News From ACFAS

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On July 23, ACFAS joined over 100 professional medical associations in sending a letter to Congress to support greater financial stability in Medicare. Among other things, the letter, which represented over one million physician and non-physician health care providers, urged Congress to maintain the 3.75 percent increase in the Medicare Physician Fee Schedule (MPFS) Conversion Factor (CF) through at least calendar years 2022 and 2023.

Visit acfas.org/FederalLegislation for more information. If you’re not joining us this weekend for ACFAS’ popular Arthroscopy of the Foot and Ankle Surgical Skills Course, you have two more chances in 2021.

October 2-3, 2021
December 11-12, 202

Mark your calendar and register today to get the latest techniques, didactic lectures and surgical demonstrations at the Orthopaedic Learning Center (OLC) in Rosemont, IL.

Visit acfas.org/skills to secure your spot today or for more information! Join us the third Thursday of each month for a new and exciting discussion of research papers on various pertinent topics. This month’s topic Charcot Diabetic Foot Reconstruction is on August 19 at 7pm CT and hosted by the North Jersey Reconstructive Foot and Ankle Fellowship and presented by Ali Saleh, DPM.

Visit acfas.org/JournalClub to register now.

Foot and Ankle Surgery

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A retrospective case-series was conducted to classify a novel minimally invasive fixation technique for managing unstable ankle fractures in high-risk elderly patients. Six elderly patients who received dual tibiotalar cannulated screw fixation for unstable ankle fractures between January 2019 and 2020 were identified. Data on post-operative pain scores, mobility and complications was gathered and pre- and post-operative radiographs were analyzed for fracture type and complications. Functional outcomes were excellent with 83.3 percent of patients in no pain and 100 percent ambulatory with walking-aids at 10.25 months follow-up. Four of the six patients (66.7 percent) underwent satisfactory post-operative radiographs, and no soft tissue injury or infections occurred from surgery.


Researchers treated 18 adolescent patients with 25 symptomatic flexible flatfeet via subtalar arthroereisis at a mean of 12.5 years, then had them fill out the American Orthopaedic Foot and Ankle Society questionnaire, undergo radiographs and get screened using dynamic and static pedobarography as well as static hindfoot axis examination at an average follow-up of 3.9 years. Results were compared to healthy controls numbering 13 subjects and 26 feet. The 25 surgically treated feet had better post-surgical questionnaire results than before, but lower scores than healthy feet. Radiological parameters showed significant improvement after surgery. Post-surgical results were not influenced by the removal of metal, while surgically treated feet had larger contact areas than normal feet, with predominance to the midfoot region. The relative maximum force, relative peak pressure and contact time were higher in the midfoot of surgically treated feet versus controls. No differences were detected in the comparison of pedobarography data of treated and untreated feet of the same patients.


Research assessed a newly-designed three-spike insole's (TSI) performance in the realization of pedal function recovery in patients with refractory plantar fasciitis as compared to treatment with total contact insole (TCI). The insoles were designed with hardness of 58 ± 5 Shore-A. The researchers randomized 28 patients with equal allocation to either TSI or TCI. Both cohorts were homogenous for most variables at baseline. Overall patient-reported satisfaction indicated improvement from mean 5.2 weeks of wearing, and all clinical outcome scores showed significant improvements in both groups over time on the Friedman test. TSI exhibited non-inferiority to TCI at each time point, while post hoc analysis showed that many scales signaled significant superiority of TSI at three months and Karlsson-Peterson score at six months.

Practice Management

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Physician burnout is having an impact on patients, according to a new survey. The research, published by virtual healthcare technology company Wheel and independent research firm Pure Spectrum, found that 80 percent of the 2000 patients surveyed noticed during a healthcare visit in the past year that their doctor or nurse was burned out. The survey found that a quarter of respondents said that their healthcare visit felt rushed and that their healthcare professional did not have the time or energy to listen to their inquiries.


The United States has fewer practicing physicians per capita than most developed countries and has failed to keep up with the production of new doctors. National health policy has instead created incentives to train and employ nonphysician practitioners. It is impossible to know the precise effect of physician replacement on patient health and cost, while evidence suggests the rapid expansion of non-physician practitioners over the last four decades may factor into higher healthcare spending. The Institute of Medicine estimated that "unnecessary services" added $210 billion to US healthcare spending in 2013. Additional healthcare utilization can also boost profits for corporations and private equity firms, who have been especially eager to replace physicians with nonphysician practitioners—leaving patients with little choice of provider. It is also unlikely that lower salaries for non-physician practitioners would compensate for higher healthcare expenses. This situation makes it imperative that health policy experts and the public question whether this trend benefits the US.


Physicians considering taking on a partner should first weigh the pluses and minuses and thoroughly evaluate the reasons for choosing a partner. To begin with, a physician partner should bring new qualities and skills to the practice, like an eye for detail or a more extroverted approach. Physicians should discuss their expectations with partner candidates to determine if they share a sense of vision and values, but not necessarily skills. Physicians should also assess what the potential partner expects regarding their commitment and whether it is equal to their own. Physicians also should draft a set of criteria that they are looking for and determine how well a potential partner aligns with it. The potential partner should also have questions for the physician and should want to know about their character, reliability and expectations. In addition to adding skills and qualities that the practice leader may lack, physician partners can promote greater creativity and innovation; help the leader move beyond old ways of doing things; assume greater risks; restrain leaders from assuming too much risk; make striving for a common purpose less burdensome; and offer motivation and support.


A New Jersey medical facility and staffing firm failed to ensure the safety and health of nurses giving flu shots and testing potentially infectious patients for the coronavirus earlier this year, according to a US Department of Labor Occupational Safety and Health Administration investigation. Lakewood Resource and Referral Center, which operates as the Center for Health, Education, Medicine and Dentistry, contracted with Homecare Therapies—doing business as Horizon Healthcare Staffing—in October 2020 for temporary nurses to initially assist staff with the administration of flu vaccines. After the assignments began, the facility required nurses to administer 200 to 300 coronavirus tests each day for patients and the public. OSHA proposed $273,064 in penalties after citing the facility for two willful violations.

Health Policy and Reimbursement

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The US Centers for Medicare and Medicaid Services' (CMS') annual Inpatient Prospective Payment System final rule contains seven updates. Hospitals that report quality data and are meaningful users of electronic health records (EHRs) will see a roughly 2.5 percent hike in Medicare rates in fiscal 2022 versus 2021, and the agency expects hospital payments to rise by an aggregate $2.3 billion; revisions to the final rule will boost payments by $3.7 billion and include a $1.4 billion reduction from other adjustments. CMS also will eliminate median payer-specific negotiated rates by Medicare severity-diagnosis related group with Medicare Advantage insurers, relieving hospitals of about 64,000 hours of administrative workloads. The agency will further distribute $7.2 billion in uncompensated care payments for fiscal 2022, about $1.1 billion less than fiscal 2021. Also finalized is an add-on payment for COVID-19 treatment through the end of the fiscal year in which the public health emergency ends. Five new measures will be added to the Inpatient Quality Reporting Program, including COVID-19 vaccination rates among healthcare staff.


A study published in Health Affairs found an association between Medicaid expansion and fewer surgical hospitalizations among uninsured patients. The researchers determined that patients going in for surgery largely first presented to the emergency department, and in 99 percent of cases their care would likely incur catastrophic visit costs. However, the rate of uninsured discharges for these procedures was lower, at 7.85 per 100,000, in states that expanded Medicaid. Medicaid expansion was also connected to a 6.2 percent reduction in the share of such hospitalizations. The researchers said such findings carry implications for states where discussions about expanding Medicaid are underway. In 2019 alone, non-expansion states could have avoided over 50,000 cases of catastrophic financial burden had they expanded Medicaid. Twelve states have not expanded Medicare under the Affordable Care Act, while Missouri has adopted expansion through a ballot measure, but has not launched it amid a legal debate. "Medicaid expansion represents a large opportunity to reduce the risk for uninsured surgeries and the associated catastrophic financial burden," the researchers concluded.

Medicine, Drugs and Devices

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The US Centers for Disease Control and Prevention in 2016 recommended against prescribing higher doses of opioids to manage patients' chronic pain and urged dose tapering if the harms of continued therapy outweigh perceived benefits. Despite an increase in opioid tapering among patients prescribed long-term opioid analgesic therapy, opioid-related mortality continued to increase. Researchers conducted a study to assess possible associations between opioid dose tapering among patients prescribed stable, long-term, higher-dose opioids and subsequent rates of overdose and mental health crisis. The retrospective cohort study used administrative claims data from OptumLabs Data Warehouse from 2007 to 2019. The study included 113,618 patients prescribed stable, long-term, higher-dose opioid therapy for at least 12 months who contributed a total of 203,920 baseline periods. Patients undergoing tapering from higher baseline opioid doses had higher associated risk for overdose or withdrawal events and for mental health crisis events compared with patients undergoing tapering from lower baseline doses. The researchers concluded that among patients prescribed stable, long-term, higher-dose opioid therapy, tapering events were significantly associated with increased risk of overdose and mental health crisis. The authors also point out that interpretation of their findings is limited by the observational nature of the study.


After significant delay, the US Food and Drug Administration (FDA) finalized a rule to confirm what evidence it will consider when determining a medical product's intended use. FDA did not accept requests from the industry to narrow its interpretation of evidence of intended use to a firm's promotional claims. FDA said in a Federal Register notice, "Nothing in the statute requires the narrow scope that the comment suggested. … The fact that intended use can be established through promotional claims does not preclude the possibility that other evidence may be relevant as well." FDA also declined several comments challenging the inclusion of "design or composition" of an article as a type of evidence relevant to establishing intended use. The agency said it is able to consider product characteristics when determining whether a product is "intended to affect the structure or any function of the body" and therefore subject to regulation as a medical device. FDA furthermore rejected comments related to the First and Fifth amendments, saying that it "does not believe this rulemaking implicates the First Amendment," and opposed calls for clearly drawn lines for what communications are permissible or impermissible. The agency wrote, "While FDA agrees that laws must give a 'person of ordinary intelligence a reasonable opportunity to know what is prohibited,' 'meticulous specificity' is not required." The final rule is set to take effect on September 1, 2021.