News From ACFAS

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Another Annual Scientific Conference is in the books! This year’s meeting looked a lot different with new COVID protocols in place and a virtual component, but with offering both in-person and virtual options, the 2021 Annual Scientific Conference was a huge success! ACFAS is proud to have never missed an annual meeting in 79 years! Thank you to all who joined us in Vegas and from home to knock another great meeting out of the ballpark.

Highlights from this year’s meeting included an electrifying opening keynote speech from ZDoggMD, a trip to a roaring 20s speakeasy for the opening reception, another full line up of educational sessions covering more trending topics in foot and ankle surgery, record-breaking manuscript and poster submissions and a much-needed opportunity to network with colleagues and friends after a rough past year.

Get full conference coverage and photos in the June issue of ACFAS Update and mark your calendars for next year! We're looking forward to a full capacity in-person meeting in 2022 and to celebrate our 80^th Annual Scientific Conference February 24-27, 2022 in Austin! ACFAS would like to thank all the members who dedicated their time and worked so tirelessly to help make this meeting a reality after such a challenging year. We couldn’t have done it without the efforts of our volunteers.

A special thank you to the Annual Scientific Conference Committee and Board of Directors: Naohiro Shibuya, DPM, MS, FACFAS, Conference Chair; Michael Dujela, DPM, FACFAS; Katherine Dux, DPM, FACFAS; Ryan Rigby, DPM, FACFAS; Aksone Nouvong, DPM, FACFAS; Katherine Raspovic, DPM, FACFAS; Amber Shane, DPM, FACFAS; Jonathan Sharpe, DPM, FACFAS; Jacob Wynes, DPM, MS, FACFAS; Thanh Dinh, DPM, FACFAS; Michael J. Cornelison, DPM, FACFAS; Eric A. Barp, DPM, FACFAS; Scott C. Nelson, DPM, FACFAS; Christopher Lotufo, DPM, FACFAS; Alan MacGill, DPM, FACFAS; Alan Ng, DPM, FACFAS; Barry Rosenblum, DPM, FACFAS; Matthew Williams, DPM, FACFAS; George T. Liu, DPM, FACFAS and Andrew J. Meyr, DPM, FACFAS. Whether you attended last week’s Annual Scientific Conference virtually or in-person in Las Vegas, let your patients know! Download the free fill-in-the-blank press release from the ACFAS Marketing Toolbox now and share it to highlight your attendance.

Once you complete the press release with your information, you can distribute it to your local media, include it in your office newsletter or post it on your practice website and social media accounts.

Looking for other free resources to help promote your practice, educate patients and increase office referrals? Visit the Marketing Toolbox at acfas.org/marketing.

Foot and Ankle Surgery

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An international study was conducted to further explore the use of musculoskeletal ultrasound (MSUS) by podiatrists within their clinical setting and obtain more insights into the perceived impact of MSUS on their management of musculoskeletal foot and ankle problems. A survey was administered to 232 eligible participants, including 159 from the UK and Spain. MSUS was used most often to assist in diagnosis of injury/pathology. According to the poll, the perceived benefit podiatrists indicated in using MSUS as part of their practice is the improvement in patient journeys through tighter, concentrated management plans and shorter waiting times. MSUS also enabled podiatrists to better notify patients of their diagnosis, which they believed encouraged better engagement and empowerment of patients in their treatment plans. The researchers propose additional exploration of patient experiences and testing of the model that embeds podiatrists' use of MSUS as a major skill in musculoskeletal foot and ankle services.


A propensity score-matched analysis sought to assess the independent impact of obesity on postoperative complications and hospital utilization following ankle arthrodesis. A review of a Medicare database was conducted on patients less than 85 years old who received ankle arthrodesis between 2005 and 2014. Morbid obesity was associated with an elevated risk of acute kidney injury, urinary tract infection, readmission and overall minor complications in comparison to patients with normal body mass index and an increased risk for acute kidney injury compared to obese patients. Obesity was not tied to worse medical complications. Although morbid obesity was linked to an increase in postoperative complications, obesity was not associated with any gain in postoperative complications following ankle arthrodesis.


Research tested the hypothesis that the need for routine clinical and radiographic follow-up of ankle fractures is limited once the fracture is deemed healed. A total of 140 patients met inclusion criteria, with average age at injury 49.5 years and 67.9 percent of patients female. The mean time to healing was 82.2 days, plus or minus 33.5 days. Following radiographic healing, one patient showed radiographic changes but was asymptomatic and full weight-bearing at their final follow-up. The institution was reimbursed an average $46 to $49 for a follow-up clinic visit and $364 to $497 for a set of ankle radiographs. Average time to healing indicated a limited utility in routine radiographic and clinical follow-up beyond 16 weeks in asymptomatic patients, which would return a savings of $950 to $1,200 per patient. Yet after ankle fractures were deemed healed, 0.7 percent of patients showed radiographic evidence of a change in implant position, and recording this did not alter the immediate course of fracture treatment.

Practice Management

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Medical practices should adopt three strategies to make sure they are reimbursed for telehealth services this year. The first step is to check to see if their state has proposed or passed legislation requiring insurers to cover telehealth, which can often be done through local medical societies. The second step is to closely watch bulletins and announcements concerning telehealth from any insurance payors the practice accepts. This monitoring should be carried out on a monthly basis, at minimum. Once the practice confirms that a particular patient's insurance accepts telehealth, they should determine if the coverage specifies the use of the payor's approved telehealth vendor only, in which case appointments performed on the practice's telehealth platform may not be covered. State telehealth regulations may in some cases specify that the telehealth appointment must be allowed to be conducted with the patient's regular provider, which could overtake the payor's requirements. The third and final strategy is to update and clarify the practice's financial policy for collection of co-pays for telehealth services.


More than one type of intellectual property (IP) can be used to protect medical practices. IP includes trademarks, copyrights, patents and trade secrets, and some practices mistakenly think that simply searching the proposed name of the company when forming their Limited Liability Company gives them trademark protection. Trademarks must be filed, and enforcing them involves scanning for and pursuing adverse users and filing a cease and desist letter; using the mark in commerce will prevent it from being deemed abandoned. Copyrights, meanwhile, accord exclusive rights of authorship of original works, but using the © symbol without filing a copyright does not entitle the practice to statutory damages and attorney fees should it legally pursue someone for copyright infringement. Derivative works are improvements to what is copyrighted using background copyrighted material, and the original co-owners are owed profits from the derivative work—yet issues often arise as to what amount of the derivative was original copyrighted material and how much of the profits need to be shared. Patents enable small companies to prevent large companies from competing against them and selling a competitive alternative. Finally, designating IP as trade secrets carries pros and cons, including the possibility that someone will reverse-engineer or apply some other process to uncover the trade secret.

Health Policy and Reimbursement

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While Congress and insurers wrote rules to protect coronavirus patients from hefty medical costs tied to the pandemic, many find that they are receiving surprise medical bills anyway. Some hospitals are not complying with the ban on balance billing, while others are incorrectly coding visits. Others are going after the debts of patients who have died from the virus, pursuing estates that would otherwise go to family members. Hospitals and insurers say they try to comply with different billing guidance, but new charge codes and new rules can muddy the waters. Without the right coding, the patients' normal deductibles and co-payments apply. The United States is estimated to have spent over $30 billion on coronavirus hospitalizations since the pandemic began, according to Chris Sloan, a principal at the health research firm Avalere. The average cost of each hospital stay is $23,489, but little research has been published on how much of that cost is billed to patients.


The US Department of Health and Human Services (HHS) has asked the Supreme Court to uphold a lower court ruling that blocks hospitals from receiving higher Medicare reimbursements for outpatient services compared to other providers. HHS filed a brief in response to a petition by the American Hospital Association and the Association of American Medical Colleges to hear the case. The Court of Appeals for the District of Columbia decided in July 2020 that HHS was entitled to cut payments to hospital-owned facilities in order to support neutrality. The high court is unlikely to hear the case, as attorneys say it only agrees to hear no more than 5 percent of cases brought to it for review that involve a federal agency, while the lack of conflict on the issue between the appeals court adds to the unlikelihood. If the Supreme Court declines, the appellate court ruling would be upheld and the site-neutral payment rule would be retained.


A study published in JAMA Network Open found 51 percent of US hospital websites are still not publicizing their prices, despite a mandate in effect since 2019. David Hsieh at the University of Texas Southwestern Medical Center added that "very few" chargemasters being posted are "actually interpretable." Lovisa Gustafsson at the Commonwealth Fund said one stumbling block is the lack of a standard way for hospitals to report price information, which makes it hard to interpret or comparison-shop among different hospitals. Maureen Hensley-Quinn at the National Academy for State Health Policy said the chargemaster price offers little real value to consumers, as hardly anyone actually pays those list prices, which are tools to negotiate payments with insurers. However, the Centers for Medicare & Medicaid Services said as of January 2021, hospitals must post additional price information, including the discounted prices offered to cash-paying patients. Hospitals must also publish, in a "consumer-friendly format," charges for 300 common, shoppable services, like joint replacement surgery or childbirth. Hensley-Quinn advised insured patients to make certain that the hospital is in their plan's network and try to find out whether all providers involved in their care will be in-network.


Some researchers believe new state laws protecting patients from being hit with steep out-of-network medical bills may be contributing to higher healthcare costs and premiums. The concerns stem from state guidelines established to help impartial arbitrators resolve disputes between providers and insurance carriers over how much should be paid for surprise, out-of-network bills. States either outline specific guidelines for the arbitration method or set a benchmark for how much an insurer must pay a provider for out-of-network services in surprise billing scenarios. In states with and without arbitration, the biggest fights involve what benchmarks would be used to determine fair rates for out-of-network services. Meanwhile, the Texas Department of Insurance (TDI) reports that when the state's law was implemented in January through October 2020, the average arbitrator decision was for $967, compared with the original average surprise bill amount of $2,775. TDI said the average bill in cases settled before arbitration was $2,537, and the average settlement amount was $763.

Medicine, Drugs and Devices

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The House Committee on Oversight and Reform revisited the issue of prescription drug pricing, with a focus on AbbVie and how it sets the cost of Humira and other top sellers. A report by Democrats on the panel reveals the manufacturer has increased the price of the widely used immunology drug more than 27 times. The cost is now 470 percent higher than what it was when the drug first came to market in 2003. Legislators also questioned AbbVie's other strategies for dodging competition from lower-priced generics, including what lawmakers suggested was patent manipulation. The company's initial patent for Humira ran out at the end of 2016, but the drugmaker has secured or applied for at least 257 others. As a result, the first lower-priced biosimilar for the drug is not expected in the United States until 2023. AbbVie CEO Richard Gonzalez represented the company at the committee session and defended its practices. He noted that AbbVie provides its products for free or at a discount to some patients who cannot afford them and portrayed the firm's use of patents as "meaningful" and transparent.


Use of the mRNA COVID-19 vaccines from Pfizer-BioNTech and Moderna
provided 94 percent protection for healthcare personnel (HCP), according to interim estimates from a large, new CDC study. "This report provided the most compelling information to date that COVID-19 vaccines were performing as expected in the real world," said CDC Director Rochelle P. Walensky, MD, MPH. "This study, added to the many studies that preceded it, was pivotal to CDC changing its recommendations for those who are fully vaccinated against COVID-19." The study involved more than 1,800 participants and compared the vaccination status of participants who tested positive for SARS-CoV-2 with the vaccination status of those who tested negative. Overall, there were 623 cases and 1,220 controls. CDC noted the large sample size in this study enabled researchers to obtain a precise vaccine effectiveness estimate with narrower confidence intervals than previous CDC research published in late March. The new data indicates that symptomatic COVID-19 illness declined by 94 percent among HCP who were had received two doses of the mRNA vaccines and by 82 percent among those who had received one dose.


The US Supreme Court declined to hear Novartis's challenge to two drug patents. The justices rejected Novartis subsidiary Sandoz's appeal of a lower court decision that upheld the validity of patents for the rheumatoid arthritis drug etanercept (Enbrel—Amgen). Etanercept is Amgen's leading drug, accounting for nearly $5 billion of the company's $24.2 billion in product sales for 2020. The case involves the active ingredient in Amgen's drug. In 2020, the US Court of Appeals for the Federal Circuit in Washington, DC, determined that Immunex did not fully take over patents held by Roche, allowing the patents to remain valid. Keren Haruvi, president of Sandoz US and head of its North America business, said: "We are disappointed the Supreme Court decided not to review our case." Haruvi noted the decision indicates that Sandoz' more affordable biosimilar of etanercept (Erelzi) "will not be available to US patients with autoimmune and inflammatory diseases until 2029; nonetheless we remain committed to providing important treatment options for patients affected by these diseases."