News From ACFAS

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Don’t miss your chance to attend the almost-sold-out Coding & Billing for the Foot and Ankle Surgeon Seminar on September 20-21 in Teaneck, New Jersey.

This interactive course puts you and your fellow attendees in the driver's seat as you work together to code and bill for a week's worth of clinics, surgeries, calls, office procedures and complex cases typically seen in a foot and ankle surgical practice. Instructors will also guide you in how to use modifiers to avoid denials and win appeals.

A special breakout session focused on private and multispecialty practices will close the seminar.

Register yourself and your coding and billing office staff at acfas.org/practicemanagement to secure your spot now! The Alamo might be Texas’ most visited attraction and San Antonio the most visited city, but you’ll want to visit the ACFAS 2020 Exhibit Hall, February 19-22!

Here you can network, connecting with colleagues and building new relationships, discover the newest services from 140+ companies, participate in interactive product demos, and check out the posters in the Grand Rounds from 1-2pm.

While you’re there be sure to also to check out the HUB theater to hear practical advice for practically everyone or stop by the Job Fair to search for your next job or new hire.

Visit acfas.org/sanantonio to find out what else you’ll find this year at ACFAS 2020 to make the most of your conference experience! The ACFAS Fellowship Committee recently determined the following fellowships exceed the minimal requirements to be upgraded to Recognized Status with the College after their first successful year:

Honor Health - Oasis Foot & Ankle Center Surgical Fellowship
Phoenix
Program Director: Eugene DelaCruz, DPM, FACFAS

Portland Foot and Ankle Reconstructive Fellowship
Portand, Oregon
Program Director: Michael Gentile, DPM, FACFAS

UT Southwestern Medical Center Wound Surgery Fellowship
Dallas
Program Director: Lawrence Lavery, DPM, FACFAS

Northern Illinois Advanced Foot and Ankle Fellowship
Sycamore, Illinois
Program Director: Douglas Pacaccio, DPM, FACFAS

Pediatric Foot and Ankle Fellowship
Cedar Knolls, New Jersey
Program Director: Mark Solomon, DPM, FACFAS

The following fellowships have been granted Conditional Status with ACFAS since the programs are new to the College and have not yet had a fellow matriculate through:

Associates in Medicine & Surgery - Sports Medicine/Reconstructive Foot & Ankle Fellowship
Fort Myers, Florida
Program Director: Eugene Batelli, DPM, FACFAS

Revisional Reconstructive Surgical Fellowship at Ohio Foot and Ankle Center
Stow, Ohio
Program Director: Aaron Chokan, DPM, FACFAS

Center for Advanced Foot and Ankle Surgery Fellowship
St. Louis
Program Director: John Holtzman, DPM, FACFAS

Pensacola Foot and Ankle Center Reconstructive Foot, Rearfoot and Ankle Surgery Fellowship
Pensacola, Florida
Program Director: Mark Lambert, DPM, FACFAS

Northern California Reconstruction Foot and Ankle Fellowship
Redding, California
Program Director: Jason Nowak, DPM, FACFAS

St. Petersburg Innovative Foot & Ankle Surgery Fellowship
Largo, Florida
Program Director: Adam Perler, DPM, FACFAS

Foot & Ankle Institute Fellowship
Indianapolis
Program Director: Sandra Raynor, DPM, FACFAS

South Central Pennsylvania Reconstructive Foot and Ankle Fellowship
Lancaster, Pennsylvania
Program Director: Michael Younes, DPM, FACFAS

All Conditional Status programs are considered for Recognized Status with ACFAS after they have received status and the first fellow completes the program.

ACFAS highly recommends taking on a specialized fellowship for the continuation of foot and ankle surgical education after residency. If you are considering a fellowship, visit acfas.org/fellowshipinitiative to review a complete listing of programs and minimal requirements

Foot and Ankle Surgery

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The study aimed to evaluate the safety and effectiveness of osteotomy adjacent to the articular surface of the metatarsal head combined with basal opening wedge osteotomy for severe hallux valgus. The double osteotomy procedure was carried out in 72 feet across 56 patients with severe hallux valgus deformity, with an average follow-up of 25 months from March 2010 to February 2019. Researchers used weight-bearing anteroposterior (AP) X-ray images to measure Hallux valgus angle (HVA), distal metatarsal articular angle (DMAA), intermetatarsal angle (IMA) and distal articular set angle (DASA) for all patients. The American Orthopaedic Foot & Ankle Society (AOFAS) scale was also used to evaluate the function of the hallux.

The HVA, IMA and DMAA reduced from 49.30 to 13.19, 19.33 to 5.97,and 29.85 to 5.63, respectively. DASA decreased from 4.33 to 4.08 and did not show a statistically significant difference. Among the 72 feet, 69 feet healed normally, three feet had bone resorption at the osteotomy edges, and none showed cases of bone sclerosis, bone necrosis, bone nonunion or ankyloses. On average, the AOFAS score improved from 34.66 (preoperative) to 88.78 (postoperative). The study indicates that the proposed double osteotomy procedure is safe, effective and feasible for correcting severe hallux valgus.


The study investigates the reliability of intermetatarsal angle (IMA) to predict contact area percentage after distal chevron osteotomy (DCO). After subdividing preoperative radiographs by severity, researchers randomly selected 50 patients with moderate hallux valgus and 50 patients with severe hallux valgus, then calculated the estimated bone contact (EBC) and investigated the percentage of patients who could have >50 percent contact area if they perform a DCO. Thirty of 50 moderate cases and 17 of 50 severe cases had greater than 50 percent EBC. Researchers performed DCO for 14 moderate patients and 10 severe patients, then assessed the clinical outcome using the 100-point American Orthopaedic Foot and Ankle Society (AOFAS) hallux-metatarso-phalangeal-interphalangeal scale.

Researchers calculated a mean IMA 16 degrees and mean EBC 66.9 percent for the moderate group and a mean IMA 20.9 degrees and mean EBC 63.1 percent for the severe group. Paired t tests showed significant improvement comparing preoperative and postoperative AOFAS scores, IMA, hallux valgus angle and sesamoid position for all operated patients. The researchers saw no recurrence of hallux valgus or hallux varus and had only one minor complication, which was managed conservatively. They note that IMA may not always be a reliable parameter to predict the stability of DCO because the stability depends on constant surfaces of osteotomy fragments, and two patients with the same IMA can have a different contact surface varying on a broad spectrum. They add that metatarsal head diameter and remaining bone contact should be the primary concerns.


The study compared three-dimensional (3D) shape variations in the subtalar joint (STJ) bones within individuals with chronic ankle instability (CAI), developed after sustaining a lateral ankle sprain (LAS) and healthy controls. 3D statistical shape models (SSMs) of the STJ bones were constructed to describe bone shape variations observed in 26 individuals with unilateral CAI (14 males and 12 females, mean age of 29) and 26 healthy controls (12 males and 14 females, mean age of 36 years.) Using the SSMs and analysis of covariance test, age- and gender-adjusted shape variations in the bones were compared within individuals with CAI and healthy controls.

Tali and calcanei did not significantly vary between ipsilateral CAI and their contralateral ankle. Two shape modes, one for the talus and one for the calcaneus, described significant differences in shape between the CAI patients and healthy controls. The CAI patients generally had flatter talar joint surfaces and a flattened calcaneal ground-contact surface. These findings suggest that specific bone shapes may increase the risk of developing CAI after sustaining a LAS.

Practice Management

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Electronic health records (EHRs) must be made easier to use if they are to realize their full potential as a tool for medical professionals. A recent study in the Annals of Family Medicine estimated that primary care physicians spend nearly two hours on EHR tasks for every one hour of direct patient care, spending an average of six hours per day within the EHR. Enhanced usability will start with input from physician end users at the product-development level, rather than relying on programmers with minimal clinical experience to make critical decisions that impact physician workflows. Vendors and health system administrators must also involve physicians when making key implementation decisions that impact patient care and the end-user experience.

Improving usability can be difficult because the trait is a subjective measure. In 2014, the American Medical Association issued eight EHR usability standards to guide vendors, but the industry has failed to make significant process achieving these standards. This might have to do with fatigue from an overwhelming number of R&D priorities, regulations and reporting requirements. Regulators should consider mandated standards to fix EHR usability gaps, likely one overseen by the Center for Medicare and Medicaid Services, as it is the country's largest payer. Alternatively, CMS could appoint an independent third-party organization to standardize and assess EHRs' adherence to these standards by evaluating workflows and tracking the time required to perform certain routine tasks.


A recent study published in JAMA Network Open finds that few patients are taking advantage of efforts to make electronic health record (EHR) information accessible on their smartphones. Researchers identified 12 geographically diverse U.S. health systems that allow patients to download their EHR data to a smartphone through third-party apps, developed with the Health Records applications programming interface (API) that Apple launched in 2018.

They found that on a month-over-month basis, the rate of unique new users was nearly flat, while on a cumulative basis, researchers saw a linear trend of 156 new users per month per health system. Only 0.7 percent of patients who logged into their health system's patient portal in a given month also used the API. The team said its findings indicate that more patients will need to use the API in order for the third-party developer ecosystem to grow. Researchers expect that more patients will adopt and use APIs to access their health information. The study only included early adopters using a single EHR from a single vendor.


According to the U.S. Substance Abuse and Mental Health Services Administration (SAMHSA), only 12 percent of those with substance use disorder (SUD) receive treatment, largely because it is difficult for patients to find or afford SUD treatment. SAMSHA estimates that 2 million people with opioid addiction would benefit from MAT are not receiving it. Researchers warn that there aren't enough specialty providers to meet the demand for even a 50 percent increase in people seeking treatment for addiction, so primary care should be mobilized as an access point. Primary care physicians can do so in part by offering medication-assisted treatment (MAT). Some medications are only dispensed in federally-regulated clinics, such as methadone, a full opioid agonist, but clinicians in office settings have other alternatives. These include buprenorphine, a partial opioid agonist that reduces symptoms and cravings; naltrexone, an opioid antagonist that reduces cravings but cannot be used in withdrawal; and naloxone, a standalone medication used to reverse the effects of an opioid overdose.

Regulations require physicians to complete eight hours of training, online or in-person and obtain a U.S. Drug Enforcement Agency (DEA) waiver in order to prescribe buprenorphine. Naltrexone is not a narcotic, so there are fewer regulations, but it is generally the most expensive MAT drug, and most patients will need to be opioid-free for about 10 days before starting the treatment. In addition to obtaining the necessary training and waivers, practices should develop resources to refer MAT patients to behavioral health therapy and reinforce an evidence-based treatment mindset among their staff.

Health Policy and Reimbursement

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The U.S. Centers for Medicare and Medicaid Services (CMS) has announced that it will require the display of the five-star Quality Rating System available nationwide for health plans offered on the Health Insurance Exchanges, beginning in the 2020 Open Enrollment Period. Under the system, Exchange health plans are rated on a one to five scale, with five stars representing highest quality. Star ratings are based on how enrollees rate the doctors in its network, how well providers coordinate with enrollees and other doctors and the overall administration of the plan, including customer service and information availability. Star ratings may not be available in all areas of the country, but the lack of a star rating does not indicate a low quality rating.

The rating is based on three categories: Medical Care reflects how well providers manage member healthcare, while Member Experience is based on surveys of member satisfaction, and Plan Administration is based on how well the plan is run. CMS conducted a limited pilot of the program in 2017 and 2018, then expanded the pilot in 2019. CMS is posting star ratings and quality measure level data from the 2019 Plan Year in a Public Use File (PUF). Ratings data for the 2020 period will be released closer to Open Enrollment.


Insurers are announcing expansions in their Affordable Care Act (ACA) plan offerings for 2020, as they increasingly generate profits despite the overall individual insurance market having shrunk. Oscar Insurance announced that it has added six new states to its current nine-state roster, including Pennsylvania and Georgia. Cigna, Bright Health, Molina Healthcare and Centene also have expanded their footprints for 2020. Meanwhile, Anthem Inc. is expanding in at least two of its states, California and Virginia. Oscar CEO Mario Schlosser said, "The market is now clearly stabilizing." The company has proposed premium decreases in three states for next year.

However, some national insurers are sitting on the sidelines of this expansion, with UnitedHealth Group Inc. planning to stay in the same three ACA markets this year and Aetna and Humana having no plans to offer ACA products in 2020. S&P Global Ratings analyst Deep Banerjee said this is due to the lack of overall growth in the ACA market and because they are likely able to generate stronger results from other lines of business.


A recent Kaiser Family Foundation report finds that Medicaid expansions under the Affordable Care Act (ACA) have improved coverage, access to care and coverage and the economy. The report combines findings from 324 separate studies conducted from January 2014 through June 2019. During that timeframe, many studies linked Medicaid expansion to improved coverage rates. Coverage in expansion states differed minimally based on whether or not the state used a waiver to expand, but some waivers negatively influenced beneficiaries' access to coverage or care. Expansion states saw better access to and utilization of care, including a lessening in health disparities.

More time and better beneficiary education may be needed to unlock further improvements as a result of the ACA. The report also presented evidence that Medicaid expansion may have boosted patient care outcomes. Quality of care, self-reported health status, and health outcomes were generally higher in expansion states, and beneficiaries generally saw shorter hospital stays. Studies also showed improved financial security and healthcare affordability for Medicaid enrollees in expansion states, and states themselves showed some healthcare savings from expanding their Medicaid program, as well as higher job growth. It is unclear whether expansion states saw higher rates of physician burnout. In some cases, Medicaid expansion led to uncompensated care costs and better hospital operating margins and financial performance, but these savings might be offset by Medicaid shortfalls.

Medicine, Drugs and Devices

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The U.S. Food and Drug Administration (FDA) has approved AbbVie's new treatment for rheumatoid arthritis. The drug, upadacitinib (Rinvoq), belongs to a class of drugs known as JAK inhibitors that block inflammation-causing enzymes called Janus kinases. The drug's label has a warning that flags risks of serious infections and lymphoma. In a notice, FDA also said that patients taking JAK inhibitors in general risked developing blood clots.


The U.S. Food and Drug Administration (FDA) has issued the first update to the Clinical Outcome Assessment (COA) Compendium since 2016, as part of its efforts to propel more patient-focused drug development. The resource can help companies comprehend how certain COAs have been applied to clinical trials to quantify patient experience and support labeling assertions, as well as tag COAs qualified for potential use in different drug development initiatives. The compendium is split into sections based on different FDA offices. The compendium's constituent charts are sectioned into five columns, concentrating on the disease or condition, the concept the COA evaluates, the COA type, how the COA is listed in labeling and the conditions under which the outcomes of interest and the COA have been employed or measured.


A U.S. Department of Health and Human Services (HHS) watchdog found that the U.S. Centers for Medicare and Medicaid Services (CMS) could lower its reimbursements for physician-administered drugs in Medicare Part B by changing the basis for price substitution. Currently, CMS reimburses providers for the average sales price (ASP) of a Part B drug, plus an additional 6 percent of that price for storage and handling. If the Office of Inspector General (OIG) ASP exceeds the manufacturer price by 5 percent for two previous quarters, HHS must substitute the ASP with a lower rate. Looking at drug utilization data from 2018, the HHS report finds that while CMS lowered the Part B reimbursement for 14 drugs after OIG's analysis of 2017 ASP data, the agency could have saved an additional $2.9 million a year if it changed the substitution policy.

HHS said the price substitution policy should trigger if the ASP exceeds the manufacturer price for one quarter. The report’s recommendation comes as HHS looks for ways to lower prices for Medicare Part B drugs, which amounted to nearly $30 billion in 2016, up 13 percent from 2015. Last year, CMS allowed Medicare Advantage plans to implement formulary management tools, step therapy and prior authorization for Part B drugs, and the agency is also considering a model to tie prices for certain Part B drugs to prices paid overseas.