News From ACFAS

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Expand your view of the forefoot and midfoot when we work “In the Trenches” next month in Torrance, California. Join us November 17–18 for this new On the Road regional program and enjoy open, informal discussion with your colleagues that lends itself to a free exchange of fresh ideas and perspectives.

Learn the latest methods for treating the most complex forefoot and midfoot cases then practice your newly acquired skills in two hands-on sawbones labs. This seminar also includes a Q&A session with faculty on Friday night during which you can share your own cases and get valuable feedback.

Visit acfas.org/ontheroad to register now for the November course, or catch On the Road in Detroit or Charlotte this spring. Take your electronic medical record (EMR) system from good to great with ACFAS' Patient Education CD Series, the most trusted information on foot and ankle health.

Upload the PDF brochures from each CD to your EMR and:

• Match them with diagnoses in your chart note assessments
• Allow your patients to access them through your EMR portal
• Print copies for your patients
• Include them in your surgery packets and promotional materials
• Post them online

All five CDs are available in English and Spanish and feature topics developed and peer-reviewed by practicing foot and ankle surgeons.

Visit acfas.org/patientCD to order now. Follow these four tips from PodiatryCareers.org, an ACFAS Benefit Partner, to make sure your first week at a new job is a success.

1. Invite Your Boss to Lunch
Invite your boss to lunch at some point during your first week. This shows your colleagues that you are someone who wants to get to know the team and who takes action. Also, the more people you know, the better you will feel when you walk into the office each day.

2. Schedule One-on-One Meetings with Everyone on Your Team
Ask your team members: What are you working on right now? What are you interested in when you are not at work? How can my work make your life a little easier? These informal meetings can quickly lead to some exciting projects because everyone will see that you are making an effort to settle in.

3. Start Conversations in the Kitchen
You will likely work cross-functionally with many of the people you see around the office every day. So introduce yourself to a few people, even if all you do is learn a few names to start. This is a great way to get comfortable in your new job sooner rather than later.

4. Be Willing to Try New Things
It is easy to default to behaviors that were acceptable at your previous job simply because they feel familiar. The more you let go of old routines and try a few new ones, the easier it will be to embrace bigger changes.

Starting a new job will make you feel uneasy, especially when all you want to do is make things feel normal. However, if you put yourself out there from day one, you will settle into your new position faster than you ever imagined.

Looking for a new job or have one to fill? Visit PodiatryCareers.org for more information.

Foot and Ankle Surgery

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A study of 33 patients was conducted to evaluate the effects of axial traction during magnetic resonance imaging (MRI) of talar dome osteochondral lesions using a small-FOV coil. The subjects underwent high-resolution MRI of the ankle using a microscopy coil with and without axial traction. Two radiologists independently quantified the tibiotalar joint space width and semiquantitatively graded intraarticular joint fluid dispersion, cartilage surface visibility of the osteochondral lesion and cartilage surface visibility elsewhere in the tibiotalar joint prior to and following traction. None of the patients reported discomfort or other symptoms during traction. The tibiotalar joint space significantly increased after traction compared with before traction. The degree of intraarticular joint fluid dispersion and the cartilage surface visibility at the osteochondral lesion and elsewhere in the tibiotalar joint improved following traction.


A study was conducted to describe the results of an all-arthroscopic method to concomitantly repair the lateral collateral and deltoid ligaments to treat patients with rotational ankle instability. The researchers treated 13 patients by arthroscopic means after failing nonoperative management, with an average follow-up of 35 months. A suture passer and knotless anchors were used to repair the ligaments with an arthroscopic all-inside technique. Twelve patients exhibited an isolated anterior talofibular ligament (ATFL) injury during diagnostic arthroscopy, and in one patient, both the ATFL and calcaneofibular ligament were affected. Arthroscopic examination of the deltoid ligament identified an "open book" tear affecting the anterior area of the ligament in all cases. The ligament was separated from the medial malleolus when applying passive internal rotation of the tibio-talar joint. This gap was sealed when the tibio-talar joint was in neutral rotation or externally rotated. All patients noted subjective improvement in their ankle instability following arthroscopic all-inside ligaments repair. The median AOFAS score rose from 70 preoperatively to 100 at final follow-up.


A study was conducted to assess the association of classes of body mass index in patients with normal weight and overweight patients with short-term complications and functional outcomes three to six years following surgical procedures for closed ankle fractures. A cohort of 1,011 patients treated for ankle fractures by open reduction and internal fixation in two hospitals was studied, with a follow-up postal survey of 959 patients using three functional outcome scores. Obese patients exhibited more severe overall complications and higher odds of any complication than the normal weight group, with adjusted odds ratio 1.67 and 1.71, respectively. A total of 479 patients responded to the questionnaire. Obese patients scored worse on the Olerud and Molander Ankle Score, Self-Reported Foot and Ankle Questionnaire and Lower Extremity Functional Scale than those with normal weight. However, overweight patients did not have worse functional scores than those with normal weight.

Practice Management

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Healthcare consultant Susan Childs, FACMPE, believes it is essential for an electronic payment system to promote prompt and efficient reimbursement. She notes it often can be easier to reach people through an email address instead of a physical one because email addresses tend to remain stable. Patients also need to understand the cost of treatment plans but should not be given too much initial time to pay via an e-payment system. About three weeks is a good general guideline, Childs says, about the same amount of time it takes to get an Explanation of Benefits. Practices can also consider an auto-pay system, getting signatures from patients who are on payment plans and obtaining a second credit card number when requesting one to put on file to serve as a backup. Physicians can also devote a separate, private room to financial discussions. "Paint it light blue or light green, something very calming. Put in a live plant, a picture, something familial," Childs says. Furthermore, she advises asking patients to pay for existing bills at check-in. "Ninety-four percent of patients expect their next experience to be based on the last one. If they didn't have to pay before, they aren't expecting this time either. If you don't collect money at the check-in, you just told them it's OK not to pay," Childs explains.


A national survey has found that one out of five Americans have suffered a medical error. The poll, which included 2,500 people, also discovered that one out of three respondents said a person whose care they were a part of had experienced a medical error. The majority of medical errors were linked with diagnosis and patient-provider communications. Meanwhile, outpatient facilities were common locations of medical errors. However, most survey respondents also signaled that they did not personally worry about patient safety. The survey was conducted by the IHI/NPSF Lucian Leape Institute and NORC at the University of Chicago.


According to a survey by West, a healthcare communications company, 25 percent of patients do not have a strong feeling that their provider cares about them as a person. Furthermore, one out of five respondents are not convinced that their provider is focused on improving their health. The survey also found that patients are willing to delay care or refuse to schedule another appointment if their expectations are not being met. Allison Hart, chief market research and insights strategist for West, warned that this dissatisfaction among patients could ultimately hurt the profits of providers in the long run. This issue is becoming particularly more pronounced as more costs are placed on patients.

Health Policy and Reimbursement

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President Trump will eliminate subsidies to health insurance companies that help pay out-of-pocket costs of low-income people. His plans were disclosed shortly after he ordered potentially wide-ranging changes to the U.S. insurance system, including sales of less costly policies with fewer benefits and fewer protections for consumers. These actions could destabilize the Affordable Care Act (ACA), raising insurance premiums substantially and causing insurers to withdraw from the ACA's online marketplaces. The top Democrats in Congress criticized Trump's move as "a spiteful act of vast, pointless sabotage leveled at working families and the middle class in every corner of America." The implementation of Trump's directive could take months, which means it will likely not affect coverage in 2018 but could lead to major changes in the following year. Physicians, hospital executives and state insurance regulators warn the changes the president's order calls for could raise costs for sick people, boost sales of barely comprehensive insurance plans and add uncertainty to unbalanced health insurance markets. Six physician groups say "allowing insurers to sell narrow, low-cost health plans likely will cause significant economic harm to women and older, sicker Americans who stand to face higher-cost and fewer insurance options."


In a study published in JAMA Internal Medicine, voluntary Medicare bundled-payment programs for joint replacements at Baptist Health System in San Antonio were found to lead to a 21 percent decline in average Medicare episode spending between 2008 and 2015. Readmissions, emergency department visits and cases with prolonged hospitalization all decreased substantially. Costs for joint implant devices fell 29 percent as a result of surgeons working with the hospital to negotiate lower prices. Furthermore, costs for postsurgical stays in rehabilitation facilities and skilled nursing facilities fell by 49 percent and 33 percent, respectively. The financial incentive of meeting a fixed cost target for an entire episode of care has encouraged a stronger collaboration between hospitals and physician groups, even those that have not set up financial arrangements in which physicians receive bonuses for meeting cost targets. "These programs are forcing physicians to look holistically at the patient for an entire episode," says Andy Tessier with the Signature Medical Group. "What I'm hearing is they are making these specialists better doctors."


The American Health Care Association (AHCA) is leading a push by skilled nursing communities and their partners to change a law requiring a three-day hospital stay to qualify care recipients for Medicare coverage. "On average, hospital stays are much shorter than they were in the 1960s, but the three-day stay requirement still applies to all Medicare [recipients]," says AHCA's James Michel. "As the hospital stays become shorter, the effect of the three-day rule is to block more and more Medicare beneficiaries from being able to access the skilled nursing [community] benefit." Medicare law dictates a recipient must be designated an inpatient at an acute-care hospital for at least three midnights to qualify for Medicare Part A coverage of skilled nursing community stays. Under the Improving Access to Medicare Coverage Act of 2017, Medicare beneficiaries would be permitted to count observation days toward the three-day stay requirement. "[This requirement is] dramatically reducing the number of admissions to [skilled nursing communities]," says Salter Healthcare co-owner Richard Salter. "In some cases, people are being sent home from hospitals unsafely." A new law enacted in March requires that hospitals give notice to Medicare beneficiaries on observation status that their outpatient categorization could affect Medicare coverage, but Salter says the Medicare Outpatient Observation Notice does not adequately protect most senior hospital visitors.

Medicine, Drugs and Devices

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Researchers from University Hospitals Case Medical Center in Cleveland have found that doctors' white coats with sleeves above the elbow were less likely to have traces of infectious viruses on them than long-sleeved coats. Long-sleeved white coats are often contaminated but rarely cleaned. The research also adds credibility to the recommendation that doctors wear short-sleeved coats. The findings were presented at ID Week, the annual meeting of the Infectious Diseases Society of America.


U.S. Food and Drug Administration Commissioner Scott Gottlieb warns that Puerto Rico may begin to see a small number of drug shortages in the coming weeks due to the slow recovery of manufacturing in the country. Puerto Rico is still recovering from the impact Hurricane Maria caused on September 20. Currently, only 16 percent of the island has power, which means drug manufacturers are dealing with uncertain access to energy. Furthermore, companies are having trouble obtaining materials used to make medicines. Gottlieb says it is unclear when the drug makers will return to 100 percent operating capacity.


The U.S. Food and Drug Administration (FDA) could soon loosen rules that prevent drug manufacturers from promoting medicines for uses other than their intended purpose. FDA Commissioner Scott Gottlieb previously called for a lighter regulatory stance on the issue. Furthermore, two federal district courts recently ruled that the First Amendment does not permit FDA to stop manufacturers from providing truthful information about medicines to doctors. Supporters of less restrictive rules say it is safer if the companies provide the information. However, critics worry loosening the rules will result in careless use of off-label drugs that could put patients at risk.