News From ACFAS

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The Diagnosis and Treatment of Ankle Arthritis Clinical Consensus Statement (CCS) is now available on acfas.org. The statement is the latest addition to the College’s library of CCSs, which provide physicians with a recommended approach to the treatment of specific conditions and pathologies.

This statement can be used by practitioners to carry meaningful discussion with their patients regarding treatment options and is useful for understanding the current trends in ankle arthritis. Of these trends, implant arthroplasty and arthroscopic arthrodesis are gaining popularity while biological options, such as resurfacing and injection therapies are still not mainstream options for ankle arthritis.

The statement is also available in The Journal of Foot & Ankle Surgery at jfas.org. Promoting “Who You Are and What You Do” is a top priority for ACFAS. We work diligently through many marketing channels to raise awareness to consumers of the profession through our Take A New Look at Foot and Ankle Surgeons public relations campaign.

Most recently, ACFAS member Brett Sachs, DPM, FACFAS was featured in an article in US News and World Report seeking care during the pandemic and two additional articles were also published, one on Foot and Ankle Symptoms You Should Never Ignore, which featured ACFAS member Jeffrey Loveland, DPM, FACFAS and reached over 116.9 million people in publications across the nation and the second featured Brett Sachs, DPM, FACFAS who shared information on Foot Care Tips for Those With Diabetes, which has reached over 146.3 million people nationally.

Google ads have also been an important part of our campaign efforts. The ads, which appear in user’s search results on Google, have helped to increase our physician searches on FootHealthFacts.org by 30 percent just in the last few months with the pandemic.

To continue promoting the profession and to share with the world what foot and ankle surgeons can do, share these features within your practice, website and social media outlets to build on this grassroots effort. Share your successes and continue promoting the great work you are doing by using the tools in the ACFAS Marketing Toolbox.

Foot and Ankle Surgery

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The objective of this paper was to develop a national survey about foot involvement in people with psoriatic arthritis using a best practice approach. A 59-item survey with eight sections was developed and sent out. There were 649 respondents, and 83 percent of respondents completed the survey in full. Extensive survey pre-testing among the target population, health professionals and experts improved the overall quality, content validity, functioning and representativeness of the survey instrument, which optimised potential response rates. Clear audit trails that mapped the analytical process at each stage substantiated the rigour of the survey development methods. Robust strategies for sampling, survey dissemination and community engagement were deemed to have made a powerful contribution to response rates and the scale of information collected.


The study used magnetic resonance imaging (MRI) to compare the effectiveness of lower-level laser therapy (LLLT) and extracorporeal shock wave therapy (ESWT) in the treatment of inflammatory plantar fasciitis. The study followed 40 patients with the diagnosis of SpA and having pain at the heels at least for six months. Patients were divided randomly into two treatment groups; one undertook 14 sessions of infrared Ga-Al-As LLLT, and the other undertook three sessions ESWT. The thickness of the plantar fascia was measured with MRI before and one month after treatment. Compared with the pretherapy, progress in the feet function by American Orthopaedic Foot & Ankle Society and Roles-Maudsley scoring and decrease in VAS levels were statistically significant in both groups. Only the VAS exercise score was superior to LLLT. The thickness of the plantar fascia had decreased significantly on MRI in all two groups.


This study investigated whether the degree of pes planus was associated with hallux valgus severity and hallux valgus surgery outcomes. A total of 122 feet were retrospectively analyzed after hallux valgus surgery. A significant correlation between radiographic parameters of pes planus and hallux valgus severity, radiographic outcomes, Foot and Ankle Outcome Score and Foot Function Index were not noted. The hallux valgus angle and inter-metatarsal angle changed significantly after the surgery; however, a significant difference was not noted between the pes planus and non-pes planus groups. A significant interaction between the time points and groups was not observed with respect to the hallux valgus angle and inter-metatarsal angle. A regression analysis showed that none of the radiographic parameters for pes planus affected hallux valgus recurrence.

Practice Management

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In order to successfully collect patient balances, practices should be thorough in educating patients about the cost of virtual services at the time of booking. Practices should decide whether they will require upfront collections, which can be complicated. Practices must also tailor patient financial engagement strategies to fit the tech-savviness of the demographics they serve. Practices should offer a payment plan when possible. Practices will need to be sensitive in continuing post-visit collections calls, sending a clear and concise invoice to minimize questions. It is important that practices employ enough billers, outsourcing if needed. Practices can facilitate payments by keeping a credit card on file that they can charge when a patient responsibility is assigned. If the practice makes a reasonable effort to collect from a patient who is experiencing financial hardship, providers may be able to offer a discount without violating Stark Law. Practices should also provide training to front-office staff.


Tax savings plans targeting doctors require careful due diligence. Physicians should remember that they are always responsible for the legality of any deductions or tax strategy you use. It is wise to check with the IRS before adopting a plan. This includes being aware of the worst plans that receive the greatest scrutiny both on the annual “Dirty Dozen List” of tax scams and on the larger and more detailed “listed transactions” list that should be an immediate red flag. Captive insurance companies and the 831(b) micro-captives that physicians in particular often end up in continue to face scrutiny from the IRS. Physicians should check that any tax promoter they use is a licensed professional, does not require a non-disclosure agreement and does not use certain questionable sales techniques that do not identify specific tax code. It is also a red flag if a promoter is unwilling or unable to provide written materials about their strategy or to answer questions.

Health Policy and Reimbursement

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The Trump administration said it was withdrawing a plan to implement stricter federal oversight over how states pay for their share of Medicaid. The move comes after some states and medical groups said the new rule would have deprived them of billions of dollars in funding amid the COVID-19 pandemic. Hospitals and other health organizations praised the decision, which was made following weeks of debate within the US Health and Human Services Department (HHS), according to sources. These people add that White House advisers had sought to tighten oversight, but some top HHS leaders, including HHS Deputy Secretary Eric Hargan, disagreed. The proposal called for setting new limits on certain supplemental payments that states give to some Medicaid providers, a change some hospitals and physicians believe would compel some providers to opt out of the program. Moreover, the proposal would have imposed new reporting requirements and restrictions on financial practices many states use to pay for Medicaid.


The US Center for Medicare and Medicaid Services (CMS) released Part I of the 2022 Medicare Advantage Advance Notice to provide plans with earlier notification of proposed payment changes. CMS updated the methodology used to calculate payments made to Medicare Advantage and Part D plans through the agency's Advance Notice and Rate Announcement process. This year, the announcement comes roughly three months earlier than usual to help Medicare Advantage and Part D plans better estimate 2022 plan costs in light of the COVID-19 pandemic. The Advance Notice Part I includes information about Medicare Advantage risk adjustment for 2022 with a 60-day comment period. Other changes to payment methodologies for 2022 will be released at a later time.


Federal data show that health insurance became slightly less common in the United States last year, even before the onset of the coronavirus pandemic. Nearly 30 million people nationwide lacked coverage at some point during 2019, about 1 million more than in the previous year. Last year also marked the third year in a row that the ranks of the uninsured increased, according to a US Census Bureau report. Census figures show that enrollment in Affordable Care Act (ACA) health plans declined by 1 million last year. The Kaiser Family Foundation's Larry Levitt observes, "President Donald Trump has been unsuccessful in repealing the ACA, but he has taken steps to weaken the law and that is showing up in these numbers." Nearly 17 percent of Hispanic people and nearly 10 percent of Black people lacked coverage throughout last year, significantly higher than among White and Asian people.


By the most recent count, the roster of Nevadans on Medicaid has climbed from fewer than 644,000 in February to about 731,000 through August, a 13.5 percent increase. Overall, caseloads had risen on average 8.4 percent through July in 30 states. Nevada's unemployment rate soared to 30.1 percent in April, the highest ever recorded for any state. The spiraling demand for Medicaid is colliding with a diminished ability by the state to pay for it. With Nevada confronting a $1.2 billion deficit, the legislature has proposed a 6 percent rate cut, the largest in the nation. In addition to lowering doctors' pay, the state reversed a 2.5 percent increase that had begun in January in the daily rate for hospitals' inpatients. In a state with a scarcity of medical professionals, the cuts will likely exacerbate the shortage and lack of access to care.

Medicine, Drugs and Devices

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A group of 243 Republican and Democratic House lawmakers sent a letter to US Department of Health and Human Services Secretary Alex Azar, urging him to use his authority to prevent pharmaceutical companies from reducing hospitals' access to 340B discounts. The letter also urges Azar to stop drug manufacturers from refusing to offer 340B discounts on drugs dispensed through community pharmacies. Eli Lilly recently informed hospitals that after September 1, it will no longer offer 340B discounts to hospitals that ship drugs to contract pharmacies instead of dispensing them in-house. AstraZeneca made a similar statement, which it said would take effect on October 1. Merck, Sanofi and Novartis have also indicated they may start withholding discounts to avoid paying duplicate discounts.


A federal appellate court ruled that the state of New York can collect $200 million from the makers and distributors of opioid analgesics to help curb the costs of opioid addiction. In 2018, a federal judge ruled that the state's Opioid Stewardship Act was unconstitutional because it would have prevented companies from passing on a surcharge to customers in New York. However, in its ruling, the Second US Circuit Court of Appeals reversed the decision, asserting the payments are a legal tax that New York can collect. The court did not provide a ruling on whether the tax could be passed on to customers, because New York did not appeal that issue and has since created a new tax without that provision that captures sales from 2019 onward. The original New York law was estimated to collect $100 million per year for six years starting in 2017, with the amounts owed by each company determined by market share. The new ruling allows the state to impose the 2017 and 2018 payments.


President Trump signed an executive order that he claimed reduces prescription drug prices "by putting America first," but experts say the move is unlikely to have any immediate benefit. The order repeals an earlier directive and expands the drugs covered by Trump's proposed "most favored nations" pricing scheme to include both Medicare Part B and Medicare Part D. The notion is that Medicare would not pay more for drugs than the lower prices paid by other developed countries. The drug industry has roundly condemned this move. PhRMA CEO Stephen Ubl cited the order as "an irresponsible and unworkable policy that will give foreign governments a say in how America provides access to treatments and cures for seniors and people struggling with devastating diseases."