News From ACFAS

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After careful consideration of ten applicants to serve on the ACFAS Board of Directors, the Nominating Committee recommends the following three Fellows for two positions in the upcoming electronic election. The committee’s deliberations included written applications, volunteer histories, CVs, Open Payment data and telephone interviews.

• Michael J. Cornelison, DPM, FACFAS (Incumbent)
• Michael D. Vaardahl, DPM, FACFAS
• Eric G. Walter, DPM, FACFAS

Two three-year terms will be filled by election. Candidate profiles and position statements will be posted at acfas.org/nominations on November 21. Eligible voters may cast one or two votes on their ballot. Regular member classes eligible to vote are Fellows, Associates, Emeritus and Life Members. Individuals who intend to nominate by petition must notify ACFAS by October 25, and petitions are due no later than November 17.

Online voting will be conducted November 30–December 17. All eligible voters will receive an email with special ID information and a link to the election website in advance. After logging in, members will first see the candidate biographies and position statements, followed by the actual ballot. Eligible voters without an email address will receive paper instructions on how to log into the election website and vote. There will be no paper ballots.

The 2018 Nominating Committee included ACFAS Fellows Laurence G. Rubin, DPM, FACFAS, Chair; Georgeanne M. Botek, DPM, FACFAS; William J. Finn, DPM, FACFAS; Robert Fridman, DPM, FACFAS; Alan A. MacGill, DPM, FACFAS; Aksone Nouvong, DPM, FACFAS; and John S. Steinberg, DPM, FACFAS. It’s official—registration for ACFAS 2019 in New Orleans is now open! Register before the December 12, 2018 early bird deadline to take advantage of exclusive low rates and get one step closer to all that awaits you, including:

• Cutting-edge clinical sessions and hands-on surgical workshops
• More than 140 exhibitors and 300+ scientific posters
• Award-winning research
• Our first-ever Residents’ Day
• The HUB theater
• The Annual Job Fair
• Unlimited networking opportunities

ACFAS 2019 will be held February 14–17, 2019 at the Ernest N. Morial Convention Center in New Orleans. Visit acfas.org/neworleans to register and book your hotel accommodations. There is still time to volunteer to serve on a 2019 ACFAS committee, Clinical Consensus Statement panel or as a reviewer of Scientific Literature. ACFAS is looking for members who are leaders, thinkers, team players and hard workers to work with the College to shape the future of our profession.

To volunteer, visit acfas.org/volunteer. The application deadline is October 31, 2018. Where can you chat one-on-one with vendors about the latest surgical devices, catch up with your friends and colleagues over lunch, win prizes, scan your badge and see hundreds of scientific and case study posters…all in one place? The ACFAS 2019 Exhibit Hall in New Orleans!

Visit the Exhibit Hall from February 14–17, 2019 for not only food, friends and fun, but also the HUB theater and ACFAS Job Fair. Hourly HUB sessions on hot topics give you handy tips and tools to help you manage the nonclinical side of your practice, while the Job Fair features a wide collection of resumes and available positions to browse through.

Register now for ACFAS 2019 at acfas.org/neworleans and be part of the daily excitement in the Exhibit Hall!

Foot and Ankle Surgery

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Hindfoot fusion procedures are increasingly performed in the outpatient setting. However, the cost savings of these procedures compared with the risks and benefits has not been clearly investigated. The purpose of this study was to compare patient characteristics, costs and short-term complications between inpatient and outpatient procedures.

Researchers conducted a retrospective review of all patients who underwent inpatient and outpatient hindfoot fusion procedures by a single surgeon at one academic institution from 2013 to 2017. Data collected included demographics, operative variables, comorbidities, complications, costs and subsequent reencounters. Of 124 procedures, 34 were inpatient and 90 were outpatient. Between procedural settings, with the numbers available, no significant increase was observed in complication rate or frequency of reencounters within 90 days. No significant differences were seen in the number of patients with reencounters related to the index procedure within 90 days. The number of reencounters within 90 days after outpatient surgery was 30 versus four after inpatient surgery. The total number of emergency room visits in the outpatient group within 90 days was significantly higher compared with the inpatient group. The average cost for outpatient procedures was $4,159 less than inpatient procedures.

The researchers concluded that outpatient hindfoot fusion may be a safe alternative to inpatient surgery, with significant overall cost savings and a similar rate of short-term complications. They suggested that outpatient management is preferable for the majority of patients, but further investigation is warranted.


In this study, researchers sought to compare the clinical outcomes between endovascular treatment and inframalleolar bypass surgery for critical limb ischemia (CLI) in patients with thromboangiitis obliterans (TAO) and to assess the role of bypass surgery in the era of innovative endovascular treatment.

Between January 2007 and December 2017, a total of 33 consecutive patients with the diagnosis of TAO presenting with CLI who underwent endovascular treatment or bypass surgery to the pedal or plantar vessels were included and analyzed retrospectively. The primary endpoint was defined as a major amputation of the index limb, and the secondary endpoint was defined as graft occlusion, regardless of the number of subsequent procedures. In the bypass group, 55 percent of patients had undergone previous failed endovascular procedures and/or arterial bypass surgery to the index limb before inframalleolar bypass, and 18 percent of patients received microvascular flap reconstruction after bypass surgery.

During the median follow-up period of 32 months, no significant differences were found in primary and secondary endpoints between the two groups, although the bypass group had a higher Rutherford class than the endovascular group. Kaplan-Meier survival analysis showed similar limb salvage and graft patency rates. The researchers concluded that endovascular treatment is a valid strategy leading to an acceptable limb salvage rate for TAO patients, and surgical bypass to distal target vessels could play a vital role in cases of previous failed endovascular treatment or extensive soft tissue loss of the foot.


Calcaneal fractures are complex injuries and have historically had a poor prognosis that results in substantial disability. However, no studies have been performed that analyze both the radiographic and plantar pressure changes after treatment of intraarticular calcaneus fracture. In this study, researchers used computerized hospital records to identify patients with intrarticular calcaneus fractures treated at the institution during the study period.

A total of 36 patients completed physical examination and radiographic and dynamic pedobarographic assessments. The follow-up period was from 13 to 82 months. The mean pain score at rest was 3.7 and during activity was 4.0 on a 10-cm visual analogue scale. The mean range of motion of the subtalar joint was restricted. The mean American Orthopaedic Foot and Ankle Society function scale score was 68.1, the mean Short Form-36 physical score was 41.8 and the mental score was 44.9.

Pedabarographic results showed that the mean maximum force in the midfoot, forefoot and toes and peak pressure in the midfoot, forefoot and contact area of the midfoot and toes were significantly increased in the injured foot. Radiologic findings showed hindfoot varus, forefoot adductus and an increase in the medial arch. Even after appropriate anatomic realignment with open reduction and internal fixation of calcaneus fractures, residual differences in plantar pressures and radiographic measures were observed compared to the uninjured foot.

Practice Management

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Siddhartha Mukherjee, the author of The Emperor of All Maladies: A Biography of Cancer, discusses how doctors may be able to avoid burnout by finding personal, deeply specialized purpose in their work. He points to the work of Austrian neurologist, psychologist and Holocaust survivor Viktor Frankl, who traced the roots of resilience not to success or power but to a sense of purpose and the acquisition of meaning. Later writers expanded Frankl's concept of meaning along three dimensions: purpose, mastery and autonomy.

Among doctors, too, it seems that resilience and survivorship track along the same essential dimensions. In one recent study, 42 percent of doctors reported feeling burned out. The least affected were doctors in procedure- or skill-oriented domains. Meanwhile, the most common reasons cited for burning out were the overwhelming strains of bureaucracy and paperwork, the vast amount of time spent at work and a lack of respect from administrators and employers.

Some solutions to fixing burnout are pragmatic, Mukherjee says, such as lessening burdens. Other solutions involve more work—including investing in research-oriented practices or concentrating on specific realms of interest—but Mukherjee says they helped him and his former classmates narrowly escape burnout. "We survived, I think, by deepening our commitments to research. We tried to increase our mastery within peculiar medical niches. And powerful, autonomous interests kept us going … when the hospital was asking us to punch numbers into terminals. We didn't burn out, perhaps, by burning a little more."


Medical practices may, at times, require a line of credit or a loan, but they present a lender with a much different set of circumstances than most other types of businesses. Like many small businesses, they may need more than just immediate access to funds. Medical practices may benefit from having a long-term lender that can also act as a financial adviser because it understands the unique nature of the business and the specific characteristics of the market.

One option is a local community bank. Community banks pay close attention to local demographics and economic conditions, likely the same factors that influence the makeup of a practice's patient load and payment mix. When these elements shift, community banks can anticipate the impact on the medical practice. Another consideration is if the bank's commercial loan officers have experience working with similar medical practices. This will give them a better understanding of anticipated cash flow, ongoing financial requirements and revenue stream.

In addition, the loan officer should understand that the practice's claims payment and net income are largely affected by the particular patient profile and payer mix. If a practice serves patients covered by Medicare or Medicaid, for example, it is likely submitting hundreds of claims monthly to multiple payers and monitoring those collectibles. If patients are primarily covered by private insurance, the claim payments could be larger but require more time. Furthermore, the bank should understand a practice's unique financial obligations and take them into account when considering its ability to handle this debt. Finally, while adding physicians should increase revenue, the bank should acknowledge that billings for those doctors will initially be delayed.


Healthcare professionals offer strategies that physicians can use to minimize errors and maximize reimbursement. Two recent studies published in the Journal of Family Practice and the Journal of General Internal Medicine suggest financial and time management benefits to hiring a scribe or coder. Another option is to use a coder to ensure maximum reimbursements by reviewing charts and physician notes and by staying on top of new and changing codes, according to a healthcare finance analyst.

Physicians should also address electronic health record (EHR) shortcuts, including creating templates for exams, such as the well-women exam, UTI exams and annual wellness visits, advised a reimbursement specialist. However, she cautioned against cloning your records. Auditors will not look favorably upon information that appears copied and pasted from a previous report. Other considerations in using EHR shortcuts are to get rid of prepopulated or autopopulated fields and to encourage the use of freeform text to individualize the record entry.

Furthermore, remember medical necessity. Medicare generally considers medically necessary services as those that are "reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member." Payers are becoming increasingly concerned about this issue. Finally, common mistakes made when billing include unbundling codes and upcoding, failing to consult the National Correct Coding Initiative edits when reporting multiple codes, adding modifiers that may not be appropriate and reporting unlisted codes without documentation.

Health Policy and Reimbursement

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The U.S. Centers for Medicare and Medicaid Services (CMS) announced that, for the first time since Affordable Care Act (ACA) plans began to be offered through the federal exchange, premium rates have declined. Premium rates for a benchmark silver plan in 2019 are decreasing a collective 1.5 percent in the 39 states that use the federal platform, CMS Administrator Seema Verma said. In some states, the decrease is even greater, such as 26 percent in Tennessee and 15 percent in New Hampshire. In addition, 23 more issuers have entered the market, including Anthem and Cigna.

CMS, under the Trump Administration, is taking credit for introducing waivers and a reinsurance program for insurers to submit high-cost claims into a risk pool. CMS will soon offer even more flexibility for states to use Section 1332 innovation waivers, Verma said. Other factors that account for the turnaround in the ACA market include the administration's allowance of silver loading, at least for 2019. In August, CMS issued new guidance for insurers to apply the full premium increase to silver marketplace plans to make up for the loss of their cost-sharing reduction payments, which were ended by President Trump. Most consumers are not harmed because nine out of 10 who purchase plans in the ACA market receive tax subsidies.


The Trump administration has proposed that Medicare embrace telemedicine by paying doctors $14 for a five-minute "check-in" phone call with their patients. The call would be used to help patients determine whether they need to come in for an appointment, Medicare said. However, doctors and consultants contend that the virtual sessions could cover a range of services, including monitoring patients starting a new drug or those trying to manage chronic illnesses. The Medicare Payment Advisory Commission criticized the proposal last month, saying it could lead to excess spending without benefiting patients. Some physicians also say the proposed reimbursement will cover a service they already do for free.

Congress has resisted expanding the use of telemedicine in Medicare due to concerns about higher spending, even though it has become widespread among private insurers. CMS officials say they believe the change would ultimately save Medicare money by reducing unnecessary office visits and by catching health problems early, before they become more expensive to treat. But in its detailed proposal, CMS acknowledges the telehealth service will increase Medicare costs. CMS does not expect rapid adoption of the telehealth service, partly because doctors can get paid from $35 to $150 for an in-person visit.

In addition to the check-in call, CMS has proposed paying physicians to review photos that patients text or email to them to evaluate certain conditions. It has also proposed compensating physicians an unspecified fee for consulting electronically or by phone with other doctors. CMS said it hopes to enact the changes in 2019. Officials will announce their final rule after evaluating public comments on the plan.


The U.S. Centers for Medicare and Medicaid Services (CMS) announced that nearly 1,300 providers will participate in Medicare's newest at-risk bundled payment initiative. The BPCI Advanced Model runs from October 1, 2018 through December 31, 2023, expanding on the Bundled Payments for Care Improvement Initiative (BPCI) that ended September 30. Participants include 832 acute care hospitals and 715 physician group practices representing 1,547 Medicare providers and suppliers nationwide, CMS said.

Under the new payment model, providers are at risk for financial losses if they cannot contain patient care costs within a spending range set by Medicare. They keep a portion of what they save on costs, as long as quality metrics are met. BPCI Advanced will include 32 bundled clinical episodes, including 29 inpatient and three outpatient. The top three clinical episodes are major lower joint replacement, congestive heart failure and sepsis.

"To accelerate the value-based transformation of America's healthcare system, we must offer a range of new payment models so providers can choose the approach that works best for them," CMS Administrator Seema Verma said, citing "robust participation." After hearing complaints from providers, CMS said it will issue preliminary target prices before each model year of BPCI Advanced to allow for planning.

Medicine, Drugs and Devices

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President Donald Trump has signed two bills prohibiting "gag order" clauses in contracts between pharmacies and insurance companies or pharmacy benefit managers. Such provisions ban pharmacists from disclosing to customers when they can save money by paying the pharmacy's lower cash price instead of the price negotiated by their insurance plan. Congress passed both bills—one for Medicare and Medicare Advantage beneficiaries and another for commercial employer-based and individual policies—in September.

"Banning gag clauses will make it easier for more Americans to afford their prescription drugs because pharmacists will be able to proactively notify consumers if a less expensive option may be available," said Sen. Susan Collins (R-Maine), who authored the bill. The change was one of the proposals in the president's plan to slash prescription drug prices released in May. According to the National Community Pharmacists Association's Ronna Hauser, many association members "say a pharmacy benefit manager will call them with a warning if they are telling patients it's less expensive" without insurance.

A study published in JAMA in March estimated that people with Medicare Part D drug insurance overpaid for prescriptions by $135 million in 2013, and copayments in those plans were higher than the cash price for nearly one in four drugs purchased in 2013. Beneficiaries overpaid by more than 33 percent for 12 of the 20 most commonly prescribed drugs.


More than half of provider organizations lack confidence in their medical device security, according to a survey by KLAS and the College of Healthcare Information Management Executives (CHIME). Most provider groups said they blamed security problems on the device manufacturers, especially if the devices cannot be properly updated or patched. This problem afflicts about a third of respondents' medical devices and is exacerbated by the fact that medical devices tend to have long lifecycles, which makes them more vulnerable to hackers.

About 18 percent of provider organizations surveyed by KLAS experienced malware attacks on medical devices in the past 18 months. Some organizations are seeking guidance from the U.S. Food and Drug Administration (FDA), whose Medical Device Safety Action Plan includes suggestions for improved security. The agency recently published a "regional incident preparedness and response playbook" for medical device cybersecurity in collaboration with Mitre Corp. FDA Commissioner Dr. Scott Gottlieb said the agency would update its 2014 premarket guidance for devices in the coming weeks.

Some respondents to the KLAS-CHIME survey criticized FDA policies, which they said restricted them to the point of being unable to bolster their devices' security. More than three fourths of respondents said a lack of resources limited their security capabilities. Insufficient resources might cause organizations to keep inaccurate inventories of their devices and their devices' security.


The issue of counterfeit prescription medicine is a growing problem, attracting the attention of law enforcement organizations and pharmaceutical companies. The U.S. Food and Drug Administration (FDA) in June convened a meeting around the problem of illegal opioids sold online and through social media. In a survey conducted last year by the Alliance for Safe Online Pharmacies (ASOP Global), 55 percent of U.S. consumers said they have bought or would consider buying medicine online, notes Libby Baney, a senior adviser to the nonprofit.

"The biggest danger is that these sites do not require a medical examination or a prescription, and the sites do not impose limitations on how much or how often the consumer purchases drugs," says Alex Khu, assistant director of the U.S. Immigration and Customs Enforcement's Global Trade Investigations division. The National Association of Boards of Pharmacy (NABP) reviewed nearly 12,000 internet outlets selling medicine to U.S. patients. Of these, about 95 percent were found noncompliant with state and federal laws and NABP standards, according to a report published in September, which highlighted the role social media sites play.

The ASOP Global survey also found that more than 80 percent of doctors do not talk to patients about where they get their medicine. If a patient says his or her medication is not working, a doctor unaware that the product was purchased from a questionable source could mistakenly prescribe a higher dose or a different drug.