August 1, 2018 | | JFAS | Contact Us

News From ACFAS

Speak Up to CMS on Discriminatory Changes to E/M Services
The College asks all ACFAS members to submit their comments to the U.S. Center for Medicare and Medicaid Services (CMS) expressing their concern about proposed changes to Evaluation and Management (E/M) services. Members should urge CMS not to:
  • Make differential payments to DPMs by requiring them to use separate E/M codes from those used by all other Medicare physicians
  • Consolidate payment rates for multiple E/M codes reflecting varying levels of intensity into a single payment rate
  • Reduce payment by 50 percent for the least expensive procedure or visit that the same physician (or a physician in the same group practice) furnishes on the same day as a separately identifiable E/M visit
Requiring podiatrists to use different E/M codes than all other Medicare physicians and to receive a lower reimbursement rate could affect access to care, outcomes and cost of care for Medicare beneficiaries.

Submit your comments to CMS at by September 10, 2018. Watch ACFAS publications for updates on this issue as they become available.
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Manuscript Submission Deadline Coming Up Fast
Just two weeks left to submit your manuscripts for ACFAS 2019! Send us your entries by August 15, 2018 so you can be part of our much-loved annual manuscript competition, set for February 14–17, 2019 at the Ernest N. Morial Convention Center in New Orleans.

All manuscripts submitted for consideration are blind-reviewed and judged on established criteria. Winners will divide $10,000 in prize money.

Visit now for submission guidelines and criteria.
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Better Than Mardi Gras: ACFAS 2019 Exhibit Hall
No need to venture out onto Bourbon Street for fun and excitement—find it all in the ACFAS 2019 Exhibit Hall, February 14–17, 2019 in New Orleans.

This is the place to get an inside look at the newest products and services from 140+ companies, meet up with your colleagues and friends for lunch, win prizes, scan your badge and browse through a wall-to-wall display of scientific and case study posters.

Also stop by the HUB theater in the Exhibit Hall to hear hourly sessions on timely and trending topics in foot and ankle surgery or visit the ACFAS Job Fair to search for your next job or new hire.

Visit for more on what you can expect at ACFAS 2019 and how to make the most of your conference experience!
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Download Back-to-School Infographics from Marketing Toolbox
The countdown to the first day of school is officially on for kids across the country. Use this time to educate your patients on how to keep kids’ and teens’ feet and ankles healthy as they start a new school year.

Head to the ACFAS Marketing Toolbox to download any of the following free infographics and display them in your office, distribute them to patients or post them on your practice website and social media sites:
  • Back-to-School Shoe Shopping Tips
  • Pediatric Foot & Cleat Injuries
  • Prevent Foot & Ankle Running Injuries
New infographics are added to the Toolbox throughout the year. Visit regularly for these and other free products designed to help you educate your patients and promote your practice.
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Foot and Ankle Surgery

Arthroscopic Debridement of Anterior Ankle Impingement in Patients with Chronic Lateral Ankle Instability
The aim of this study was to determine the functional and radiological outcomes of arthroscopic treatment of anterior ankle impingement (AAI) in patients with chronic lateral ankle instability (CAI).

A total of 60 patients with CAI underwent open modified Broström repair of lateral ankle ligaments. They were divided into two groups: AAI group (with anterior ankle impingement) and pure CAI group (without anterior ankle impingement). The patients were followed up with at a mean of 37 ± 10 months. Preoperatively, the AAI group had a significantly lower American Orthopaedic Foot and Ankle Society (AOFAS) score and Tegner activity score when compared with the pure CAI group. The ankle dorsiflexion of the AAI group was also significantly lower than that of the pure CAI group. However, postoperatively, no significant difference existed between the two groups in the AOFAS score, the Karlsson score, the Tegner score or ankle dorsiflexion. X-ray examination was also applied to investigate anterior tibiotalar osteophytes. The postoperative X-ray images demonstrated complete osteophyte resection in all patients and no recurrence of osteophyte.

Given that the functional outcome scores and dorsiflexion significantly improved postoperatively, the researchers concluded that combined treatment of chronic ankle instability and anterior ankle impingement produced satisfactory surgical outcomes in patients with CAI accompanied by anterior ankle impingement symptom.

From the article of the same title
BMC Musculoskeletal Disorders (07/19/18) Yang, Qining; Zhou, Yongwei; Xu, Youjia
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Comparison of Surgical Site Infections in Ankle Fracture Surgery with or without the Use of Postoperative Antibiotics
In this multicenter study, researchers examined the use of postoperative antibiotics in ankle fracture surgery. They studied and compared three groups: inpatients receiving 24 hours of intravenous antibiotics, patients receiving 24 hours of oral antibiotics and patients receiving no postoperative antibiotics.

A total of 1,442 patients with ankle fractures requiring operative fixation were retrospectively reviewed. The researchers discovered no differences between the three groups in the rates of cellulitis, infection requiring additional antibiotics or infection requiring return to the operating room. No differences were observed among the groups for any risk factors for infection, including body mass index, previous infection, hepatitis C virus (HCV) or human immunodeficiency virus (HIV) status, smoking status or diabetes.

The researchers concluded that the use of antibiotics postoperatively did not reduce the incidence of surgical site infection. The study findings suggest that the routine use of postoperative antibiotics after ankle fracture surgery is not beneficial.

From the article of the same title
Foot & Ankle International (07/23/2018) Lachman, James Robert; Elkrief, Justin I.; Pipitone, Paul S.; et al.
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Risk of Damaging Anatomical Structures During Minimally Invasive Hallux Valgus Correction (Bösch Technique): An Anatomical Study
Percutaneous, transverse distal metatarsal osteotomy with K-wire fixation (the Bösch technique) is an established technique for hallux valgus correction, but the risk of harming the anatomical structures during the operation is unknown.

In this study, 40 fresh-frozen anatomical foot specimens with hallux valgus deformity underwent a percutaneous corrective procedure. Specimens of group A were operated on by an experienced surgeon while specimens of group B were operated on by untrained residents. The dorsal cutaneous nerve was injured in one of 20 cases in group A and in six of 20 cases in group B. There was a significant difference in overall complication rate between specimens of both groups. The results showed an increased risk of perioperative injury of the dorsal cutaneous branch of the deep peroneal nerve as well as a significant effect of the surgeon's experience on the overall complication rate.

Results of this study are highly relevant for all surgeons who perform percutaneous, minimally invasive hallux valgus surgery to avoid damage to the peripheral nerves. The findings also indicate that intensive training for surgeons is needed before they perform minimally invasive hallux valgus surgery without supervision.

From the article of the same title
Foot & Ankle International (07/18/2018) Kaipel, Martin; Reissig, Lukas; Albrecht, Lukas; et al.
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Practice Management

Crash Test Your Legal and Financial Planning
Being a doctor is both a high-reward and high-liability profession, and your financial and legal planning should address the most predictable and widely applicable risks.

First, crash test your life planning. Do you have a personal liability umbrella insurance policy of at least $1 million? Are you financially prepared for an event that would prevent you from continuing to practice your profession? If an employee or partner is vital to the business, are you adequately insured for their loss or disability? Is there a latent risk in your life you are aware of and have been avoiding addressing for any reason, such as a physical safety issue at your business or on your property?

Next, crash test your estate planning. If you have an estate plan, does your family know about it, is it up-to-date and are you comfortable with your instructions and the guardians and trustees you left in charge? Has your spouse been sufficiently included in your relationship with your legal, tax and investment advisors and are those relationships good enough to provide the guidance your family will need? Is the amount of wealth your family would be left with tomorrow enough to provide the income and stability for them to have and do everything you are working to provide? Addressing these issues will make your and your family's future more predictable and prosperous.

From the article of the same title
Physicians Practice (07/24/18) Devji, Ike
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Ensure Your Medical Practice Supports Its LGBTQ Employees
With more than 5 million U.S. workers identifying as lesbian, gay, bisexual or transgender, practices can take steps to both attract and retain this niche group of talent in the workplace. Society may be shifting toward greater acceptance of LGBTQ issues, but discrimination and bias are still reported. One area where medical practices can set themselves apart is by creating all-encompassing and equitable benefits to all groups, no matter how family is defined.

The Family Medical Leave Act (FMLA) requires employers to give eligible employees 12 consecutive weeks off for certain family and medical reasons, but employers are not legally required to grant the same rights to LGBTQ employees in most states. To support a healthy and diverse workforce, practices can create unique employee benefit packages that include maternity and paternity leave, same-sex partner healthcare coverage options and PTO and job protection policies for family and medical leave for same-sex couples. Competitive benefits packages help attract and retain top talent, and providing LGBTQ benefits to employees and their families can be a low-cost, high-return investment.

Another opportunity for companies to consider for their recruitment and retention strategies is to appeal to millennials. They are the largest generation in the workforce, and more than 8 percent of millennials identify as LGBTQ, according to a recent Gallup Poll. Business owners need to bridge the gap between these two key workplace demographics with modern culture tactics and to create an inclusive culture that will ultimately affect the bottom line.

From the article of the same title
Medical Economics (07/23/18) Byers, Kristin
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Physicians Aren't 'Burning Out.' They're Suffering from Moral Injury.
Physicians are often the victims of burnout, which is characterized by exhaustion and reduced productivity, but they also experience moral injury, a term originally used to describe soldiers' responses to their actions in war. Moral injury represents "perpetrating, failing to prevent, bearing witness to or learning about acts that transgress deeply held moral beliefs and expectations." While burnout can be seen as a symptom of the broken healthcare system, the moral injury of healthcare is being unable to provide high-quality care and healing.

Most physicians enter medicine following a calling and go through years of dedication and sacrifice. Failing to consistently meet patients' needs has a profound impact on physician wellbeing, which is the core of consequent moral injury. In an increasingly business-oriented and profit-driven healthcare environment, physicians must consider a multitude of factors other than their patients' best interests when deciding on treatment, including financial considerations, electronic health records and the prospect of litigation.

In order to ensure that compassionate, engaged and highly skilled physicians are leading patient care, executives in the healthcare system must recognize that the issue is not just physician burnout. The simple solution of establishing physician wellness programs or hiring corporate wellness officers will not solve the institutional patterns that inflict moral injuries. Practices need leadership willing to acknowledge the human costs and moral injury of multiple competing allegiances and to minimize those competing demands. Leaders must recognize that caring for their physicians results in thoughtful, compassionate care for patients, which is ultimately good business.

From the article of the same title
STAT (07/26/2018) Talbot, Simon G.; Dean, Wendy
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Health Policy and Reimbursement

CMS Expands Site-Neutral Payments, Extends 340B Drug Discounts
The U.S. Centers for Medicare and Medicaid Services (CMS) has proposed expanding its site-neutral payments between what Medicare pays for at doctors' offices and off-campus hospital clinics, as well as extending 340B drug discounts to off-site hospital clinics. The agency said it was making the changes to address concerns about healthcare consolidation and that the move would save hundreds of millions of dollars.

CMS said it would apply a physician fee schedule-equivalent payment rate for the clinic visit when a patient is seen at an off-campus provider-based department paid under Medicare's Hospital Outpatient Prospective Payment System (OPPS). The OPPS payment rate would rise by 1.25 percent under the rule, bringing payments to OPPS providers to $74.6 billion—an almost $5 billion increase from this year. The agency said the proposed change would result in lower copayments for beneficiaries, as well as Medicare savings estimated at $760 million for 2019.

In addition, CMS is extending its new hospital payment methodology for 340B drugs to outpatient clinics. That means it will pay nonexcepted off-campus hospital clinics average sales price minus 22.5 percent for drugs acquired through the 340B program. The agency said it has saved beneficiaries $320 million since it began the change earlier this year. CMS would also shift more care to ambulatory surgery centers instead of hospitals by changing payment rates and would allow more procedures to be performed at such centers.

From the article of the same title
American Journal of Managed Care (07/26/2018) Inserro, Allison
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Eli Lilly CEO Denounces Plan to Consider Drug Imports
Executives at pharmaceutical company Eli Lilly have condemned the Trump administration's proposal to consider ways to import prescription drugs from abroad, calling for regulatory reforms instead. Executives said the concept of importing drugs from other countries, even in limited circumstances, is worrisome.

The U.S. Department of Health and Human Services (HHS) recently announced it is creating a working group to study how the United States could import pharmaceuticals from abroad as a way to fight steep price increases for drugs that are produced by one manufacturer and that are not protected by patents or exclusivities. HHS Secretary Alex Azar, who used to oversee Lilly's U.S. division, argues that importing drugs could increase competition and discourage manufacturers from implementing extreme price jumps just to make a profit.

David Ricks, Lilly's chairman and CEO, said he supports expanding access to prescription drugs and keeping prices affordable. But he said importing drugs is not the solution and pressed for regulatory reforms instead. Ricks also said he is planning for a policy change and noted he is open to changing the Medicare drug rebate structure—something currently under criticism by Azar, who thinks rebates provide an incentive for higher drug prices.

From the article of the same title
The Hill (07/24/18) Weixel, Nathaniel
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Senate Panel Approves Bill Banning 'Gag Clauses' in Pharmacy Contracts
The Senate Health Committee has approved legislation banning "gag clauses" that restrict pharmacists from letting customers know when they can save money on prescriptions by paying with cash instead of insurance. These clauses are sometimes included in contracts between pharmacies and insurers or pharmacy benefit managers.

Sen. Susan Collins (R-Maine), who sponsored the bill, described the measure as a "concrete action to lower the cost of prescription drugs." She noted that "insurance is intended to save consumers money. Gag clauses in contracts that prohibit pharmacists from telling patients about the best prescription drug prices do the opposite ... Americans have the right to know which payment method provides the most savings when purchasing their prescription drugs."

From the article of the same title
The Hill (07/25/18) Hellmann, Jessie
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Medicine, Drugs and Devices

House Votes to Repeal Tax on Medical Devices
The U.S. House of Representatives has voted to repeal the excise tax on medical devices, such as artificial joints and pacemakers. The 2.3 percent tax was created under the 2010 Affordable Care Act to help pay for expanding health insurance, but lawmakers suspended it until 2020 amid pressure from medical device companies and their home-state allies in both parties.

The vote was 283 to 132, with just one Republican opposing the measure and 57 Democrats supporting it. The bill would lower federal revenue by approximately $22 billion over 10 years. The Senate is unlikely to take up the legislation before the end of 2018, and the bill's future remains unclear.

From the article of the same title
Wall Street Journal (07/24/18) Rubin, Richard; Andrews, Natalie
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Institutional System Changes May Improve Ankle Fracture Fixation Outcomes
New research suggests that institutional system changes for treatment of ankle fractures may reduce malreduction and complication rates. "Ankle fractures should not be treated as simple fractures and even less complex ones can be fixed poorly," said Andrew Molloy, FRCS (Tr and Orth) in a presentation at the American Orthopaedic Foot and Ankle Society Annual Meeting. "Education alone is ineffective in producing change as it emphasizes what has been done badly, not what one should do."

Among 94 patients who underwent ankle fracture fixation in 2009, Molloy found a malreduction rate of 33 percent and a major complication rate of 8.5 percent. A period of reeducation was implemented after these results that included presentations of departmental meetings and teaching of junior staff. Researchers reviewed 64 patients who underwent ankle fracture fixation from a seven-month period in 2014 and found a deterioration in outcomes. "The malreduction was 43.8 percent. The major complication rate was 10.9 percent," Molloy reported.

Multiple system changes were implemented throughout the department, including new treatment algorithms, dedicated foot and ankle trauma lists and clinics and next-day review of all intraoperative radiographs by independent attendings. From January 2015 to September 2016, researchers collected prospective data on 205 patients who underwent ankle fracture fixation. "The results of the system changes are hugely significant," Molloy said. "It went down to a malreduction rate of 2.4 percent and a complication rate of 1 percent."

From the article of the same title
Orthopedics Today (07/18) Tingle, Casey
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Sprained Ankle? Opioid Rx More Likely in Some States Than Others
The likelihood of being prescribed opioids for minor injuries varies significantly based on where patients live, according to a new study published in the Annals of Emergency Medicine. Patients who sought care for a sprained ankle in states that were "high prescribers" of opioids were about three times more likely to receive a prescription for the drugs than those treated in "low-prescribing" states.

The researchers focused on ankle sprains because they are common and because it is established that "opioids should be rarely used to treat this, given other strategies are just as—or more—effective for controlling pain," said study author Dr. M. Kit Delgado of the University of Pennsylvania.

Of nearly 31,000 patients who were treated for an ankle sprain between 2011 and 2015, one quarter were prescribed an opioid. Prescribing of opioids declined during the study period, from a national average of 28 percent in 2011 to 20 percent by 2015, the research showed. However, the researchers found that in "high-prescribing states, mostly concentrated in the southern U.S., the [opioid] prescribing rate was around three times higher than in low-prescribing states." For example, while less than 3 percent of North Dakota's ankle sprain patients were prescribed an opioid, that figure reached 40 percent in Arkansas.

Delgado suggested that differences in state opioid laws, guidelines and monitoring likely play a role, as well as differences in the severity of local opioid crises. "There may [also] be regional differences in how doctors practice," he added, as well as "how doctors weighed the risks and benefits of prescribing an opioid."

From the article of the same title
HealthDay News (07/26/18) Mozes, Alan
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This Week @ ACFAS
Content Reviewers

Mark A. Birmingham, DPM, FACFAS

Gregory P. Still, DPM, FACFAS

Jakob C. Thorud, DPM, MS, FACFAS

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This Week @ ACFAS is a weekly executive summary of noteworthy articles distributed to ACFAS members. Portions of This Week are derived from a wide variety of news sources. Unless specifically stated otherwise, the content does not necessarily reflect the views of ACFAS and does not imply endorsement of any view, product or service by ACFAS.

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