News From ACFAS

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On October 14, the U.S. Centers for Medicare and Medicaid Services (CMS) released its final rule implementing the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). This bill repealed the Sustainable Growth Rate and replaced it with two more palatable payment options, the Merit-Based Incentive Payment System (MIPS) and the Advanced Alternative Payment Models (APMs).

CMS has made the following changes as part of the final rule:

• Physicians will be able to pick their pace if they choose one of the four participation options during the 2017 reporting year and thereby exempt themselves from the risk of penalty. Physicians who do not participate will experience an automatic four percent negative payment adjustment.
• During the 2017 reporting year, resource use/cost will not be factored into the final MIPS score. This changes the following domain scores: Quality Activities will compose 60 percent of the final score, Clinical Improvement Activities will compose 15 percent of the final score and Advancing Care Information will compose 25 percent of the final score.
• The final rule exempts physicians whose practices take in less than $30,000 in Medicare payments or fewer than 100 Medicare patients from MACRA.

The reporting period begins on January 1, 2017 for 2019 payment adjustments. For more information, contact Sarah Nichelson, JD, ACFAS director of Health Policy, Practice Management and Research. Hit the jackpot with three new preconference workshops set for Sunday, February 26 at The Mirage in Las Vegas. Choose from:

• The Malaligned Foot: Primary Through Revision
  (7am–Noon, 4 CE contact hours, includes wet lab)
• Fusions: Ankle to Toe and Everything in Between
  (Noon–5pm, 4 CE contact hours, includes wet lab)
• Practice Management/Coding Workshop
  (7:30am–5:30pm, 8 CE contact hours)

These hands-on, next-level learning opportunities will strengthen your surgical technique, improve your coding skills and give you a sneak preview of everything that awaits you at ACFAS 75. Registration details coming soon—check acfas.org.
Hotel poachers are coming out of the woodwork, especially in Las Vegas! Stop them in their tracks by booking your hotel room for the 75^th Annual Scientific Conference through onPeak, LLC, the College’s official housing partner.

If anyone other than onPeak contacts you regarding your accommodations, do not give them your credit card information or a cash deposit. These are unauthorized third parties not related to ACFAS 75.

Reserve your room safely and securely through acfas.org/asc and take advantage of exclusive low rates available just for attendees. Planning to sell your practice? You can now post a sales announcement on PodiatryCareers.org to reach potential buyers across the country!

PodiatryCareers.org also allows you to:

• Search hundreds of podiatry jobs nationwide
• Set job alerts to save time and keep you informed of positions that interest you
• Upload and activate your resume to make applying to jobs easier and to make sure employers can find you
• Browse current healthcare news, job search tips and career advice

Visit PodiatryCareers.org to take advantage of everything it has to offer and put your career on the fast track! Thank you and congratulations to ACFAS’ loyal and dedicated members who have been a part of the College for 40 years or more! In appreciation, these members receive Life Membership status with ACFAS. The ACFAS Board of Directors honors this year’s 40-year members:

• Stevan J. Anselmi, DPM, FACFAS, Wellsboro, PA
• Michael J. Burns, DPM, FACFAS, Fort Collins, CO
• Timothy J. Byron, DPM, FACFAS, Gallatin, TN
• Richard M. Evans, DPM, FACFAS, Lincoln, NE
• Robert I. Garnet, DPM, FACFAS, Miami, FL
• Joseph T. Garofalo, DPM, FACFAS, Santa Barbara, CA
• Richard L. Hecker, DPM, FACFAS, Fish Creek, WI
• Danny A. Kaplan, DPM, AACFAS, Southgate, MI
• Gregory P. LaNata, DPM, AACFAS, Baton Rouge, LA
• Sheldon Z. Rubin, DPM, FACFAS, Hickory Hills, IL
• George M. Rutan, DPM, FACFAS, Dublin, OH
• Carl D. Solomon, DPM, FACFAS, Dallas, TX
• Louis A. Sorto, Jr., DPM, FACFAS, Des Plaines, IL
• Harvey Strauss, DPM, FACFAS, New York, NY

Foot and Ankle Surgery

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In patients with type 2 diabetes, the risk of vascular diseases remains substantial. Researchers examined the absence of dorsalis pedis and posterior tibial pulses as risk indicators for major macrovascular and microvascular events, cognitive decline and death in 11,120 type 2 diabetes patients. Absent peripheral pulses were associated with increased five-year risks for macrovascular events, myocardial infarction, stroke, cardiovascular death, heart failure, all-cause mortality, microvascular events, nephropathy, end-stage renal disease and peripheral neuropathy. Patients with absent dorsalis pedis or posterior tibial pulses shared comparable hazard ratios, and risks increased with the number of absent peripheral pulses. The highest risks were observed in patients with three or four absent pulses.


Researchers evaluated the versatility of the medial sural artery perforator (MSAP) flap in ankle and foot reconstruction and its use for covering small-to-moderate size defects. Twenty-two patients with variable defects of 4 x 4 centimeters to 18 x 7 centimeters underwent MSAP flap reconstruction, with flap size ranging from 6 x 4 centimeters to 21 x 9 centimeters. Patients with reconstruction of the ankle-hindfoot or hallux showed significantly lower AOFAS ankle-hindfoot scores (P=0.021) or hallux scores (P=0.034) when compared to patients without reconstruction. Reconstruction of the midfoot resulted in not significantly different AOFAS midfoot scores (P=0.265) compared to patients without reconstruction. The SF-36 physical and mental scores for all three regions did not differ significantly between those with and without flaps. All flaps survived and all patients regained ambulation.


A meta-analysis of comparative studies was performed to determine whether a significant difference exists between total ankle arthroplasty (TAA) and ankle arthrodesis (AA) in terms of clinical scores, patient satisfaction, reoperation rate and prevalence of complications for the treatment of end-stage ankle arthritis. Four prospective and six retrospective studies were included. No significant differences were found between TAA and AA in the American Orthopaedic Foot and Ankle Society ankle-hindfoot score, Short Form-36 physical and mental component summary scores, visual analogue scale for pain or patient satisfaction. TAA was associated with a significantly higher risk of reoperation and major surgical complications.

Practice Management

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The key to passing an electronic health records meaningful use audit is thorough documentation, according to eHealth Consulting’s Susan Clark. A health information management professional can help healthcare organizations prepare for a meaningful use audit and oversee information governance initiatives. “This is more of a compliance project than an IT project,” says Clark. As part of the U.S. Centers for Medicare and Medicaid Services program, covered entities must retain documentation for six years for each year of meaningful use. Organizations will also need to meet state documentation requirements if targeted for an audit. Before attesting for meaningful use, covered entities must conduct a security risk assessment and a Health Insurance Portability and Accountability Act remediation plan. Clark recommends doing a mock audit to learn more about an organization’s strengths and weaknesses. The criteria for selecting covered entities for an audit is unclear, but some issues are common indicators, such as entities having once attested for meaningful use but not having done so again.


Small, independent physician practices are having trouble implementing care coordination strategies that they claim strains their finances, stretches their workload and hinders their ability to deliver quality healthcare. Physicians are swamped with data entry tasks to meet regulatory requirements and are unhappy that after large investments in electronic health records (EHRs), they are unable to share patient data with outside hospitals or other providers using different EHRs. Physicians cite limited resources, a dearth of interoperable health IT systems and payment plans that do not offer enough money to pay for care coordination costs. The federal government has outlined an interoperable health IT infrastructure plan and says by 2024 the healthcare system will have many interoperable health IT products and services to support transparency and to provide access to real-time patient data. Because the care coordination model is accompanied by higher operational costs and less income to offset those expenses, practices are exposed to more risk. Virginia Commonwealth University Professor Peter Cunningham cites four elements needed for successful care coordination: an integrated delivery system, support by nonclinicians, financial incentives that cover the extra costs of care coordination and a higher degree of patient engagement through communication via email, mobile apps, Web portals and other technologies that can help patients better manage their health. Cunningham notes that among the barriers practices face is a lack of sufficient patients to enable economies of scale. Stricter guidelines from the U.S. Centers for Medicare and Medicaid Services and the purchase of small practices by large hospital systems are additional obstacles.


Moving data to the cloud is a sensible strategy for small physician practices, as it removes the need to maintain internal IT infrastructure and staff adequate in-house expertise to manage these resources. Still, it is vital to ask questions upfront about the practice's IT systems, the vendor and the vendor's performance before committing to a cloud migration. Such questions include whether the vendor has references from practices that are similar to your practice. A second question concerns what changes the practice will need to make to its internal network, necessitating research into the vendor's bandwidth requirements for each computer and guaranteeing that the practice has an Internet connection that can handle both the cloud vendor and other Internet uses. A third question characterizes how the migration will affect the practice's ability to share and integrate data with other applications, while a fourth question focuses on how good the vendor's security capabilities are, especially with ensuring HIPAA compliance. A fifth point to determine is the vendor's application update strategy and whether it assures compatibility with other interfaced software under certain conditions. A sixth question addresses the vendor's service-level agreement and escalation policy, and a final question concerns what would happen if the practice opts to leave the vendor, merge with another company or close business.

Health Policy and Reimbursement

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A coalition of 22 healthcare organizations is calling on Congress to lift an 18-year-old ban preventing the U.S. Department of Health and Human Services (HHS) from creating a national patient identifier. The Healthcare Information and Management Systems Society, the College of Healthcare Information Management Executives and the Blue Cross and Blue Shield Association were among the signatories of a joint letter to the House Appropriations Committee. The letter asks the committee to develop a coordinated strategy for more accurately matching patients to their health information. Providers currently use the probabilistic matching technique to match patients to their records using mathematical algorithms and demographic data. Critics of this technique say it risks patient safety and hinders efficient health information exchanges. The Health Insurance Portability and Accountability Act previously called for the adoption of a unique patient identifier, but HHS was cautioned by its health information technology advisory group to wait until after federal privacy legislation was passed.


The GOP Doctors Caucus has criticized the proposed rule for implementation of the Medicare Access and CHIP Reauthorization Act (MACRA) and is calling on the U.S. Centers for Medicare and Medicaid Services (CMS) to simplify its reporting system. The caucus’s October 6 letter to CMS focuses on the Merit-Based Incentive Payment System (MIPS), which would require practices to measure and monitor their performance on at least 22 measures. According to the group, MIPS will be successful only if its reporting and scoring systems are not overly burdensome and its quality feedback loop is short enough to allow physicians to make the necessary changes without penalty. Under the proposed rule, there would be a two-year lag between physician performance and financial consequences. The caucus also says the January 1 start date and duration of the MIPS performance reporting period is unrealistic; like several other medical societies, the group is calling for a 90-day reporting period. To avoid the continued consolidation of small practices, the caucus suggests lowering the patient minimum reporting thresholds and raising the low-volume threshold.


The American Medical Association (AMA) has released several online tools to help physicians navigate the impending payment and delivery changes under the Medicare Access and CHIP Reauthorization Act (MACRA). The resources include payment model evaluation, strategies for practice improvement and MACRA-focused podcasts. The AMA Payment Model Evaluator offers initial assessments so physicians and staff can determine how their practices will be impacted by MACRA. This interactive tool also provides guidance for participating in either the Merit-Incentive Payment System (MIPS) or Alternative Payment Models. On the AMA Steps Forward platform, practices can access a collection of practice improvement modules, including team-based care implementation and electronic health record selection.

Medicine, Drugs and Devices

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The number of people in the United States being treated for severe joint pain jumped from 10.5 million in 2002 to 14.6 million in 2014, according to research from the U.S. Centers for Disease Control and Prevention (CDC) published in the Morbidity and Mortality Weekly Report. This figure is expected to rise along with the number of arthritis cases, as more than a quarter of all adults with arthritis rate their joint pain as severe. Arthritis affected about 52.5 million adults from 2010 to 2012 and is projected to plague 78.4 million adults by 2040. Nearly 46 percent of disabled Americans and 52 percent of those unable to work cite severe joint pain. CDC researchers note acetaminophen and NSAID analgesics may relieve some pain, but they warn against prescribing opioid therapy for chronic pain.


Insulin prices are on the rise, but drugmakers are not benefiting from the price increases. Insulin makers are making the same amount or less than they did several years ago. However, the price increases are benefiting pharmacy-benefit managers who negotiate rebates and fees based on list prices. The payment system is said to encourage high list prices and secretive discounts. The system also provides bill payers lower costs, but uninsured patients and those with certain healthcare plans ultimately pay more. Meanwhile, the higher drug costs are driving health insurers and employers to require higher payments from patients.


Additional therapy is recommended for rheumatoid arthritis patients with inadequate response to first-line disease-modifying antirheumatic drugs (DMARDs), but one third of patients discontinue DMARDs because of intolerance and begin biologic monotherapy. Researchers reviewed 13 clinical trials evaluating the safety and efficacy of tocilizumab monotherapy and combination therapy in 6,679 RA patients. Compared with DMARD therapy, the odds of achieving remission were higher with both tocilizumab monotherapy (RR 3.95, 95 percent CI 2.23-7.00, P< 0.001) and tocilizumab combination therapy (RR 8.77, 95 percent CI 4.10-18.75, P< 0.001). The risk of adverse events was higher for both tocilizumab monotherapy (RR 1.08, 95 percent CI 1.01-1.15, P=0.03) and combination therapy (RR 1.12, 95 percent CI 1.06, 1.18, P<0.001) when compared with patients receiving DMARDs alone. The study was published in Arthritis Research & Therapy.