News From ACFAS

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The ACFAS Nominating Committee seeks experienced members to participate in the upcoming election to serve on the College’s Board of Directors. If you are an ACFAS Fellow, believe you are qualified and would like to help lead the profession, submit your nomination application by September 15, 2021. Visit acfas.org/nominations for the nomination information and application, including complete details on the recommended criteria for election candidates. Note the application submission process will now be completed using an online application process.

The Nominating Committee will announce recommended candidates to the membership no later than October 28, 2021. Candidate information and ballots will be emailed to all voting members no later than December 11. Electronic voting ends on December 28. Time’s running out to get the same coding and billing information you missed at ACFAS 2021 at your convenience! Coding and Billing for the Foot and Ankle Surgeon is still available on demand until August 15.

Make sure you and your office staff have access to the same expert tips and insights shared at ACFAS 2021 in Las Vegas by taking advantage of this valuable recording. All participants will walk away with knowledge on simplifying your coding and reimbursement practices as well as 4.5 CME hours. The course covers timely topics, including what’s new in foot and ankle surgical coding, telehealth coding and addresses changes such as coding for prolonged services and several CCI edits relating to foot and ankle surgery.

Registration is required prior to watching the program. Visit acfas.org/PracticeManagement now to take advantage of this offer before it’s too late. The ACFAS Clinical & Scientific Research Grant Program is seeking new and experienced researchers to submit their research for grant consideration. The grant program is offering funding of up to $75,000 each year for an established investigator and up to $25,000 for a new researcher, thanks to support from PICA and the ACFAS Regions.

Letters of intent should be submitted by September 15 at 5pm CT and final applications are due by October 15 at 5pm CT. Visit acfas.org/ResearchGrant for more information. We’re hitting the road with the new ACFAS Regional Learning Series—Common Pathologies: How to Resolve and Maximize Function by Restoring Structure. First city up, Charlotte, NC, September 24-25.

The new 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.

Don’t miss us in Charlotte or the many other cities we are headed to with this program! View the course brochure or visit acfas.org/ComingToYou to register today.

Foot and Ankle Surgery

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A meta-analysis sought to probe how taping techniques affected arch deformation in adults with pes planus. The researchers combed databases including Web of Science, Pubmed, EBSCO, CNKI and Cochrane Library up to March 2020. I2 index and funnel plots were used to evaluate heterogeneity and publication bias, respectively, and Cochrane scale was used to assess the quality of research. Navicular height for three antipronation taping techniques significantly rose immediately after taping compared with baseline. The most gain was seen in Augmented low-Dye (ALD), with modified low-Dye (MLD) gains only surpassed by ALD. Navicular height after walking for 10 minutes was much higher than baseline with MLD decreasing less than ALD. Low-Dye could bring the resting calcaneal stance position closer to neutral position, although none of the three taping methods could maintain this immediate navicular height effect after an interval of higher intensity weight-bearing exercise.


A study was held to evaluate the preoperative features and pre- or postoperative function of adult acquired flatfoot deformity (AAFD) patients who received direct operative repair of an spring ligament (SL) tear compared to those without a tear. Eighty-six patients undergoing operative correction of grade 2B AAFD by one fellowship-trained foot and ankle orthopedic surgeon were reviewed at an average follow-up of 45.9 months. Thirty-five feet in total had an SL tear that underwent concomitant debridement and direct SL repair. Patients with an SL tear had significantly lower Foot and Ankle Ability Measure activities of daily living (FAAM-ADL) and sports scores (FAAM-Sports), with higher visual analog scale (VAS) pain scores preoperatively. Patient age, talonavicular uncoverage percentage and talonavicular angle were tied to SL degeneration. At final follow-up, patients exhibited a significant improvement in all outcome parameters, with no statistical difference observed in terms of patient satisfaction, final postoperative VAS pain, FAAM-ADL or FAAM-Sports in those requiring a repair of their SL versus the control cohort.


Research was conducted to compare the preoperative risk factors and postoperative outcomes between Charcot neuroarthropathy patients with dislocation compared to purely fracture pattern breakdown, as well as compare the same factors between Charcot neuroarthropathy patients with dislocation versus fracture-dislocation pattern breakdown. Fifty-five patients with forefoot, midfoot or hindfoot Charcot Neuroarthopathy were evaluated at a mean follow up of 2.99 years. Dislocation pattern Charcot had statistically significant higher rates of broken hardware, mean age and revisional exostectomy in comparison with pure fracture pattern Charcot. Dislocation pattern Charcot was 12 times more likely to have revisions exostectomy and eight times more likely to have osteomyelitis versus fracture-dislocation pattern Charcot. Patients with pure fracture pattern Charcot were 58.8 times more likely to exhibit Charcot breakdown involvement of the talonavicular joint compared to the dislocation pattern group. Involvement of the talonavicular joint in the fracture pattern Charcot was associated with medial column collapse occurring at the onset of Charcot breakdown. The dislocation pattern in Charcot Neuroarthropathy was at higher risk propensity for residual collapse as indicated by the higher rates of broken hardware, osteomyelitis and need for revisional exostectomy.

Practice Management

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A rising number of healthcare providers are turning to chatbots that act as "symptom checkers." The chatbots ask patients about their health issues and escalate serious cases to physicians. Stanford University's Mildred Cho notes, "All kinds of technologies that can be used remotely were greatly accelerated during the pandemic," including chatbots, telemedicine appointments and even virtual dental screenings. Researchers and some healthcare professionals say more data is needed about how accurate such technologies are. Chatbots deal with sensitive and often urgent information and getting the right answers is essential. Companies that develop the technologies say they proceed cautiously and regularly evaluate and test their results with trained medical professionals. Chatbots frequently rely on artificial intelligence to understand patients' symptoms and match them to probable illnesses. Health tech firm Gyant says its Scout chatbot was trained on 17 million patient interactions.


Despite signs of an emergent recovery from the COVID-19 pandemic in the healthcare sector, the growth of telehealth services, text messaging and other technologies has forced a reevaluation of the patient-provider relationship. Patients are now more likely to view their healthcare options as consumers and leave providers if their digitally connected care experience falls short. This will spur providers to seek patient engagement solutions to match trending patient preferences and expectations in order to competitively retain and draw customers. Analysis in the Annals of Internal Medicine determined that "convenience and access" override reputation among patients across 50 considered prospective providers. These tools include, but are not limited to, the provider's website and the patient portal. In the latter's case, patients demand portals that they can easily sign into to access lab results and other relevant health data. In terms of text messaging, patients favor receiving automated texts for appointment reminders, pre-visit directions and post-care follow-up instructions and patient education, as well as real-time two-way communication. Also desirable for patients is being able to fill out forms electronically at their own convenience before appointments and a streamlined appointment workflow.


Video visits and Virtual Care, which have exploded in the healthcare sector during the pandemic, differ substantially. Video visits were a fast stop-gap solution for the pandemic, and now many healthcare providers likely see the need to transition to a longer-term Virtual Care strategy and technology partner. Gartner reports that providers are switching from disjointed solutions to a long-term, enterprise-wide strategy, which should be approached carefully given market fragmentation and varying solution capabilities and cost. Fragmentation is embodied by the various "non-virtualized" physical steps with the team members who must conduct a single video visit for just one patient. As many as eight staff are often needed to navigate and transact the video visit process, while multiple software and interfaces are in operation as well. Those interfaces include the practice management suite; the Electronic Health Record system; the two-way video system; and the staffers who are phoning, emailing, texting, diagnosing, adjudicating, billing, charting and prescribing. By contrast, an end-to-end solution saves time and work costs and realizes a higher gross margin/visit as high as 75 percent.

Health Policy and Reimbursement

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The American Medical Association, the American College of Physicians, the American Academy of Pediatrics and the American Public Health Association are part of a group of over 50 major medical organizations jointly calling for all healthcare and long-term care employers to require their employees be vaccinated against COVID-19. The coalition called this mandate "the logical fulfillment of the ethical commitment of all healthcare workers to put patients as well as residents of long-term care facilities first and take all steps necessary to ensure their health and well-being." They cited highly contagious COVID variants and significant unvaccinated populations as causing infections, hospitalizations and deaths to again spike throughout the nation. White House Press Secretary Jen Psaki said the White House backs the associations' call to require vaccines for all US health staff, adding that "our own federal healthcare providers may look at similar requirements as they do with other vaccines." The Department of Veterans Affairs also declared that it will require many of its frontline health workers to be inoculated, making it the first federal agency to mandate shots among some personnel. The American Medical Association estimated that 96 percent of US physicians polled in early June said they were fully vaccinated, but the level declines substantially among other types of healthcare workers.


The US Centers for Medicare and Medicaid Services' (CMS) advance copy of the calendar year (CY) 2022 Medicare Physician Fee Schedule proposed payment rule rejects all requests to permanently add new telehealth services next year, reports the National Law Review. CMS got several requests to permanently add various services to the Medicare telehealth services list effective for CY 2022, but none fulfilled its criteria for permanent addition. The codes apparently were unsatisfactory on a Category 1 or Category 2 basis, with CMS raising issues on patient safety, the ability of the services to be accurately and thoroughly conducted via telehealth and insufficient data to demonstrate a clinical benefit to Medicare beneficiaries. Although the agency last year created a set of Category 3 codes to designate telehealth services covered provisionally during the Public Health Emergency, it has not yet compiled sufficient evidence to meet the criteria for permanent coverage. Healthcare providers have been asked to collect clinical data to help CMS determine whether these codes should be added permanently. CMS is soliciting comments on whether to adopt a policy to permanently allow provision of direct supervision via telehealth. Under Medicare requirements, this demands the physician to be physically present in the same office suite as the supervised non-physician and immediately available to deliver assistance and direction throughout the performance of the procedure.

Medicine, Drugs and Devices

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A study sought to investigate influences on children's choice of footwear, how they perceive footwear comfort and the language used to describe footwear experiences as an initial step toward designing scale to measure footwear comfort in children. The authors deployed an thematic analytical approach based on a pragmatic qualitative design. Passive observation and short interviews were performed with 23 children aged one to 12 at a footwear manufacturer headquarters and store. The participants generally equated comfort to softness, but factors influencing footwear choice were multidimensional including aesthetics, psychosocial influences, identified "comfort" and "discomfort" areas, practical issues and predictive concerns. All these influences also interacted with the age of the child. Among younger children, footwear preference is related to idiosyncratic tastes in aesthetics, physical ability and comfort. As children get older, societal influences start broadening the social function of footwear denoting group membership, to include themes that go beyond the functional and social function of footwear.


The US Food and Drug Administration (FDA) has cleared the first interchangeable insulin, Mylan Pharmaceuticals' Semglee, which can be used in place of Sanofi's Lantus at the pharmacy without requiring a separate prescription. Semglee reportedly enhances glycemic control in adults and pediatric patients with type 1 diabetes and in adults with type 2 diabetes. As a newly-designated "interchangeable biosimilar," Semglee has no clinically meaningful difference from the reference product and may be substituted for that product without prescriber intervention. "Biosimilar and interchangeable biosimilar products have the potential to reduce healthcare costs, similar to how generic drugs have reduced costs," the FDA stated. "Biosimilars marketed in the United States typically have launched with initial list prices 15 percent to 35 percent lower than comparative list prices of the reference products."


The US mask supply chain is in trouble as a new wave of COVID-19 erupts due to the delta variant, with declining sales driven by vaccinations, expired mask mandates and the resumption of foreign-made mask imports prompting some mask makers to halt production. This dovetails with the larger challenge of guaranteeing a reliable domestic supply of personal protective equipment (PPE) for the next crisis. Megan Ranney at the Get Us PPE organization warns that it is "incredibly shortsighted to have items of national security importance produced predominantly overseas." Production capacity thus far is keeping pace with domestic demand for masks, but not for nitrile gloves or surgical gowns. The Government Accountability Office calculates that in May, US manufacturers made more than sufficient N95s and almost met the need for surgical masks, but shortages could again ensue due to factory closures. Although the Strategic National Stockpile has PPE in reserve and the federal government, states and hospitals have additional stockpiles, those supplies will be depleted.

If US PPE manufacturers close, foreign companies will again become the primary sources of protective gear. Bigger manufacturers like 3M and Honeywell International could repurpose their production lines to produce masks if needed, but the American Mask Manufacturers Association says smaller outfits fabricate more US-made masks. PPE manufacturers need committed procurement from both the federal government and health systems to "create a sustainable supply chain for the future," says Soumi Saha at hospital supply purchasing group Premier Inc. Some experts think the federal government may have to nudge hospitals to buy domestic-made PPE.


Pfizer paid US regulators $24 million in 2018 to settle claims it paid kickbacks and reimbursed Medicare patients for out-of-pocket medication costs to boost its sales. The Department of Justice said Pfizer made excessively costly medicines essentially free for patients and influenced them to use the company's drugs. Pfizer is now suing the federal government in an effort to essentially legalize similar practices. Pfizer's lawsuit, filed in the Southern District of New York, seeks to obtain a judge's permission to directly reimburse patient costs for two of its heart-failure drugs, which are each priced at $225,000 annually. An outside administrator would use Pfizer contributions to cover Medicare copays, deductibles and coinsurance for those drugs, which otherwise would cost patients roughly $13,000 per year. Stacie Dusetzina, an associate professor of health policy at Vanderbilt University, says allowing pharmaceutical firms to put money directly into patients' pockets to pay for their medicines "does induce people to get a specific product" instead of shopping for a less costly or more effective alternative. She says, "It's kind of the definition of a kickback." Federal regulators have allowed the industry to help patients with copays by routing money through external charities, as long as they are "bona fide, independent" entities that do not match drugmaker money with specific drugs.