News From ACFAS

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APMA is hotsting a virtual Leadership Town Hall Forum on August 11, 2021 from 8pm to 10pm EST to discuss the AMA Resolution and the supporting White Paper. The town hall will provide an opportunity for an open discussion and exchange of opinions and ideas. Interested attendees should register for the event. If you would like to speak or submit written questions, email Stephanie Simmons, APMA chief governance administrator. Mark your calendars, we’re heading to Austin for ACFAS 2022, February 24-27!

We’re looking forward to celebrating 80 years of cutting-edge education with an in-person, full-capacity meeting and hope you’ll join us. We’re hard at work planning to bring you more pre-conference workshops, new topics in the HUB, two global symposia, hands-on workshops, a wrap party and so much more!

ACFAS 2022 marks a huge milestone for ACFAS you won’t want to miss. Program information will be found at acfas.org/asc when registration opens in late September, so save the date and check back to learn more. High-quality poster presentations are an important part of the Annual Scientific Conference. We invite you to submit your latest discoveries and late-breaking research to be considered for display at ACFAS 2022, February 24-27 in Austin.

Poster abstracts must be submitted to ACFAS by September 15 to be eligible for review. PDFs of eligible posters are due November 10.

Visit acfas.org/PosterSubmission to view newly revised guidelines/criteria and submit your poster today! ACFAS is coming to a city near you this fall with our new Regional Learning Series—Common Pathologies: How to Resolve and Maximize Function by Restoring Structure.

Our newest program combines case presentations, lightning lectures and hands-on labs to give you a better understanding of contributing factors associated with foot and ankle surgery complications and help in applying new skills to maximize function and restore structure. See where we’re headed:

September 24-25, 2021
DoubleTree by Hilton Charlotte | Charlotte, NC

November 5-6, 2021
Embassy Suites by Hilton St. Louis Downtown | St. Louis

April1-2, 2022
Renaissance Denver Downtown City Center Hotel | Denver

April 29-30, 2022
Embassy Suites by Hilton Berkeley Heights | Berkeley Heights, NJ

May 20-21, 2022
Hilton Orlando Bonnet Creek | Orlando, FL

Visit acfas.org/ComingToYou to view full agendas, get more information or to register.

Foot and Ankle Surgery

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A systematic review intended to identify and assess the evidence for non-pharmacological interventions and corticosteroid injections in the management of Achilles tendon (AT) pathology in people with inflammatory arthritis (IA). Included in the review were quantitative longitudinal designs like randomized controlled trials, pseudo randomized and non-randomized experimental studies, observational studies, cohort studies and case control studies. Only two out of 10,911 articles that explored the effectiveness of corticosteroid injections for AT engagement in IA fulfilled the inclusion criteria, and none were noted for non-pharmacological interventions. Both injection studies had low quality rating for internal and external validity, and by extension overall validity. The studies only delved into pain and ultrasound (US) identified abnormalities and vascularity in the AT. Evidence was thin concerning a short-term improvement of six to 12 weeks in pain and for the reduction in some abnormal US detectable features at the AT and surrounding structures following corticosteroid injection. The absence of relevant literature highlights a pressing need for more research to assess non-pharmacological interventions for the AT in people with IA.


A systematic review and meta-analysis sought to evaluate the effectiveness of end-to-end repair, neurolysis, nerve grafting and nerve transfer in improving motor function following tibial nerve injury. The researchers ultimately selected 19 studies covering 677 patients. The most common cause of injury was gunshot wound, and the mean MRC of all patients was 3.7 plus or minus 0.6. Good outcomes were classified as an MRC of 3 or more. End-to-end repair treatment had the most number of good outcomes, followed by neurolysis. Patients with preoperative intervals of less than seven months were more likely to experience good outcomes than those with intervals longer than seven months. Patients with sport injuries had the highest concentration of good outcomes compared with patients with transections and who were in motor vehicle accidents. No statistically significant difference was observed in good outcomes between the use of sural and peroneal donor nerve grafts, nor between age, graft length and MRC score.


An evaluation of percutaneous Achilles tenotomy performed under local anaesthetic to correct equinus deformity in congenital talipes equinovarus patients in clubfoot clinics determined that the procedure was safe and clinically successful for both parents and children during the COVID-19 pandemic. Included were 25 patients (36 tenotomies), median age nine weeks. All patients realized a postoperative ankle dorsiflexion of greater than 15 degrees. Neither patients nor their parents contracted the COVID-19 virus, and all parents reported a positive experience and 99 percent were less anxious about having the operation performed in clinic rather than in theater.

Practice Management

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Clinical burnout among medical practitioners can be relieved via locum tenens, which carries benefits that doctors often miss. Locum tenens physicians enjoy far more freedom and flexibility than traditional clinic or hospital employment offers. Practitioners can work on a schedule that best suits them, giving them time to focus on outside interests while still being able to practice their profession. A flexible patient schedule and the right working hours allows physicians to devote more time and energy to individual patients. Locum tenens doctors can still benefit traditional facilities and physicians, as they can be assigned shifts in hospitals to allow regular physicians to take longer breaks or less burdensome shifts. They can also operate in short-staffed facilities, realizing a better workforce balance. The increasing normalization of telemedicine also unlocks more opportunities to serve patients remotely via locum tenens. The general advantages of locum tenens doctors include less stress on traditional clinicians, an improved work-life balance for healthcare workers and a higher retention rate for regular physicians.


US states have statutes designed to deter the corporate practice of medicine, and make sure physicians retain full and autonomous clinical decision-making authority over patients no matter their business or profit motive. However, management services organizations (MSOs) permit non-physician investment into "on-clinical" aspects of healthcare, and their growing size and clout have blurred the boundary between clinical and non-clinical functions. Overall, plaintiff attorneys have accepted that traditional MSOs are not appropriate parties in medical professional liability (MPL) actions, as they have no clinical involvement. Yet certain MSOs have outgrown the traditional model and are increasingly shaping clinical decision-making in a variety of ways. This undermines their protections, and it behooves these organizations to defend themselves. The first defensive strategy is to familiarize themselves with grounds for litigation, including vicarious liability, direct liability and MSO liability. MSOs should then consider clarifying to patients that they do not employ physicians or supply clinical services where applicable; avoid appointing MSO-specific staff as directors of clinical activities; vet agreements between the medical practices and the MSO; and review MSO insurance coverage to verify coverage of emerging MPL lawsuits against MSOs.


Medical providers can improve their documentation, patient care and reimbursement by following five tips. The first recommendation is to avoid shortcuts via electronic health records, which can complicate support of medical necessity for the patient's continued inpatient status. The second tip is to specify procedures and any unusual situations that occur in surgical notes, which ensures accuracy. The third tip involves inpatient coders documenting diagnosis details in full, as both successful care and appropriate reimbursement hinge on the accuracy of the patient's record. The fourth tip is to document evaluation and management services in full, and the fifth and final tip is to uphold documentation accuracy when time is a factor.

Health Policy and Reimbursement

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A proposed physician payment rule from the US Centers for Medicare & Medicaid Services (CMS) that does not include pay hikes for medical providers has provoked ire. This year's physician fee schedule originally backed an increase for primary care providers by slashing payments to specialists, but Congress interceded and mandated an across-the-board 3.75 percent increase for the 2021 calendar year, which would cost taxpayers $3 billion. This year's hike allowed Medicare to cover more office visits and avoid larger cuts for specialists, but only because Congress opted to boost Medicare spending rather than complying with the program's budget neutrality requirement. With the short-term increase's expiration imminent, CMS has proposed a 3.75 percent reduction in the physician fee schedule's conversion factor for 2022, which means total provider payments will see no rise next year unless Congress allocates additional money.

"Today's proposed rule maintains the cuts to surgical care that Congress stopped last year," said American College of Surgeons Executive Director David Hoyt in a joint statement from the Surgical Care Coalition. "These cuts harm the care patients need and deserve, which is the opposite of what CMS is trying to achieve." Furthermore, the Association of American Medical Colleges' Gayle Lee said physicians and other providers could be hit with more cutbacks unless Congress halts Medicare sequestration and other budget regulations that require spending reductions.


The US Centers for Medicare and Medicare Services (CMS) has proposed a new rule designed to update the Medicare Physician Fee Schedule and pursue more health equity and telehealth use among physicians. The proposed rule would create a new conversion factor for physician Medicare reimbursement next year, and the agency has proposed decreasing the factor over a dollar to $33.58 starting Jan. 1. CMS said the proposed conversation factor mirrors a statutory update of 0.00 percent and required changes based on alterations in relative value units and expenditures from other proposed policies in the rule. Those policies include expanding telehealth services under the Physician Fee Schedule. If finalized, the rule would codify recently enacted legislation that eliminates certain statutory limits on telehealth use for diagnosis, evaluation and treatment of mental health disorders, and let patients access telehealth in their homes. Physicians also would be reimbursed for mental health visits delivered to rural and vulnerable populations in rural health clinics and federally eligible health centers, including visits conducted via interactive telecommunications technology.

Moreover, the Medicare Physician Fee Schedule would reimburse qualifying physicians for certain mental and behavioral health services delivered through audio-only phone calls. "The changes we are proposing will enhance the availability of telehealth and similar options for behavioral healthcare to those in need, especially in traditionally underserved communities," declared CMS Administrator Chiquita Brooks-LaSure. CMS has also invited feedback through the proposed rule on the collection of health equity data via confidential reports. Data collection would include, but not be limited to, LGBTQ+ status, race and ethnicity, dual-eligibility, disability and rural location.


Providing medical insurance to millions of poor Americans in states that have spurned the Affordable Care Act's (ACA) Medicaid expansion is a daunting challenge for Democratic lawmakers, who sources say have narrowed their choices down to three options. These strategies, which would leverage the existing ACA insurance marketplaces or require the Biden administration to found a new coverage program, each come with risks, while a clear path forward is elusive as time runs out to assemble an omnibus package of Democratic priorities. Other healthcare priorities are jockeying for position in infrastructure legislation, including an expansion of Medicare benefits and permanently boosting financial aid to people who buy coverage on the ACA's health insurance marketplaces. Disagreement over how best to spend limited healthcare funding could force Democrats to choose between leveraging their government control to strengthen the ACA, or add coverage of dental, vision and hearing to Medicare to appeal to swing voters. Congressional staff are still working out policy issues on expanding coverage to poor adults in the holdout states, without a clear preferred policy. Potential drawbacks include inadvertent penalties for states that already expanded Medicaid.

Options being weighed include letting low-income adults receive free private coverage through the ACA's insurance marketplaces; instructing the Department of Health and Human Services to create a new Medicaid-like program for people who would otherwise be covered by Medicaid expansion in the holdout states; and a hybrid option in which people could quickly receive free coverage on the ACA marketplaces until federal officials can set up a new program that offers better benefits.


Senate Majority Leader Chuck Schumer (D-NY) announced Tuesday that Democrats on the Senate Budget Committee agreed to about $3.5 trillion in spending for their broad health care and antipoverty plan. Democrats are using a process tied to the budget known as reconciliation to further the bill through the 50-50 Senate without Republican support and avoid the 60-vote threshold usually needed in the Senate. With the top-line numbers set, legislators will still need to work out the details of the policy provisions in the $3.5 trillion deal. "We are very proud of this plan, we know we have a long road to go, we are going to get this done for the sake of making average Americans lives a whole lot better," Schumer said. The total falls short of the $6 trillion previously sought by progressives; however, it is in line with President Biden's approximately $4 trillion economic agenda.


The US Centers for Medicare and Medicaid Services (CMS) has proposed to revise certain rules implementing the Physician Self-Referral Law, or Stark Law. The Proposed Rule would again amend the definition of indirect compensation arrangement (ICA), effectively reverting to the definition of that term before the latest Stark Law rulemaking published on Dec. 2, 2020 (the Modernizing and Clarifying the Physician [MCR] Self-Referral Regulations), as it refers to most indirect financial relationships between designated health services bodies and referring physicians. The proposal would also characterize the term "unit" and the phrase "services that are personally performed" as pertaining to the ICA definition. CMS said the MCR Final Rule "inadvertently omitted" from the revised ICA definition a provision that would have ensured that a subset of unbroken chains of potentially abusive financial relationships would have continued to fulfill the definition. The new proposal would change ICA's definition so the MCR Final Rule's added clause would only apply if the compensation arrangement closest to the physician concerns compensation for that physician's personally performed services.

To assist in this application, CMS proposes adding specific text that "[s]ervices that are personally performed by a physician...do not include services that are performed by any person other than the physician...including, but not limited to, the referring physician's...employees, independent contractors, group practice members or persons supervised by the physician."

Medicine, Drugs and Devices

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A new report from the US Food and Drug Administration (FDA) reveals that the agency eased certain regulations and priorities during the COVID-19 pandemic to prevent drug shortages. For instance, it streamlined more than 100 original abbreviated new drug applications (ANDAs) and 150 ANDA supplements for coronavirus-related products, according to FDA's "Drug Shortages for Calendar Year 2020" report.

FDA said 43 new shortage emerged, but 199 were avoided, compared with 2019's 51 new shortages and 154 avoided shortages. There were also 86 ongoing shortages last year, compared with 76 in 2019. The authors wrote, "This increase of ongoing shortages at the close of CY 2020 as compared to the close of previous calendar years is due to the previously discussed closures of manufacturing facilities for remediation purposes, as well as the increase in demand for many drug products due to the COVID-19 pandemic." According to the data, 512 potential drug and biological product shortage situations were reported by 120 different manufacturers in 2020. The agency received 575 notices from 109 manufacturers in 2019. The authors also noted that drug shortage staff are focusing on hospital intensive care drugs related to ventilators, including sedatives, opioid analgesics, and neuromuscular blocking agents. They concluded, "To address shortages, including those related to the COVID-19 pandemic, FDA is working with manufacturers and other partners to help prevent shortages from occurring and to mitigate the impact of shortages that cannot be prevented."