News From ACFAS

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Turn up the heat on your practice marketing efforts this summer. Download the latest issue of FootNotes from the ACFAS Marketing Toolbox, customize it with your office’s contact information then:

• Post FootNotes on your practice website and social media pages
• Print copies of FootNotes for new and existing patients
• Distribute FootNotes at any community health fairs you will speak at this summer

Articles in this edition include:

• 10 Vacation Tips for Healthy Feet
• Runners & Joggers: Watch for Morton’s Neuroma
• Weekend Warriors Vulnerable to Foot & Ankle Injuries

Access free healthcare provider referral tools, PowerPoint presentations, infographics and more at acfas.org/marketing to promote your practice throughout the year. Register now for Coding and Billing for the Foot and Ankle Surgeon, set for July 21–22 in Philadelphia and October 13–14 in Phoenix, and learn how to simplify your coding and reimbursement processes for:

• multiple-procedure cases when performing forefoot, rearfoot or ankle reconstructive surgery
• open reduction and internal fixation of multiple fractures
• complex arthroscopy cases
• diabetic foot surgery

Work through case-based and interactive procedures with expert faculty and also code real-time patient scenarios from start to finish.

Visit acfas.org/practicemanagement to register today. Would you like to design an original research study but don't know where to start? Visit the ACFAS Clinical and Scientific Research Grant webpage for:

• new tips from the College's Research Committee
• guidelines for designing a research study
• other helpful resources

If you have specific questions about designing your research study, email research@acfas.org.

Foot and Ankle Surgery

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Foot pain has long been linked to fall risk among seniors, according to a study published in the journal Gerontology, but the new Framingham Foot Study has examined the contributions of pain severity, foot posture and foot function. A total of 1,375 participants with an average age of 69 were asked about falls over the last year, with logistic regression used to calculate odds ratios (ORs). According to the results, 21 percent reported foot pain: 40 percent mild pain, 47 percent moderate and 13 percent severe. Roughly 33 percent reported falls in the last year, with foot pain associated with a 62 percent increased risk of recurrent falls. Those with moderate and severe foot pain showed increased odds of less than two falls versus those with no foot pain. Foot function was not associated with falls, according to researchers. Finally, compared to normal foot posture, those with planus foot posture had a 78 percent higher chance of two or more falls. The results indicate that both foot pain and foot posture may play a part in increasing the risk of falls among seniors.


Achilles tendon repairs and other surgeries involving the hindfoot typically have a higher rate of wound healing complications and surgical site morbidity. To evaluate the complication profile and risk factors for adverse short-term clinical outcomes after primary repair of Achilles tendon ruptures, researchers evaluated cases of primary Achilles tendon repair entered into the National Surgical Quality Improvement Project database between 2005 and 2014. Of 1,626 patients with an average age of 44 years, hypertension (20.7 percent), morbid obesity (8.3 percent) and diabetes (4.9 percent) were among the most common medical comorbidities. A total of 28 (1.7 percent) of patients sustained perioperative complications, including 0.7 percent superficial wound infection and 0.4 percent wound disruption. Systemic complications occurred in 0.4 percent, most commonly with deep venous thrombosis or nonfatal thromboembolism. Preoperative albumin was independently associated with an increased risk of local wound complications. Chronic obstructive pulmonary disease and bleeding disorder were more likely to result in a systemic complication, and preoperative creatinine correlated with an increased risk of any complication. In total, there were five (0.3 percent) readmissions with two (0.1 percent) unplanned reoperations attributed to local wound complications. The researchers concluded that among a broad-based demographic of the United States, the rate of local wound complications was notably low in the short-term perioperative period, although this risk may be magnified with subtle decreases in albumin levels. Preoperative risk stratifications should be carefully scrutinized for subtle abnormalities in nutritional parameters and renal function prior to undergoing Achilles surgery.


The American College of Physicians (ACP) has issued new guidance for treating low bone density and osteoporosis to prevent fractures in male and female patients, reports the Annals of Internal Medicine. The recommendations are an update to those published by the organization in 2008. Based on a review of published evidence, ACP thinks clinicians should use alendronate, risedronate, zoledronic acid or denosumab to reduce the risk of hip and vertebral fracture in women with known osteoporosis. The group also recommends a five-year pharmacologic treatment interval for osteoporosis. Meanwhile, ACP advises clinicians to refrain from treating women with menopausal estrogen therapy or raloxifene. In the female osteopenic population aged at least 65 years, the guidelines call for providers to base decision-making on patient risk profile, patient preferences, benefits, harms and medication costs. In instances where pharmacologic intervention is followed, ACP recommends that bone density monitoring be performed during that time. To curtail the risk for vertebral fracture in osteopenic men, ACP prefers treatment with bisphosphonates.

Practice Management

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The WannaCry ransomware attack affected many hospitals and healthcare information systems worldwide, and the U.S. Department of Health and Human Services (HHS) emphasizes that organizations should be careful in opening any emails and email attachments to prevent the malware from spreading. "We are ... aware that there is evidence of this attack occurring inside the United States," says HHS' Laura Wolf. To prevent ransomware attacks via email, HHS advises people to open emails only from parties they know and those they are expecting. Attackers can also masquerade as familiar senders, or the computer belonging to others may be infected without their knowledge. HHS also notes it is important to keep computers and antivirus programs updated and urges organizations to report any incidents of ransomware attacks to the Internet Crime Complaint Center. In addition, HHS cites the need for healthcare cybersecurity best practices, reminding organizations to visit the US-CERT National Cyber Awareness System webpage, the National Cybersecurity and Communications Integration Center portal for those who have access and the Federal Bureau of Investigation's Liaison Alert System page.


Rebecca Fox, MD, has struck out on her own and now has an office space but nothing in it except for a few coffee mugs. It is really easy to drop a small fortune on furniture, equipment and supplies, especially when purchasing all new things, writes Fox, who would rather do anything than borrow money from a lending institution. She offers some tips for furnishing a medical practice in a cost-effective way. Check thrift stores and used furniture shops for furniture that can be cleaned and refurbished. Also check eBay and Craigslist for furniture that would be suitable to an office. Depending on the time of year, many stores will hold big sales. Spend money on what is important, such as new computers, telephones, software and medical equipment. Shop around for pricing on services, such as website development, and do not be afraid to bargain. Also, manage the inventory of supplies carefully and hire people only as business picks up, adds Fox.


A recent American Journal of Managed Care study reveals that nurse practitioners (NPs) and physician assistants (PAs) did not contribute to higher healthcare costs as a result of ordering more ancillary or costly services compared to primary care providers (PCPs). Researchers examined roughly 180,000 Kaiser Permanente Georgia patient cases involving treatment for neck or back pain and acute respiratory infections between January 2006 and March 2008. The assessment revealed that PCPs ordered significantly more low-value and expensive services. According to the data, PCPs were more likely to order a CT or MRI (3.3 percent of cases) compared to PAs and NPs (2.1 percent of cases). PAs and NPs also tended to order more nonnarcotic analgesics with a prescription in 13.5 percent of cases compared to just 8.5 percent for primary care providers. The study also found that advanced practice clinicians prescribed musculoskeletal relaxants in slightly more cases with an order 45.8 percent of the time versus 42.5 percent for PCPs. While primary care providers tended to order more tests and services overall, physician assistants and nurse practitioners tended to prescribe more antibiotics for acute respiratory infections. These clinicians ordered any antibiotic for 73.7 percent of patients, whereas primary care providers only prescribed them for 65.8 percent of patients. Researchers attributed less low-value ordering habits of physician assistants and nurse practitioners to their education. "Training of NPs/PAs typically emphasizes patient education and self-management over other interventional strategies," the study stated.

Health Policy and Reimbursement

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The U.S. Centers for Medicare and Medicaid Services (CMS) has released guidelines on a new "proxy direct enrollment pathway" that will be available for the 2018 individual Affordable Care Act market via HealthCare.gov. The new proxy direct enrollment pathway will only be available for the federally facilitated exchange (FFE) and for state-based exchanges and solely for simple cases. Consumers with complex enrollments, special enrollments or terminations need to proceed through the existing "double redirect" enrollment process. Applicants and enrollees using direct enrollment (DE) will be able to complete the process of determination of marketplace, premium tax credit and cost-sharing reduction payment eligibility, as well as qualified health plan enrollment, on a DE entity's websites. The guidance states that CMS "may require" DE entities to inform consumers of privacy, security and other issues. Consumers will need to be aware of the full range of products available through HealthCare.gov and to supply appropriate documentation. Entities seeking to participate in the proxy direct enrollment process must retain third-party auditors to validate their compliance with requirements and undergo compliance audits. If more applications from DE entities are received than can be processed, CMS will process them on a first-come, first-served basis. Access to the FFE will be suspended immediately if a DE entity is found out of compliance or if an entity attempts to use the proxy direct enrollment process without approval.


A new survey from the U.S. Centers for Disease Control and Prevention (CDC) says progress in reducing the number of uninsured Americans stalled last year. CDC estimated that 28.6 million people were uninsured in 2016, a flat figure from 2015. The uninsured rate was nine percent, compared to 9.1 percent in 2015. The implication of these estimates is the core elements of the Affordable Care Act (ACA) were reaching their limits in the final year of the Obama administration. Premiums for private insurance were about to climb, and 19 states continued to block the ACA's Medicaid expansion. The number of uninsured could rise again under certain policies being considered by President Trump and congressional Republicans. "It's disappointing that it's stalled out," says health economist Gail Wilensky. "The real question is, will we be able to keep the gains that we have made?" An unpopular GOP bill passed by the House would restrict Medicaid funding and curb subsidies for many consumers buying their own private policies. The GOP would also repeal the mandate that most Americans carry health insurance or risk fines. Congressional analysts anticipate the legislation will lead to a spike of 24 million uninsured people within a decade, while there are 20 million fewer uninsured since 2010 under the ACA.


A new study determined rural residents who shopped for coverage on the state health insurance marketplaces this year often had only one or two insurers to choose from and regularly faced significantly higher premiums than did people in metropolitan areas. In areas with one insurer, monthly premiums were $451 or more in half of the silver “benchmark” plans on which premium subsidies are based. Meanwhile, in regions where six or more insurers offered plans, monthly premiums were lower for comparable coverage, with $270 or less. Premium growth from 2016 to 2017 also showed significant variance, according to the number of insurers participating in a region. Average premium growth was 30 percent in regions with one insurer versus five percent in regions with at least six carriers. “All the problems seem to be very strongly correlated with the size of the population,” notes study coauthor Linda Blumberg with the Health Policy Center at the Urban Institute. “If you've got a big population, more insurers are coming in to compete for that business.”

Medicine, Drugs and Devices

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A new report published in Diabetes Care indicates that the first four years of the U.S. National Diabetes Prevention Program (DPP) have resulted in promising results. DPP is an evidence-based program developed by the U.S. Centers for Disease Control and Prevention (CDC) in collaboration with nongovernmental partners. Sessions with lifestyle coaches take place weekly for the first 6 months and then switch to monthly for a 22-session minimum. CDC statistician Elizabeth K. Ely and colleagues analyzed data from 14,747 adults who were enrolled in year-long DPPs from 2012 to 2016. Participants attended an average of 14 sessions through the year, and 35.5 percent of participants achieved the weight loss goal of five percent of body weight. For every additional session attended and for each 30 minutes of weekly activity reported, participants lost 0.3 percent of body weight, while nearly half (41.8 percent) who reported physical activity reached the goal of 150 minutes a week. DPP includes stress reduction, dietary coaching and moderate physical activity over a 12-month period. It can take up to 36 months of a program running for it to gain full recognition and for participants to start reaching the five percent weight loss goal, Ely noted. For example, some organizations take a break between the weekly and monthly sessions, which can impede participants' momentum. Some organizations realized that the jump from weekly straight to monthly sessions was too difficult, so they took it upon themselves to start biweekly sessions to help transition to the maintenance phase.


Researchers have evaluated minimal footwear and gait retraining intervention for runners over the course of six weeks. For the study, researchers randomly assigned 12 trained male runners to minimalist footwear transition combined with gait retraining (“Combined” group) examined in both footwear, and 12 trained male runners to a gait retraining group only with no minimalist footwear exposure (“Control” group). They assessed participants for loading rate, impact peak, vertical, knee and ankle stiffness, and foot strike using 3D and kinetic analysis. Loading rate was significantly higher in the Combined group in minimal shoes in pretests compared to a Control, reduced significantly in the Combined group over time and was not different to the Control group in posttests. The impact peak and ankle stiffness reduced over time in both groups. Loading rate and vertical stiffness was higher in minimalist footwear than conventional running shoes both before and after intervention. There was a higher tendency over time to nonrearfoot strike in both interventions but more acute changes in the minimalist footwear. A Combined intervention can potentially reduce impact variables. However, a higher loading rate initially in minimalist footwear may increase the risk of injury in this setting, researchers conclude.


U.S. policymakers are feeling public pressure to take action on drug pricing, and U.S. Health and Human Services Secretary Tom Price recently heard views from various patient groups, insurers, hospital groups and other organizations. Price and his colleagues have so far not dropped hints about what proposals they are leaning toward, according to meeting attendees. Among the proposals are increasing competition via generic drug development, price transparency and greater dialogue between regulators and government payers. Faster generic drug approvals and more transparency in pricing appears to be a common interest. Modifications to raise competition are probable, and a Senate user fee bill would affect generic drug development by providing drugmakers with more opportunities to meet with the U.S. Food and Drug Administration earlier in the application process for guidance. Some are pushing for more pricing transparency from drugmakers, with itemized breakdowns of how much they invest in research versus marketing, profits and executive compensation. “If you have the transparency in place, all stakeholders can see the flow of money and who is making what, and that sets competition on a much more level footing, and we believe that will drive down prices,” says National Health Council CEO Marc Boutin.