News From ACFAS

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Reap the harvest of increased patient recruitment and higher visibility of your practice with FootNotes. Articles in the fall issue include:

• Keep Kids’ Ankles Safe During Fall Sports Season
• Have You Heard of a Lisfranc Injury?
• Bunion Surgery FAQs

Download FootNotes from the ACFAS Marketing Toolbox, customize page 2 with your practice contact information then:

• Print and distribute copies of FootNotes to your patients.
• Post FootNotes on your practice website and social media pages.
• Bring copies of FootNotes to any local health events you will speak at this fall.

Go a step further and supplement this latest issue with the PowerPoint presentation Dos and Don’ts of Diabetic Feet and the infographic Dos and Don’ts for Diabetic Foot Care, both available at acfas.org/marketing, to educate your patients during National Diabetes Month in November. This month’s free clinical session, Rethinking Flexible Adult Acquired Flatfoot, highlights five presentations from previous Annual Scientific Conferences to help you see flatfoot deformity from an entirely new viewpoint:

• How to Get a Flat: Making Sense of the Latest Research and Data
• What to Do with the Posterior Tibial Tendon: Fix, Transfer or Cut It Out?
• Deciding on Calcaneal Osteotomies: Which, Why and How Do They Work?
• Medial Column Procedures: Which Is the Key to the Perfect Arch?
• How to Recognize Over or Under Correction

Hear your colleagues explain what surgical approaches work best for flatfoot conditions and how to decide on the right treatment options for your patients. After you watch the presentations, complete a short CME test to earn 1.5 continuing education contact hours.

Visit acfas.org/e-Learning to access this session and the many other free resources in the ACFAS e-Learning Portal, including monthly podcasts, downloadable Surgical Techniques videos, e-Books and more. A new school year means new shoes for kids. Teach your patients how to find the right fit with the free infographic, Back-to-School Shoe Shopping Tips, available in the ACFAS Marketing Toolbox.

This quick reference guide explains how to select kids’ shoes that make the grade. Tips include:

• How to determine the proper size
• When to replace worn-out shoes
• The best shoes to buy for children
  with flat feet

Visit acfas.org/marketing for more infographics you can share with your patients and many other free resources to help put your patient education and practice marketing efforts at the head of the class.

Foot and Ankle Surgery

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It is unknown whether the height of a heel-rise performed in the single-leg standing heel-rise test one year after an Achilles tendon rupture (ATR) correlates with ankle biomechanics during walking, jogging and jumping in the long term. Researchers conducted a study to explore the differences in ankle biomechanics, tendon length, calf muscle recovery and patient-reported outcomes at a mean of six years after ATR between two groups that, at one-year follow-up, had less than 15 percent versus greater than 30 percent differences in heel-rise height. Seventeen patients with less than 15 percent and 17 patients with greater than 30 percent side-to-side difference in heel-rise height at one year after ATR were evaluated at a mean 6.1 years after their ATR. Ankle kinematics and kinetics were sampled via standard motion capture procedures during walking, jogging and jumping. Achilles tendon length correlated with ankle kinematic variables whereas heel-rise work correlated with kinetic variables. Limb Symmetry Index (LSI) tendon length correlated negatively with LSI heel-rise height. No differences were found between groups in patient-reported outcome. The researchers concluded that height obtained during the single-leg standing heel-rise test performed one year after ATR related to the long-term ability to regain normal ankle biomechanics. Minimizing tendon elongation and regaining heel-rise height may be important for the long-term recovery of ankle biomechanics, particularly during more demanding activities, such as jumping.


Liposomal bupivacaine (LB) is widely used in joint arthroplasty, but little is reported on the use of LB in foot and ankle surgery. Continuous popliteal sciatic nerve block (CPSNB) is more commonly used for major foot and ankle reconstructions. The purpose of this study was to compare use of intraoperative LB injection to CPSNB as a regional anesthetic for total ankle arthroplasty (TAA), with attention to postoperative pain scores, narcotic use and complications. Retrospective review of TAA patients of two fellowship-trained orthopaedic foot and ankle surgeons was performed. Patients received either preoperative single-shot popliteal sciatic nerve block with 0.2 percent ropivacaine followed by intraoperative injection of LB or preoperative CPSNB alone. Outcomes examined included visual analog scale pain score at eight hours, 24 hours, one week and three weeks following surgery and need for opioid pain medication refill. Seventy-five patients were identified who underwent TAA and met inclusion criteria, of whom 41 received LB and 34 received CPSNB. Sixteen of 41 (39 percent) LB patients had narcotic refills, versus 12 of 34 (35 percent) CPSNB patients. Two of 41 (5 percent) LB patients had a complication postoperatively, versus four of 34 (12 percent) CPSNB patients. The researchers note that this is the first study evaluating the use of LB for TAA, concluding that LB was safe and effective as an option for regional anesthetic and postoperative pain control, with comparable results to CPSNB.


This prospective study sought to identify the different trajectories of quality of life (QOL) in patients with distal radius fractures (DRF) and ankle fractures (AF). A total of 543 patients completed the World Health Organization Quality of Life assessment instrument-Bref (WHOQOL-Bref); the pain, coping and cognitions questionnaire; NEO-five factor inventory (neuroticism and extraversion); and the state-trait anxiety inventory (short version) a few days after fracture. The WHOQOL-Bref was also completed at three, six and 12 months post fracture. The number of classes ranged from three to five for the WHOQOL-Bref facet and the four domains with a total variance explained ranging from 71.6 percent to 79.4 percent. Sex was only significant for physical and psychological QOL, whereas age showed significance for overall, physical, psychological and environmental. Percentages of chronic comorbidities were 1.8 to 4.5 higher in the lowest compared to the highest QOL classes. Trait anxiety, neuroticism, extraversion, pain catastrophizing and internal pain locus of control were significantly different between QOL trajectories. The importance of a biopsychosocial model in trauma care was confirmed. The different courses of QOL after fracture were defined by several sociodemographic and clinical variables as well as psychological characteristics. Based on the identified characteristics, patients at risk for lower QOL may be recognized earlier by healthcare providers offering opportunities for monitoring and intervention, the researchers concluded.


Isolated cuboid dislocations are rare injuries. It is clinically significant and important in surgical education, as it is an injury and a source of lateral foot pain that can be misdiagnosed at the time of initial presentation and may be difficult to identify clinically or with imaging. The authors present a case report in a 33-year-old rugby player, who was injured during a match after a tackle. The patient had ongoing concerns that he was not recovering following initial discharge, as he was unable to bear weight since his initial presentation to the Emergency Department (ED), and he had ongoing lateral foot pain. Important clinical findings include lateral foot pain, a palpable gap at the cuboid level and difficulty bearing weight. Closed reduction is usually difficult as it can be blocked mechanically by the extensor digitorum brevis muscle or peroneus longus tendon. Initial x-rays may be inconclusive with this presentation. CT scanning is indicated if suspicion for pathology is high. Open reduction and internal fixation with Kirschner wires are usually necessary for isolated cuboid dislocations. The authors’ take-home message from this case report is that cuboid dislocations are rare injuries and are important to be aware of in reviewing x-rays in the ED. This is particularly true in patients with inversion and plantar flexion type injuries to their foot and ankle joint, with an inability to bear weight and lateral midfoot pain following their injury.

Practice Management

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Healthcare advocacy group Access Project estimates that up to 80 percent of all medical bills contain mistakes, while Kaiser Health reported that $68 billion in lost healthcare spending can be attributed to medical billing mistakes. Jim Leonard, director of healthcare business development at GRM Document Management, a records retention and management service, says problems with billing are less an issue of errors than attempting to file a claim with unverified information. "Many specialized companies exist to manage the revenue cycle for smaller or less sophisticated healthcare organizations," he says. Joseph T. Jenkins, MD, a general surgeon with FACS of Tri-State Vein Center in Dubuque, Iowa, says he reduces errors by using software that helps generate the note and check items within the HPI, ROS, PFSH and physical exam to keep track of where he stands with meeting the different levels of care provided. Elvira Kasimova, billing department supervisor for the WCH Service Bureau, notes that practices often fail to conduct regular training about coding and billing updates and other changes. She says another way mistakes happen is due to improper communication, such as a physician or staff member not relaying the correct information to a provider concerning things like eligibility and coverage. Every practice should have a compliance plan and policy as well as someone responsible for enforcing it, Kasimova says. Either the medical director or a staff member should function as the compliance person.


Physicians do not enter medicine to practice business, but that is what the law now requires of them. Contracts should reflect the reality of the practice. From a revenue perspective, physicians should consider using the data for Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) compliance to support claims for greater commercial reimbursement. An efficient office depends on clear expectations, so physicians should use this opportunity to make sure they are all on the same page. To this end, it is a good idea to review the practice's founding documents. For instance, if the property is owned 50/50, perhaps now is the time to consider what will happen when one of the owners wants to sell or retire and the other does not. If a practice is set up as a corporation but has not observed corporate formalities, the personal assets of physicians may be at risk. Planning now is more sensible—and cheaper—than leaving money on the table or fighting in the long run. Physicians spend hours keeping up-to-date on medical developments, but they also need to devote time to consider changing the legal landscape. Just as the business demands of medicine have grown over the years, so has the professional population of attorneys who specialize in representing physicians.


Research from HIMSS Analytics reveals that adoption of electronic health record (EHR) systems at outpatient practices has been accelerating. According to HIMSS's Annual Outpatient PM and EHR Study, 92 percent of hospital-owned outpatient facilities have a "live and operational" electronic medical record (EMR) system. The research is based on a web-based survey aggregating data from a total of 436 respondents, including physicians, practice managers/administrators, practice CEOs/presidents and practice IT directors and staff, as well as HIMSS's market intelligence that provides insight into 47,800 hospital-owned practices and 92,000 freestanding practices. The study indicates nearly 70 percent of respondents representing freestanding outpatient facilities report having an EHR. When asked about whether they plan to purchase a new system or to replace or upgrade their current ambulatory EHR solution within the next two years, close to 60 percent of respondents indicated that they are staying with their current vendor rather than replacing their solution. For the first time in four years, the respondents with no investment plans dropped below 60 percent (59.4 percent), from 66 percent in 2016, 61 percent in 2015 and 66 percent in 2014. Six percent of respondents said they planned to purchase a new solution, which represents a drop from nine percent in 2016. This further indicates the near universal adoption of EHR solutions across the outpatient space.


Verifying patient identity during telemedicine consultations can sometimes fall by the wayside, but it is a vital step to ensure the integrity of the patient's protected health information. In the nonemergency telehealth environment, an identity problem can occur when an individual without insurance uses the identity of a friend to get treatment, says Ralph Derrickson, president and CEO at telemedicine vendor Carena. "It is common for those with access to services to help those without services," Derrickson explains. That is when "the weaknesses in our systems are exposed," he says, and it represents a serious patient safety issue. The patient in front of the doctor may have allergies of which the physician is not aware because they do not appear in the electronic health records system, but the physician may nevertheless prescribe medications that are inappropriate for the patient. Other times, a patient with an established telemedicine relationship with a physician may mislead the doctor about a condition and then provide the prescribed medication to a sick friend. To avoid doctor shopping via telemedicine, physicians should have a process to authenticate the patient, including running an insurance eligibility check and confirming personal details, such as a Social Security number, Derrickson says. For an established patient, the doctor can ask questions on prior medical history to determine if the patient's responses match the medical records. "You need to take time to have a conversation and make sure you know who the patient really is and provide the right information," Derrickson says. "But most patients just want help and to give good information."

Health Policy and Reimbursement

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Starting on January 2, 2018, hospitals will attest for meaningful use in 2017 via the QualityNet Secure Portal. The U.S. Centers for Medicare and Medicaid Services (CMS) is moving Medicare hospitals to the QualityNet Secure Portal. Physician practices, nursing homes, ambulatory surgical centers, inpatient psychiatric facilities, end stage renal disease networks and facilities, and data vendors are also among the entities that can use the portal. However, the vast majority of physician practices are finding it difficult to comply with the Merit-Based Incentive Payment System (MIPS), according to a new survey by the Medical Group Management Association (MGMA). The survey found that 82 percent of practices see MIPS as very or extremely burdensome, 74 percent view the lack of national electronic attachment standards as similarly detrimental, while 68 percent perceive the lack of EHR interoperability as debilitating. Conducted in July and based on responses from 750 group practices, the MGMA survey found that the vast majority of those surveyed are participating in MIPS in 2017 and 72 percent plan to exceed the minimum reporting requirements, 80 percent indicated that they are very or extremely concerned about the clinical relevance of MIPS to patient care, and 73 percent of respondents view MIPS as a government program that does not support their practice's clinical quality priorities. MGMA's Robert Tennant says a key hurdle facing physician practices is the lack of a nationally adopted standard for electronic attachments.


At least 17 states have enacted rules to curb the number of opioid analgesics doctors can prescribe. Some—including Arizona, Connecticut, Delaware, Massachusetts, New Jersey and Ohio—have passed laws limiting the duration of initial opioid prescriptions to five or seven days. Others are passing dosage limits. In Kentucky, a law went into effect last month capping opioid prescriptions for acute pain to three days. The U.S. Centers for Disease Control and Prevention (CDC) last year issued guidance for providers, recommending shorter durations for opioid prescriptions, stating that three days should be sufficient and a course of more than seven days "will rarely be needed." According to a CDC study, patients who use such drugs for longer periods of time are more likely to end up addicted to them. Sens. John McCain (R-Ariz.) and Kirsten Gillibrand (D-N.Y.) introduced federal legislation in April to limit an initial opioid prescription to seven days. It would not apply to the treatment of chronic pain, cancer, hospice or palliative care. Some physicians have concerns with the new state laws. In Connecticut, doctors worried that a law limiting initial opioid prescriptions to seven days would be overly prohibitive, said David Emmel, chair of the Connecticut State Medical Society's legislative committee. But now that the regulations have been in place for about a year, doctors have adapted to the rules, which Emmel said are "not horrifically restrictive."


The Trump administration said it will freeze a so-called 25 percent rule that reduces Medicare reimbursement rates for hospitals for one year while it assesses whether the policy is needed. Under the proposed rule, if more than a quarter of a long-term care hospital's patients come from a single acute-care hospital, the long-term care hospital would receive a reduced Medicare reimbursement rate for patients exceeding that threshold. The reduced rate would be between 50 percent to 60 percent less than what they would have received otherwise, according to the National Association of Long Term Hospitals. Long-term care hospitals will avoid an $85 million reimbursement cut in 2018 thanks to the one-year freeze, according to the U.S. Centers for Medicare and Medicaid Services (CMS). Long-term care hospitals nationwide hope the Trump administration will permanently eliminate this proposed policy. The 25 percent rule was first introduced in a 2004 inpatient pay rule and has been delayed frequently by both CMS and Congress in response to provider push back. Most recently, the 21^st Century Cures Act delayed its implementation until October 1, 2017. Long-term care hospitals already face reduced Medicare funds due to a new site-neutral payment policy that took effect last year. CMS estimates that payments to long-term care hospitals will decrease by approximately 2.4 percent, or $110 million in fiscal 2018, because of that change, on top of the $363 million cut they received this fiscal year.


Large employers expect healthcare benefits costs in 2018 will increase by five percent for the fifth year in a row, according to the National Business Group on Health's (NBGH) annual healthcare strategy and plan design survey. The average cost of providing health insurance to employees and their dependents is expected to rise from an estimated $13,482 per employee in 2017 to an average of $14,156 in 2018—of which employers will cover nearly 70 percent, while employees will be responsible for 30 percent. Employers once again cited spiking specialty drug costs as the top driver of rising costs. In response, the survey respondents are increasingly managing where certain high-cost medications are administered, building outcome-based pricing into their purchasing agreements for specialty drugs and launching programs to manage the effect of manufacturer coupons. Employers are also realizing that traditional cost-control methods, such as cost-sharing and plan design changes, are not sufficient, said Brian Marcotte, president and CEO of NBGH. Thus, "they are also ramping up efforts to positively affect the supply side of the healthcare system by pursuing healthcare payment and delivery reform initiatives." In addition, 96 percent of employers will make telehealth services available in states where it is permitted in 2018, the survey found. Next year, almost twice the percentage of employers will offer telehealth for behavioral services compared with 2017's numbers.


Many orthopaedic surgeons are pleased with the U.S. Centers For Medicare and Medicaid (CMS) announcement that it is considering paying for total knee and hip replacement procedures in outpatient settings, but many hospital leaders are not. Hospital executives fear losing substantial inpatient revenue from total joint procedures—one of their bigger profit centers—to ambulatory surgery centers, as they have previously lost many other surgical procedures. In addition, they and doctors on staff are not necessarily comfortable at this point doing the operations in either hospital outpatient departments or ambulatory surgery centers. A CMS decision to pay for total joint replacements in outpatient settings would speed the migration of these procedures out of the hospital by encouraging more private payers to cover them. "We have not seen a lot of data that would show performing those procedures in ambulatory centers with no inpatient stay would result in better outcomes," said Sabra Rosener, vice president of government affairs for UnityPoint Health, which operates hospitals and clinics in Iowa, Illinois and Wisconsin. Most orthopaedic surgeons continue to do their joint replacements in the hospital, although many are shortening length of stay to one day or even 23 hours in preparation for performing the procedures on an outpatient basis. Still, those surgeries are being billed at hospital inpatient rates, rather than at significantly lower ambulatory surgery rates.

Medicine, Drugs and Devices

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President Donald Trump has declared the ongoing trend of opioid addiction, overdose and death an "official" national emergency that is deserving of federal funding and attention. Trump stopped short of announcing exactly how his administration plans to tackle the problem, which, according to a preliminary report from the President's Commission on Combating Drug Addiction and Opioid Crisis, is now responsible for more fatalities than gun violence and vehicular accidents combined. White House aides say Trump is still reviewing the report and its recommendations for action. Theoretically, however, Andrew Kolodny, codirector of opioid policy research at the Heller School for Social Policy and Management at Brandeis University, said a presidential emergency declaration could empower DEA to require prescriber education. Caleb Alexander, codirector of the Johns Hopkins Center for Drug Safety and Effectiveness, said formal emergency status could be used to funnel more money toward treatment and other services, but he worried that it could also spark a law enforcement crackdown on users. "We're not going to arrest our way out of this epidemic," he warned. A White House statement said the president "has instructed his administration to use all appropriate emergency and other authorities to respond to the crisis caused by the opioid epidemic."