integrations can take months, going through multiple interface changes, and could cost nearly $200,000. "Moving data is very difficult," says Jacqueline Fincher, a primary care physician and member of the American College of Physicians' Board of Regents. For Fincher's merger, new hardware cost $55,000, new servers cost $35,000 and around $100,000 was spent in personnel time, excluding physician productivity. After struggling to integrate dueling EHRs, Fincher devised a list of questions that every practice should ask itself should it decide to go the integration route:

1. What data do you absolutely need to have in your new system and what is negotiable?
2. Will you choose to load data manually or digitally?
3. What data will be archived, and how will you find it in a timely way?
4. Will you maintain your old system? If so, for how long and how much will it cost?
5. How will new data (laboratory tests, consults, etc.) be received?
6. What did forms look like in the old system for each visit, and how will they look in the new one?
7. What is the workflow for each type of visit and what forms are used?

Health Policy and Reimbursement

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The U.S. Department of Health and Human Services (HHS) has announced an innovation challenge called "A Bill You Can Understand," aimed at encouraging healthcare organizations, developers, designers and digital tech companies to create a medical bill that is easier to understand. HHS is rewarding the two best submissions $5,000 each. The initiative highlights the complexity of the medical billing process, which has roused critics for years. The process can often place multiple bills in multiple hands, and patients and doctors alike are often unaware of the specifics. The contest will have two categories: easiest to understand and most improved billing system. Entries will also be judged based on plain language use, transparency as well as uniqueness and creativity of solution. Several organizations have agreed to test or implement the winning solutions.


A new study from Accenture has found that high-quality customer experiences increase net profits compared with average performers. Hospitals with superior customer experiences saw 50 percent greater margins, indicating that service is likely the best way to cut costs, as opposed to terminating jobs. In addition, the relationship between service and savings has become increasingly significant over time. Over six years, with a 10 percent improvement in Hospital Consumer Assessment of Healthcare Providers and Systems scores, hospital margins saw 70 percent growth, the study showed. These figures hold true for most hospitals regardless of size, affiliation or category. Urban hospitals were an outlier, averaging margin increases around eight times higher than rural hospitals. The study shows that hospitals should reexamine their cost-saving strategies. According to the data, a hospital system with $2 billion in revenue would need to cut 460 jobs to accomplish the same 2.3 percent margin growth that could come from improving customer satisfaction.


A new study in JAMA reveals that price transparency does little to lower health spending. Researchers studied 149,000 employees of two large companies who were provided with an online tool to let them compare prices for healthcare services provided by physicians, a hospital or another site. Only 10 percent of employees used the tool, and those who used it did not spend any less than a control group that was not offered the tool. Those offered the tool saw an average increase of $59 in outpatient spending and an average $18 increase in out-of-pocket spending for employees. The study authors offered suggestions for why this may be, including that many patients may believe that higher prices equate to better quality of care. In those situations, patients may not be interested in lower prices because their health is more important to them than saving money. In addition, most patients using the tool searched for amounts higher than the highest deductible. According to the authors, price transparency still needs to increase even if it has little effect on prices. Some benefits of increased transparency include making patients more aware of their benefits and deductibles. In the future, researchers said, more studies need to be conducted to determine if other tools are able to lower prices.


Workgroup for Electronic Data Interchange (WEDI) has released research concluding that the federal government should use ICD-10 as a template for future sweeping mandates. Despite the months of warnings and confusion leading up to ICD-10 implementation, the study found that providers and technology vendors had enough time for testing and made the transition easier for all. In addition, most healthcare organizations reported ICD-10 has had a neutral productivity effect. Those that fell behind did so because they felt coding and other functions were more difficult, but very few vendors or health plans have experienced negative operation effects. "Based on the survey responses and other industry sources, it seems the transition as a whole went very well," according to WEDI, "and lessons learned could be leveraged for implementing future mandates."

Medicine, Drugs and Devices

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The Smart Tissue Automation Robot (STAR) is a new mechanism that conducts suturing during soft-tissue surgery. It can reduce surgical errors and increase efficiency, and it could open the door to more advances in surgical technology. Suturing is difficult regardless of how skilled a surgeon may be, and leakage along the seams of sutures is a significant problem in many surgeries. Simon Leonard, a computer scientist at Johns Hopkins University, designed STAR to precisely stitch together pieces of soft tissue. STAR was then compared against five surgeons in the areas of open surgery, laparoscopic and robot-assisted surgery. STAR achieved superior results in every category. Leonard compared its abilities to a manufacturing assembly line and said it could become standard in hospitals in the future. It could also lead to robotic surgery for rigid structures such as bones, and Leonard noted that those parts of the body could be easier to fix because they do not move as much during surgery.


The U.S. Food and Drug Administration (FDA) has issued new draft guidance for medical device manufacturers who use 3D printing. FDA in March approved the first-ever 3D-printed drug, signaling a new era in drugmaking. But medical devices are far more advanced when it comes to 3D printing, so the guidance is aimed at providing manufacturers with the agency's thinking about the technical considerations for creating such devices. The guidelines cover design, manufacturing and device testing. Because 3D printing (also known as additive manufacturing) poses unique challenges to device characterization and verification, FDA based the guidelines on some major takeaways from a 2014 public workshop on the practice. For design and manufacturing, FDA expects 3D printing technologies to adhere to quality systems requirements. The agency also wants companies to understand the effects different steps in the manufacturing process can have on a device. For testing and validation, FDA says the data required for approval should be based on a device's "intended use, risk profile and classification."


The U.S. House of Representatives has approved a new bill to create a national task force on opioid policies. The task force would be led by the U.S. Department of Health and Human Services and would include participants ranging from hospital CEOs to patients suffering from chronic pain. The bill, put forth by Rep. Sarah Brooks, establishes that the task force receive five years to set national guidelines for prescribing opioids. The hope is that the task force will help reduce the use of unneeded medications that could lead to addiction. The bill also calls for mandatory physician training, which has faced pushback from healthcare organizations that believe it is an unnecessary addendum. While many organizations are in favor of the bill, some believe more needs to be done. The American Academy of Family Physicians, for example, wants the bill to more specifically address the idea that treatment should be based on research showing the treatment's effectiveness.