News From ACFAS

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John Foley, former lead solo pilot with the Blue Angels, knows better than anyone that high stakes require high performance. He and his fellow pilots consistently flew at speeds of more than 500 mph and in formations as close as 18 inches apart. Achieving such precision as a team took commitment, discipline and trust—principles that can help you reach and sustain excellence in your practice.

Hear more from Foley as he delivers the ACFAS 2019 keynote address on February 14, 2019 in New Orleans and highlights the parallels between an elite team like the Blue Angels and the work you do every day as a foot and ankle surgeon. Using Blue Angel methodology as a model, Foley will show you how to make the same journey toward excellence.

ACFAS 2019 will take place February 14–17, 2019 at the Ernest N. Morial Convention Center in New Orleans. Visit acfas.org/neworleans for details and updates. The ACFAS Nominating Committee seeks experienced members 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, send your nomination application by September 12.

Visit acfas.org/nominations for the nomination application and complete details on the recommended criteria for candidates. For more information, contact ACFAS Executive Director J.C. (Chris) Mahaffey, MS, CAE, FASAE, at mahaffey@acfas.org or (773) 693-9300. Questions regarding eligibility criteria should be directed to Nominating Committee Chair Laurence G. Rubin, DPM, FACFAS, at lgrubin@comcast.net or (804) 746-5488.

The Nominating Committee will announce recommended candidates to the membership no later than October 18. Candidate information and ballots will be emailed to all voting members no later than December 2. Electronic voting ends on December 17. New officers and directors will take office during ACFAS 2019, February 14–17, 2019 in New Orleans. Explore the link between accurate coding and billing procedures and maximum reimbursement in Coding and Billing for the Foot and Ankle Surgeon, October 19–20 in downtown Chicago. Gain practical tips and tools to help you:

• Structure your work week
• Code for amputation, forefoot, rearfoot and ankle reconstructive surgery
• Code for evaluation and management services
• Use modifiers to avoid denials
• Code for diabetic foot cases, minor office procedures and complex arthroscopy cases
• Navigate new government reimbursement systems and methods

You will also code actual patient cases and scenarios alongside expert faculty for a hands-on look at each step in the coding and billing process.

New! Breakout sessions designed for each attendee will include:

• Effective Office Management Strategies for Private Practice Surgeons
• Current Market Value for Productivity and WRVU Conversion Factors for Surgeons in Multispecialty Groups
• Group Discussions to Help with Coding, Billing, Appeal & Denial Questions for Coders, Billers & Office Staff

All attendees are encouraged to bring their burning questions for these small breakout group discussions.

This course is worth 12 continuing education contact hours (Category 1 credit). Don’t miss out—register today at acfas.org/practicemanagement.

Foot and Ankle Surgery

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Open reduction and internal fixation (ORIF) methods, primarily plates and screws, remain the standard of care for treatment for distal fibular fractures. The purpose of this study was to evaluate the use of a cannulated intramedullary screw as a minimally invasive treatment method for distal fibular fractures, which has not been reported in the current literature.

This retrospective study included 45 patients with distal fibular fractures treated with cannulated intramedullary screw fixation. All patients included in the cohort had a soft-tissue condition and/or comorbidity. The Weber classification system was used to assess the type of fracture. Average time to union, average time to weightbearing and complications were monitored. Reduction quality criteria were collected using previously published guidelines. Accordingly, reduction was determined to be good in 25 cases, fair in 15 and poor in five. A low complication rate of 4 percent was reported. Average time to union was 10 weeks, whereas average time to weightbearing was 14 weeks.

Cannulated intramedullary screw fixation can serve as a minimally invasive, safe and satisfactory treatment for distal fibular fractures with resulting high union rates and low complication rates.


Lateral lengthening calcaneal osteotomies (LLCOT) are commonly used to treat flexible pes planovalgus deformity. The aim of this study was to examine which anatomic structures were affected by two different osteotomy techniques.

Two experienced foot and ankle surgeons each performed an Evans (E)- or Hintermann (H)- osteotomy on seven cadaver feet. After H-LLCOT, no damage of the peroneus longus tendon occurred, whereas after E-LLCOT, damage was seen in one case. The peroneus brevis tendon was once cut after H-LLCOT and eroded after E-LLCOT. In one cadaver, the sural nerve was partially damaged after H-LLCOT, but no damage was seen with the E-LLOCT. The calcaneal anterior and medial articular facets were intact after H-LLCOT in 100 percent and 85.7 percent of cases and after E-LLCOT in 42.9 percent and 71.4 percent of cases, respectively. The posterior articular surface was not affected in any cadaver.

The researchers concluded that anatomic structures can be damaged after both osteotomies. With the Hintermann osteotomy, the calcaneal anterior and medial articular surface can be protected to a larger extent than with the Evans osteotomy. The Hintermann osteotomy appears to be superior regarding damage of the articular surfaces of the subtalar joint.


When treating intra-articular displaced calcaneal fractures with surgical interventions, sinus tarsi approach provides secure access to the lateral wall and joint facets. This study sought to compare cannulated screw (CS) fixation versus mini-plate (MP) fixation via sinus tarsi approach with Sanders types 2 and 3 fracture of calcaneus.

Sixty patients with Sanders types 2 and 3 calcaneal fracture who underwent surgical intervention were randomly allocated into two groups as group MP fixation and group CS fixation for a five-year period. Open reduction via sinus tarsi approach was performed in both groups.

Preoperative age, type of fracture, calcaneal length, height, pre- and postoperative Gissane and Böhler angles, time to surgery, length of hospital stay and operation duration were not different between the groups. The postoperative calcaneal widening was reduced in group MP compared with that of group CS. The incidence of reoperation and algoneurodystrophy was statistically higher in group CS than in group MP. Maryland Foot Score (MFS), which was used to evaluate functional outcomes, was also higher in group MP than in group CS at final visit.

The researchers concluded that MP fixation via sinus tarsi approach is superior to CS fixation in Sanders types 2 and 3 calcaneal fractures.

Practice Management

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Healthcare organizations need to have a plan for decommissioning information technology, which likely contains patients' financial or protected health data, according to the Office for Civil Rights (OCR) of the U.S. Department for Health and Human Services. OCR offers 10 recommendations for securely handling device and media decommissioning.

First, know where an organization stores its data, and ensure the data disposal plan is up to date. Generally, the plan should encompass information preservation, media sanitation and hardware or software disposal, OCR says. A disposition plan can become dated as technology changes. For example, USB sticks can hold significantly more financial and protected health information than they did several years ago. As a result, a plan must be updated to include disposition of USB devices. In addition, remove asset tags and corporate identifying marks. Identify and isolate all asset recovery-controlled equipment and devices, taking special care with those that served a backup role because they are likely to contain vast troves of corporate information. Ensure outside entities handling data destruction, as well as the individuals handling the organization's data assets, are certified.

Furthermore, understand the chain of custody for devices. Determine if hard drive destruction should occur onsite, and manage equipment that will be disposed of and destroyed offsite. At minimum, memory in devices should be overwritten and then destroyed to render them inoperable and unusable. When devices and media are moved to an outside entity for disposition, ensure that holding areas and the transportation process are secured.


When physicians receive and respond to the right kind of alert in an electronic health record (EHR), it can lead to fewer complications and lower costs among hospitalized patients, according to a new study published in the American Journal of Managed Care. Researchers from Cedars-Sinai Medical Center and Optum Advisory Services examined alerts that surfaced on physician computer screens inside their EHR system when their care instructions deviated from evidence-based guidelines. Those alerts were based on the "Choosing Wisely" initiative in which different specialties have identified common tests and procedures that may not benefit patients and should be avoided.

Examining nearly 26,500 inpatient admissions at Cedars-Sinai Medical Center between October 2013 and July 2016, the researchers studied whether the physician followed either all or none of the Choosing Wisely guidance. In 6 percent of visits, physicians followed all of the triggered alerts, and in 94 percent of visits, physicians followed none of the alerts. In particular, they analyzed data in which one more of the 18 most frequent alerts were triggered.

For patients whose physicians did not follow the alerts, the likelihood of complications increased by 29 percent and the risk of readmissions within 30 days of the patients' original visit was 14 percent higher. There was also a 6.2 percent increased length of stay and an additional 7.3 percent increase in costs. Although more research is needed to examine the direct impact of the alerts, officials said, the study shows using tools, like alerts, could have a real impact on costs and quality.


Achieving clinician engagement early in the electronic health record (EHR) implementation process can help reduce slowdowns, improve physician satisfaction with EHR technology and enhance clinical efficiency. One strategy is to gather clinician feedback during EHR selection. Before committing to a large capital investment, executives at Virtua Health System invited more than 1,500 staff members to attend 80 product demonstrations for two competing systems: Epic and Cerner. Clinicians ultimately scored Epic higher than Cerner against almost every criterion. According to Virtua leaders, putting users at the center of the EHR selection process helped to sustain high levels of clinician engagement after the go-live and boost provider satisfaction with the new system.

Executives must also ensure that providers know how to use the technology by mandating thorough EHR training. Pennsylvania-based Uniontown Hospital required all clinicians to attend three-hour training sessions prior to going live with new health IT tools to ensure all staff had a common understanding of the new technology. In addition to offering plenty of sessions to fit different physician schedules, Uniontown also made efforts to allow each clinician to get hands-on experience with new tools.

Finally, healthcare organizations can invite clinicians to provide input on the design of clinical workflows and EHR interfaces. This feedback can give EHR vendors and health system leadership an idea of which clinical information clinicians would like to see prominently displayed on the EHR interface and which information can be hidden. Specializing the EHR interface can help promote widespread user adoption and can improve common challenges with EHR usability.

Health Policy and Reimbursement

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Oregon officials are considering a novel plan to end coverage of opioids for many chronic pain patients enrolled in the state Medicaid program. Starting in 2020, these patients would see their opioid doses eliminated over the course of 12 months. Officials could potentially approve the change as soon as October.

Opponents to the proposal argue that cutting off access to prescription painkillers could cause some patients to seek opioids by any means necessary, experience the return of debilitating pain or even commit suicide. Oregon says the status quo—keeping thousands of vulnerable patients on high doses of drugs now considered dangerous—is unsustainable. Health officials there say they have achieved similar success recently by ending coverage of opioid therapy for some forms of lower back and neck pain.

However, experts say the science supporting either argument is extremely limited. "What is notably missing is any review of any literature regarding the centerpiece of their proposed policy: Forced opioid taper to zero for all persons," said Stefan Kertesz, MD, a pain and addiction specialist at the University of Alabama, Birmingham, School of Medicine. Oregon officials cited a new study, which indicated that pain intensity, on average, does not worsen after stopping long-term opioid therapy. However, a recent systematic review of dose reduction and discontinuation concluded that additional evidence was needed to assess both the notion that forced opioid tapers can increase suicidal thoughts and the overall outcomes of such a practice.


Major technology companies have pledged to eliminate technological barriers that have hindered online access to healthcare data for both doctors and care recipients. At a Trump administration event, Amazon.com, Google, Microsoft and others promised to "share the common quest to unlock the potential in healthcare data to deliver better outcomes at lower costs."

Some estimates say enhanced communications and data exchanges among health information technology systems and devices could generate more than $30 billion in annual savings. "We want to lean into technology and use it as a potent force to create more efficiencies in our system," said U.S. Centers for Medicare and Medicaid Services Administrator Seema Verma. Even when providers transitioned from paper to digital records, many types of electronic data have been contained in digital silos that are not readily available.

Facing pressure to lower costs and improve outcomes, providers and policymakers aim to develop interoperable systems, a trend expedited by large tech companies that see lucrative opportunities, such as new uses for cloud and artificial intelligence solutions. "This is about cloud infrastructure and platforms, building tools and leveraging" data analytics, said Google's Gregory Moore.


Although premiums have risen little since Medicare Part D was introduced, costs for taxpayers have skyrocketed 72 percent from 2007 to 2016. Much of this increase is due to growing enrollment and higher drug prices, but reinsurance spending—which is not reflected in premiums—has also been rising rapidly. A recent study in Health Services Research found that the disconnect between premiums and reinsurance costs has escalated over time.

In addition, insurance companies that do not fully manage the use of high-cost drugs had higher reinsurance costs. This is consistent with insurance plan incentives to push enrollees into the catastrophic range of spending. According to the Medicare Payment Advisory Commission, the number of enrollees entering the catastrophic drug cost range increased 50 percent between 2010 and 2015, now accounting for 8 percent of enrollees, while reinsurance is the fastest-growing component of Medicare's drug program, rising at an 18 percent annual rate between 2007 and 2016.

Meanwhile, the Affordable Care Act requires pharmaceutical manufacturers to pay some of the cost of the drug benefit, contributions that the industry counts as out-of-pocket payments for enrollees in order to reach the catastrophic threshold and trigger reinsurance. That means enrollees do not need to spend as much to trigger the reinsurance program, which is simultaneously beneficial to enrollees while also increasing taxpayer liability for the program. Potential reforms to the program include changing the extent to which manufacturer's contributions count as enrollee out-of-pocket spending, increasing the liability of insurance company plans in the catastrophic range and decreasing the liability of taxpayers.

Medicine, Drugs and Devices

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The Trump administration has proposed reducing manufacturing quotas for six frequently misused prescription opioids by 10 percent next year in an effort to combat the opioid epidemic. The proposal by the U.S. Department of Justice and the U.S. Drug Enforcement Administration (DEA), part of the administration's Safe Prescribing Plan, would advance a federal effort to slash opioid abuse by limiting the drugs' availability.

In a release, the agencies said the proposed rulemaking represents the third straight annual decrease in the allowed manufacture of prescription opioids. "Ultimately, revised limits will encourage vigilance on the part of opioid manufacturers, help DEA respond to the changing drug threat environment and protect the American people from potential addictive drugs while ensuring that the country has enough opioids for legitimate medical, scientific, research and industrial needs," the release states.

However, abuse of prescription opioids represents only a fraction of the crisis compared to the impact of synthetic opioids, such as fentanyl. Last year, synthetic opioids contributed to about 30,000 overdose deaths, more than heroin and prescription opioids combined, according to the National Institute of Drug Abuse.


Johns Hopkins Hospital has published guidelines in the Journal of the American College of Surgeons recommending its doctors give patients far fewer opioids following surgery than they have in the past. A panel of doctors, nurses and patients looked at the prescribing habits of physicians and developed guidelines for how much opioids doctors should prescribe for patients after 20 specific surgeries.

"Our feeling is we shouldn't just be using draconian, one-size-fits all prescribing," said Martin Makary, MD, a professor of surgery and health policy expert at the Johns Hopkins University School of Medicine and the study's senior author. "Everyone is different. Opioid prescribing should fall within a best practices range and currently, we don't do very well with that. Our hope is that this represents a first step in better understanding how we can treat pain better." Johns Hopkins will begin teaching doctors in its residency program the new guidelines developed by the panel. The hospital's electronic medical system will also default to the new prescribing guidelines. Currently, the system suggests a 30-day supply for surgeries, defaults that have been "dangerously high" for too long, Makary said.


Approximately 72,000 overdose deaths occurred in the United States last year, about a 10 percent increase from 2016, according to preliminary estimates by the U.S. Centers for Disease Control and Prevention (CDC). The figures reflect two factors: a growing number of Americans are using opioids, and these drugs are becoming deadlier as strong synthetic opioids, such as fentanyl, have become mixed into other drugs. CDC estimates that overdose deaths involving synthetic opioids have jumped, while deaths from heroin, prescription opioids and methadone have declined.

The epidemic, which has ravaged parts of the East and Midwest, has been less severe in much of the West, although early evidence suggests this could change. Notably, the number of overdoses has begun to fall in states that have each prioritized public health campaigns and addiction treatment, including Massachusetts, Vermont and Rhode Island. In another hopeful sign, the CDC figures suggest that deaths might have begun leveling off by the end of 2017. Continued funding may help more states develop the type of public health programs that appear to have helped in New England.