News From ACFAS

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On April 11, 2018, leaders from the American Academy of Orthopaedic Surgeons, the American College of Foot and Ankle Surgeons, the American Orthopaedic Foot & Ankle Society and the American Podiatric Medical Association came together in Chicago for a first-of-its-kind meeting of a Joint Task Force of Orthopaedic Surgeons and Podiatric Surgeons.

The task force will work to enact policy initiatives, both at the state and federal levels, that are of mutual benefit to podiatric surgeons, orthopaedic surgeons and their patients. It will also examine the education and training of graduates from colleges of podiatric medicine with the goal of consensus on options for education, training and certification.

“The first meeting of our task force was full of positive energy,” said John Steinberg, DPM, FACFAS, co-chair of the task force.

“It was the first of many meetings to come and is a great example of the collaborative spirit of our two professions,” said Steven Ross, MD, co-chair.

Watch for more information to come about the joint task force and its efforts. Congress has passed S. 2372, the Veterans Administration MISSION Act of 2018. This legislation include the VA Provider Equity Act that reclassifies podiatrists as podiatric surgeons within the Veterans Health Administration (VHA) and gives them parity with allopathic and osteopathic physicians. This update will help address recruitment and retention issues in the VHA and will improve foot and ankle care for veterans. The bill now goes to the President for an anticipated signature.

"ACFAS joins the profession in celebrating this great step forward for our specialty," said ACFAS President John S. Steinberg, DPM, FACFAS. "We applaud the efforts of many members of our field and also those of orthopaedic surgery who collaborated on this for the sake of patient care. I’m hopeful this can move us closer to the passage of the HELPP Act to correct Title XIX Medicaid law so that DPMs are recognized as physicians.” You should have already received either the ACFAS Member Insights Survey or Practice Economics Survey via email from ACFASpresident@perceptionsolutions.com. If you've not yet submitted your survey responses, please do so by June 15.

Don’t miss your chance to be one of eight lucky respondents who will win either an iPhone X or Bose noise-canceling headphones.

We value your feedback, so respond now and have a say in the College’s future! Just a few simple changes to your coding and billing procedures can make all the difference in maximizing reimbursement for the care you provide. Register now for Coding and Billing for the Foot and Ankle Surgeon, July 13–14 in Portland, Oregon or October 19–20 in Chicago, and gain practical tips to help you:

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

You will also code actual patient cases and scenarios step by step with faculty to get an inside look at how the coding and billing process works. This course is worth 12 continuing education contact hours (Category 1 credit). Visit acfas.org/practicemanagement to register today.

Foot and Ankle Surgery

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The study authors sought to examine the feasibility and safety of an advanced, acellular and flowable wound matrix (FWM) in patients with diabetes-related cavity or tunnel lesions involving deep structures. Patients with diabetic foot ulcers were hospitalized at the General and Geriatric Surgery Unit of the University of Campania in Naples, Italy, between March 2015 and December 2015. Twenty-three patients with tunneled or cavity ulcers were treated.

The lesions were filled with the FWM. Surgical wound edges were either approximated with stitches or left to heal by secondary intention. After six weeks, 78.26 percent of patients completely healed after a single application of the FWM. The healing time for all healed wounds was 30.85 ± 12.62 days, or 26.11 ± 5.43 days in patients for whom wound edges were approximated by stitches, and 57.66 ± 3.05 days in the patients who healed by secondary intention. Permanent tissue regeneration was observed in a high percentage of patients. Study authors observed a low rate of complications, such as major amputation and increased hospitalization.


New research shows that when treated in an injury-specific manner, stage four rotational ankle fractures with posterior malleolus fractures had similar outcomes to ligamentous-equivalent injuries. Researchers collected foot and ankle outcome scores for 187 ankle fractures treated with injury-specific anatomic fixation of either a posterior malleolus fracture (n=122) or torn PITFL (n=56). Results indicated that patients in the posterior malleolus fracture group were significantly older, were more likely to be female, had a lower mean BMI and a greater rate of medial malleolar fractures versus the PITFL group.

Other fracture and baseline characteristics were similar in the two groups, researchers note. The posterior malleolus fracture group had a median length follow-up of 16.3 months versus 12.8 months for the PITFL group. At the time of most recent follow-up, univariate and multivariable analyses showed no differences in foot and ankle scores for symptoms, pain, activities of daily living, sports or quality of life.


Researchers explored whether older patients with stage II adult-acquired flatfoot deformity (AAFD) had inferior clinical outcomes or an increased number of subsequent surgical procedures after flatfoot reconstruction when compared with younger patients. They divided 140 consecutive feet with stage II AAFD in 137 patients into three groups based on age: younger than 45 years, 45 to 65 years and 65 years and older. Preoperative and postoperative Foot and Ankle Outcome Scores (FAOSs) at a minimum of two years were compared.

The researchers reviewed hospital records to determine if patients underwent a subsequent procedure postoperatively. Patients in the older group did not demonstrate any differences in changes in FAOS subscales compared with patients in the young and middle-aged groups (all P > .15). The older group had significant preoperative to postoperative improvements in all the FAOS subgroups ( P < .01). In addition, patients in the older group were not more likely to have a subsequent surgery than were the younger patients (all P > .10). The researchers concluded that older patients have improvements in patient-reported outcomes and rates of revision surgery after surgical reconstruction that were not significantly different than those of younger patients.

Practice Management

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The rise of electronic health records (EHRs) at healthcare facilities has increased the workload of doctors and nurses. This added work can result in burnout if not managed properly. Rick Roesemeier, manager at ECG Management Consultants, has proposed four ways that healthcare organizations can improve support of staff and lower the risk of EHR-related burnout.

First, let doctors customize EHR interfaces. Leveraging tools, such as customized templates and view filters, can foster a unique EHR experience that makes providers' documentation responsibilities easier. Second, provide extensive EHR training for doctors. Training has been proven to increase overall satisfaction and is vital to reducing physicians' EHR frustrations. Third, sync EHR and clinical workflows. The vast amounts of data stored in the EHR can be overwhelming if not aggregated in a way that produces actionable insights. Finally, respond to comments and criticisms regarding EHR technology. Leaders should seek out physicians' feedback and strive for constant improvement.


It is essential for medical practices to be aware of 2018 changes to the Medicare Access and CHIP Reauthorization Act (MACRA) and Merit-Based Incentive Payment System (MIPS) in order to be in compliance and receive the maximum positive adjustment. A change made in the Quality category, which comprises up to 50 percent of a physician's total score in MIPS, is the inclusion of more "topped out measures," including Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (when indicated in all patients) (Measure 23).

For 2018, the U.S. Centers for Medicare and Medicaid Services will allow physicians and clinicians to report their MIPS data via a "virtual group," indicating "a combination of two or more [tax identification numbers] assigned to one or more solo practitioners or one or more groups consisting of 10 or fewer eligible clinicians who elect to form a virtual group for a performance period for a year." Furthermore, fewer physicians will be required to comply with MIPS. Physicians are excluded if they either bill less than $90,000 to Medicare Part B or see 200 or fewer Medicare beneficiaries. Some exclusions remain the same, such as a physician who is new to Medicare is excluded for that calendar year.


The introduction of artificial intelligence (AI) to consumer and clinical electronics has big implications for how we treat and identify disease, and it could even help doctors predict disease before it becomes catastrophic. Potential challenges exist as well, including the need to educate patients and practitioners about how to use these tools, potential privacy issues around patient data and the possibility of overdiagnosis. Despite these concerns, medicine might be uniquely suited to a safe and effective rollout of AI. It is a highly regulated industry, full of risk-averse practitioners who are used to incorporating new technology and insights.

In the doctor's office, AI has so far helped identify disease, monitor heart activity and prevent seizures. The NeuroPace Responsive Neurostimulation System, which is implanted in the brain, uses machine-learning algorithms to stimulate patients' brains to interrupt a seizure at its onset.

AliveCor, the maker of the KardiaMobile, a pocket-size electrocardiogram monitor, is also gathering the type of data from its devices that could someday feed a machine-learning system that doctors could use to spot disease. One potential application is a "bloodless blood test," which would look at a subtle shift in the EKG that is characteristic of a potential potassium blood-level elevation. Currently, the condition can be diagnosed only by drawing blood.

Health Policy and Reimbursement

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The U.S. Government Accountability Office (GAO) says the U.S. Centers for Medicare and Medicaid Services (CMS) has not authorized the continuation of prior authorization experiments despite the fact that they could save Medicare billions of dollars. The experiments stipulate that CMS only covers some items and services after providers and medical product suppliers have shown they complied with coverage and payment rules. The agency uses prior authorization in Medicare for nonemergency ambulance rides, hyperbaric oxygen therapy, home health services and power wheelchairs.

GAO estimates that CMS may have saved up to $1.9 billion due to prior authorization since it started the experiments in 2012. However, most of the experiments have concluded or soon will, and CMS has not announced plans to continue most of these efforts, with the exception of those involving power wheelchairs. "By not taking steps, based on results from the evaluations, to continue prior authorization, CMS risks missed opportunities for achieving its stated goals of reducing costs and realizing program savings by reducing unnecessary utilization and improper payments," GAO warns.

The office determined that providers and suppliers have had problems with prior authorization, noting it can take months to secure required documentation from referring doctors and others before submitting a prior authorization request, while clinicians lack financial incentives to furnish that information.


The U.S. Centers for Disease Control and Prevention's National Health Interview Survey estimated that the population of Americans with health insurance did not appreciate last year for the first time since the Affordable Care Act (ACA) was passed in 2010. Last year, 29.3 million people, or 9.1 percent of the U.S. population, were uninsured, versus 28.6 million people, or 9 percent, the year before. These numbers are still well below the 16 percent of the population lacking health insurance when the ACA was passed.

However, this could be the start of a reversal as Republicans push to repeal the law. The GOP succeeded in repealing the individual mandate requiring most people to have some form of health insurance or pay a tax penalty, as part of the broader tax law it approved in December. Experts predict this move will leave more people uninsured, as well as highly elevate premiums in ACA exchanges as healthier, younger people choose to skip coverage.


A new House bill mandates the application of discounts for drugs in Medicare's prescription drug program when the medications are purchased at the pharmacy, to ensure customers get the full discount instead of some of the money going to insurers and drug intermediaries. The Phair Pricing Act of 2018 is built on a platform released by President Trump, highlighting little transparency in the negotiations over rebates to reduce prices for drugs in Medicare Part D.

The legislation would direct "all price concessions, incentive payments and price adjustments" to be included when a senior purchases the medication from the pharmacy. U.S. Department of Health and Human Services Secretary Alex Azar has intimated that the Trump administration could rescind rebate agreements for Medicare drugs and instead set fixed price discounts applied at the point of sale.

Medicine, Drugs and Devices

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Older adults with Medicare Part D plans are paying more for generic prescriptions even as the market price of these drugs remains unchanged, according to an Avalere analysis. This is because over time the generic drugs are being placed on higher formulary tiers where patients pay greater out-of-pocket costs.

The number of generic prescription drugs placed on the least-costly, lowest tier declined 53 percent between 2011 and 2015. That resulted in a 93 percent hike in total patient cost sharing for these drugs, or a total of $6.2 billion. This higher cost sharing and transition of generics to higher tiers did not correlate with a rise in the underlying price of generic drugs over that period, the analysis found. "It shows that the price to the consumer is rising much more rapidly than the price of the drugs," said Dan Mendelson, president of Avalere.

In 2011, 71 percent of generic drugs were put on tier 1, the lowest tier in the formulary. By 2015, 19 percent of covered generics were placed on tier 1, 46 percent were placed on tier 2 and 35 percent were placed on tier 3 or higher. Mendelson said the analysis "reflects the general trend of more expensive generic drugs."


A recent study shows that to get patients to comply with recommendations and medications, the means of communication may be as important as the message itself, maybe even more so. It also suggests that healthcare need not take place in a doctor's office—or be provided by a physician—to be effective. In the study, such communication took place in a barbershop, a setting that fosters both confidentiality and camaraderie, to try reaching men to talk about hypertension.

The control group consisted of barbers who encouraged lifestyle modification or referred customers with high blood pressure to physicians. In the intervention group, barbers screened patients, then directed them to pharmacists who met with customers in the barbershops. They treated patients with medications and lifestyle changes according to set protocols, then updated physicians on what they had done.

After six months, systolic blood pressure in the control group had fallen about 9 mm Hg to 145.4. In the intervention group, though, blood pressure had declined 27 mm Hg to 125.8, which is close to "normal." Furthermore, the rate of cohort retention was 95 percent.

The findings are also notable because the barbershop customers were part of a population that is traditionally hard to reach, and getting barbers involved meant health messages came from trusted members of the community.