News From ACFAS

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If you missed last week’s Coding & Billing for the Foot and Ankle Surgeon Virtual Course, don't fret—we're back LIVE in December.

December 4-5
(Friday/Saturday)
Walt Disney Swan & Dolphin Hotel
Lake Buena Vista, FL
Register

Join us and get a leg up on the new E&M coding changes set to hit January 1, 2021. The course will also cover timely topics, including telehealth coding and coding and billing changes such as coding for prolonged services and several CCI edits relating to foot and ankle surgery.

Don’t miss the chance to get ahead of the changes. Visit acfas.org/practicemanagement to register yourself and your office coding staff today. This fall is a great time to fill in any gaps you may have with your continuing education hours by taking advantage of ACFAS’ Clinical Sessions. All sessions are videos of live presentations, released on the 15^th of each month and freely available for members. Check out what’s now available in the library and what’s coming next.

Now Available:
Optimizing Arthrodesis
Debating the Bunion: Surgical Decision Making in the “Grey” Areas

Coming Up:
October: Biologics – Why, When and Where
*In this session, various techniques, mechanisms and indications associated with the use of Orthobiologics will be discussed.

November: Chronic Midsubstance Achilles
*This session will cover clinical considerations, contributing factors and decision-making options.

Visit the ACFAS OnDemand learning portal at acfas.org/OnDemand to access all available ACFAS clinical sessions and other e-learning resources. Make sure you are maximizing all the College has to offer by updating your ACFAS profile. By keeping your profile current you will have access to the ability to gain new patients from FootHealthFacts.org, connect with your colleagues through the ACFAS Member Directory, get the latest edition of The Journal of Foot & Ankle Surgery and the latest news from ACFAS on the profession and the College.

How do I make sure my content is up-to-date? Log into your account at acfas.org to access your profile to:

• Check and update your work and personal email addresses, fax number and your work, home or cell numbers.
• Opt in to include yourself in the “Find an ACFAS Physician” search tool on FootHealthFacts.org and in the ACFAS Membership Directory.
• Confirm your preferred mailing address for The Journal of Foot & Ankle Surgery and ACFAS Update.

Whenever you know you have a change of address or information, you can always log in and update your profile. And if you have any questions, reach out to the Membership Department.

Foot and Ankle Surgery

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The study investigated the efficacy of posterior-anterior (PA) screws, anterior-posterior (AP) screws and a PA plate in the fixation of posterior malleolar fractures (PMFs) across 243 patients. All patients were divided into two groups based on whether their fragment size was greater than or equal to 15 percent of the articular surface of the tibia or less than 15 percent. After reduction of PMF under direct vision via a posterolateral approach, PA, AP screws and PA plate were used for fixation of PMF in the two groups. In the larger fragment size group, the average AOFAS score of patients treated with PA screws, AP screws and a PA plate were 91.5, 91.8 and 90.8, respectively. In the smaller fragment size group, the average American Orthopaedic Foot & Ankle Society score of patients treated with PA screws, AP screws and a PA plate were 92.3, 91.9 and 84.1, respectively, indicating that the PA and AP screws provided good fixation.


In preaxial polydactyly of the foot, the choice for excision of the lateral or medial hallux is not straightforward, especially with proximal phalangeal (type IV) and metatarsal (type VI) duplication. The study evaluated whether medial or lateral hallux excision gives better outcomes in these duplication types. A group of children with type IV or type VI duplication, all of whom were operatively treated by excision of the lateral or medial hallux, were assessed for foot function using plantar pressure measurements and clinical examination. Foot aesthetics were scored by the child, an expert and 10 laypersons, and additional patient-reported outcome questionnaires were obtained. Outcomes were compared between lateral and medial excision, per duplication type. In the 11 children who had type IV duplication, lateral excision showed a better distribution of peak pressure between the hallux and first metatarsal with significantly lower median first metatarsal peak pressure. Lateral excision showed more medial hallux deviation. In the 12 children with type VI duplication, lateral excision showed a 59 percent higher hallux peak pressure, larger medial hallux deviation and more reoperations.


The study investigates the treatment and rehabilitation of Achilles tendon ruptures by looking at the course of patient-reported symptoms, function and quality of life during the early rehabilitation period. Thirty-three patients with an acute Achilles tendon rupture treated with minimally invasive tendon repair were included in this study. At six weeks, patient-reported outcomes are poor regarding quality of life and sports but quite high in the domain activities of daily living, symptoms and pain. All scores improve over the course of six months. Pain does not improve significantly, but patients have good pain scores from the start. There are no significant differences between patients with or without physical therapy. There were three minor complications and no re-ruptures in this cohort.

Practice Management

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Small physician practices are struggling with the impact of the COVID-19 crisis. Doctors are shifting large portions of their patients to virtual telehealth visits while making do with less revenue, some of which may never return. Medical associations say some doctors are retiring early or joining larger groups as they seek strength in numbers. With the fee-for-service payment system magnifying economic pain for doctors as patients shun medical care amid the pandemic, the coronavirus crisis also may be accelerating changes in the way doctors are paid, specialists said. In addition to the fiscal crisis, doctors are juggling more work because of layoffs or staffers who quit, coping with chronic shortages of personal protective equipment and struggling to keep track of chronically ill people who are afraid to leave their homes. In the short term, telehealth has been a vital link in the crisis, doctors said. Advocates for overhauling payment practices in health care hope the crisis will steer contracts away from fee-for-service agreements. Instead, they argue, insurers should pay providers an upfront fee to manage a patient's health for the duration of the coronavirus crisis.


Administrative tasks are a significant time burden for many physicians. The COVID-19 pandemic has made it increasingly necessary for practices to shift certain time-consuming administrative tasks from a manual to a digital workflow. Having patients check themselves in can boost staff efficiency while simultaneously decreasing patient wait times. When using a check-in app, patients also can review outstanding balances and pay the amount owed. Patient-provider communication can and should be conducted through text, which improves patient satisfaction and reduces administrative burden with minimal training. Practices also may be able to use HIPAA-compliant texting to facilitate and bill for chronic care management. When coordinating care with other providers, practices spend a considerable amount of time sending and receiving paper faxes. Moreover, speech recognition software can help reduce documentation time by as much as two hours a day for most physicians. It can also generate higher reimbursement.


The article provides five self-care tips to help physicians curb stress and improve patient care. Physicians need to seek out joy and experience happiness, even in the midst of the pandemic. Physicians need to limit the ways they gather and share events with other people, but they can still plan social events to connect with other people without putting them at risk. Volunteering for a good cause can also be grounding for healthcare providers. Physicians should set clear life goals to guide themselves, such as finishing a research manuscript or developing a unit protocol. They should also monitor their own physical health.


A new study suggests that physician burnout is difficult to measure because its definition varies widely. The research, published in JAMA Surgery, surveyed 7,000 general surgery residents in the United States about whether they experienced symptoms of burnout and if so, how often. Past studies have suggested more than half of practicing physicians have at least one symptom of burnout. In the new study, the researchers focused only on emotional exhaustion and depersonalization, which they said are the strongest and most consistent indicators of burnout. If burnout was defined as having either of the symptoms a few times a year, 91 percent of residents met the definition for burnout. If it was defined as being a daily symptom, the burnout rates reduced to 11 percent. By comparison, 90 percent of residents reported experiencing both symptoms at least once a year, while 3 percent reported having them on a daily basis. No matter what the symptoms, residents who reported symptoms of burnout were also more likely to have thoughts of attrition and suicidal thoughts. Moving forward, the researchers are trying to reduce burnout by giving training programs and toolkits to general surgery residents, but experts say burnout is a symptom of a deeper structural dysfunction in the healthcare system.

Health Policy and Reimbursement

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A framework formulated by a group of doctors and published in Academic Medicine proposes guidance for medical residency programs to implement standardized curricula on the health effects of climate change. The framework breaks down how climate change harms health, how clinicians can adapt clinical practice to health conditions and diseases worsened by climate change and how climate change disrupts healthcare delivery. "This is an important step, but first step, for figuring out how this will work in different rotations and different residency programs," explained Lead author and Emory University School of Medicine pediatrician Rebecca Philipsborn. She added that the framework can hopefully function as a starting point for residency program directors, and regards the inclusion of climate change-related content to be "somewhat inevitable."


The US Department of Health and Human Services has revealed a plan to enhance rural healthcare services. Some experts say the plan falls short of the complete overhaul the problem requires, and a fair number of the directives it includes are already in place. The plan includes steps to expand the availability of telehealth services, to link residents to non-local healthcare providers. It directs the federal government to provide more than $8.7 million in grant funding for up to 29 providers to provide emergency care consults virtually to rural providers without specialists over the next four years.


The experience of getting healthcare from a single doctor is falling out of favor, evolving towards a system in which patients have a team of healthcare professionals whose compensation is linked to keeping patients healthy. That team may be led by a doctor, but with a growing shortage of physicians, a nurse practitioner is increasingly likely to be in charge. A number of studies have suggested the quality of primary care provided by nurse practitioners is as good or better than care by doctors, with comparable outcomes at equivalent or lower costs. Patients will also receive more care virtually and in nontraditional settings such as drugstore clinics. The Covid-19 pandemic is accelerating this restructuring of primary care. Physician groups have pushed back against removing restrictions on nurse practitioners and physician assistants. Although a majority of primary care doctors work for large health systems, independent doctors are also forming their own networks or testing new approaches to offering care.

Medicine, Drugs and Devices

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Congress passed laws requiring insurers to pay for COVID-19 tests, and the Trump administration created a program to cover the bills of the uninsured. However, people nationwide have seen unexpected fees and are being denied claims related to coronavirus tests. Health data firm Castlight says roughly 2.4 percent of coronavirus tests billed to insurers leave the patient responsible for some portion of the payment. With 77 million tests performed so far, it could add up to hundreds of thousands of Americans who receive unexpected bills. In some cases, the charges appear to violate new federal laws intended to make coronavirus tests free for privately insured patients. In other cases, insurers are interpreting gray areas in these new rules in ways that work in their favor.


Frontline healthcare workers, hospital officials and the US Food and Drug Administration have highlighted the scarcity of medical masks as a continuing issue as the COVID-19 pandemic persists. Months into the pandemic, pressure on the medical supply chain remains severe, according to the American Medical Association. In particular, hospitals still lack sufficient numbers of medical N95 masks, a crucial component of which is meltblown textile. In 2019, the United States produced just 15 percent of the world's meltblown textile, while China accounted for 45 percent. This year, US meltblown textile manufacturers have been ramping up supply, but many said they need more government support in order to meet demand. This is in part because they are wary of investing significant money and resources into meltblown textile if demand for the component plummets after a coronavirus vaccine is distributed. Meanwhile, some US meltblown manufacturers are shipping their products overseas in the absence of an order from Washington banning the export of meltblown textile.