News From ACFAS

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In a win for foot and ankle surgeons nationwide, the U.S. Centers for Medicare and Medicaid Services’ (CMS) newly released 2019 Medicare Physician Fee Schedule final rule does not include podiatry-specific codes for Evaluation and Management (E/M) services.

CMS originally proposed that podiatrists be required to use different E/M codes than all other Medicare physicians and to receive a lower reimbursement rate. This could have had a negative impact on access to care, outcomes and cost of care for Medicare beneficiaries.

Thank you to all ACFAS members who submitted their comments on this issue to CMS back in September. This could not have happened without you! It’s the birthplace of jazz, the home of Creole cuisine and the place where French, Spanish, Carribbean and African cultural influences collide in a brilliant explosion of flavors, emotions and sounds. It’s New Orleans, and it’s ready to welcome you to ACFAS 2019, February 14–17, 2019 at the Ernest N. Morial Convention Center.

Register now for this unforgettable event and experience not only the rich history and unmatched southern hospitality that New Orleans is known for, but also everything you have come to expect from the Annual Scientific Conference. Advanced clinical sessions, hands-on surgical workshops, state-of-the-art exhibits and award-winning research await you.

Come down a day early on February 13, 2019 for special preconference workshops and our innaugural Residents’ Day to get a head start on the excitement.

Take advantage of special early bird pricing when you register at acfas.org/neworleans before December 12, 2018. See you in New Orleans! If you are a Fellow or Associate member and have not already renewed your ACFAS membership for the 2019 calendar year, you will receive a dues reminder in the mail. You can pay your dues online now or via mail or fax once you receive your reminder. Payment is due by December 31, 2018.

Visit the Member Center at acfas.org to learn more about the many benefits your ACFAS membership provides. If you have suffered personal or financial challenges as a result of Hurricane Michael and cannot make your ACFAS dues renewal payment at this time, please let us know. We can assist you by waiving your 2019 dues.

To request a dues waiver, contact Terry Wilkinson, ACFAS membership manager, at (773) 444-1301 or membership@acfas.org.

We are thinking of you and hope you are staying strong as you get your life—and profession—back to normal.

Foot and Ankle Surgery

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A study was conducted to compare the radiographic and clinical results of moderate and severe hallux valgus treated by extended distal chevron osteotomy (EDCO) and distal soft-tissue release.

The team rated the utility of EDCO for the treatment of a moderate hallux valgus cohort consisting of 36 patients and 46 feet, and a severe hallux valgus cohort of 36 patients and 42 feet. Radiologic outcomes were assessed based on the preoperative and three-year follow-up x-rays.

The mean postoperative intermetatarsal angle, hallux valgus angle, tibial sesamoid position and relative metatarsal bone length differed significantly versus the preoperative values for both the moderate and severe groups. At three-year follow-up, intergroup differences were seen in the mean postoperative intermetatarsal angle, hallux valgus angle and tibial sesamoid position, yet mean radiographic results were within the normal range for both cohorts.

No intergroup differences were observed for either the first metatarsal bone length or shortening, nor was any significant difference in the Manchester-Oxford Foot Questionnaire apparent between the cohorts at three-year follow-up. In terms of satisfaction analysis, 82.6 percent of the moderate group and 81.0 percent of the severe group had good to excellent results.


A study was conducted to compare the outcomes of patients with chronic ankle instability who underwent augmented direct anatomical repair via a Broström-Gould procedure with those who underwent lateral ligament reconstruction using a split peroneus brevis tendon.

No major complications were observed. The mean overall AOFAS, Karlsson-Peterson and Tegner scores significantly rose at follow-up versus preoperatory status, although no statistically significant differences concerning these factors were observed between the Broström-Gould and lateral tenodesis cohorts. Sagittal ROM was full in 36 out of 40 patients, with four subjects in Group B experiencing 5 degrees dorsiflexion limitation compared to the contralateral side. Patients treated with lateral tenodesis noted a statistically significant reduction in the values of radiographic anterior talar translation versus those in the Broström-Gould group.

Augmented direct anatomical repair and lateral tenodesis were found to provide satisfying long-term outcomes in terms of subjective and objective parameters up to 15 years post surgery in patients with chronic ankle instability without leading to significant arthritic changes. Lateral tenodesis appeared to improve more effectively restoration of laxity; the reduced ROM reported in 20 percent of patients did not considerably affect the overall functional outcome.


A meta-analysis was conducted to compare surgical and nonsurgical treatment methods for repair of acute rupture of the Achilles tendon, characterizing the rerupture rate, incidence of complications other than rerupture, functional outcomes and the proportion of patients returning to previous levels of sporting activities, while also investigating disparities in rerupture rate if established early functional rehabilitation protocols were followed.

Ten randomized clinical trials with a total of 934 randomized patients were included. Patients in the nonsurgical group experienced more reruptures than patients in the surgical cohort, but the rerupture rates were equivalent in the nonsurgical group and the surgical group if an early range of motion exercises protocol was conducted. A reduced occurrence of complications excluding rerupture was observed in nonsurgical patients, but the surgical group had better functional outcomes when assessed by two different jump tests and one muscular endurance test. Neither cohort had a significant difference in the proportion of patients returning to previous levels of sporting activities.

Practice Management

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A session at Psych Congress 2018 educated healthcare professionals about the risk of burnout in the healthcare setting, contributing factors, remedial strategies and tools for regular assessment to prevent future burnout. Identifying areas of control, creating meaning and purpose in life, staying connected to others, refreshing skills and practicing self-care were highlighted as coping strategies.

Physicians see the highest rates of emotional exhaustion and burnout in their mid-career stage, while those in their early career exhibit the highest rates of work/home conflict. Excessive bureaucratic tasks, spending too much time at work, sleep deprivation, work-life imbalance and lack of control over work environment are cited as common burnout causes. Furthermore, female physicians are 60 percent more likely to report burnout while also dealing with increased vulnerability to sexual harassment and assuming most domestic responsibilities at home.

Suggestive preventive strategies include mentorship and reinforcement of growth and achievement. Also recommended is administering the Maslach Burnout Inventory Human Services Survey for Medical Personnel and the WHO-5 Wellness Scale for evaluating burnout and resiliency.


Physician practices are eager to find ways to save their business money, but arriving at the right formula can be tough. Michael O'Connell, the senior vice president of operations at Stanford Health Care in Newark, California, interviewed medical practice leaders across the country and compiled the best cost-saving ideas.

One tactic is to implement an electronic medical record (EMR) vendor's cloud billing. By doing this, Pioneer Physicians Network, Inc., in Akron, Ohio, was able to eliminate service hosting fees, provider licenses, support and maintenance fees, saving $125,000 annually. Another option is to reformulate operating room packs. Unused surgical and anesthesia supplies must be either discarded or resterilized, creating much waste. A health system and medical group reformulated packs for a hospital and ambulatory surgery center operating rooms. By consolidating 60 packs down to less than 20, the organization saved more than $200,000.

Practices can also save money by creating an expired supply product board. The Mayo Clinic in Rochester, Minnesota, created a board to post supplies nearing their expiration date so that doctors were aware they should use those products first. It reduced the cost of expiring products from 10 percent to 12 percent of their total expenditure. Similarly, by logging unused and soon-to-be-expired medications and sharing the information with other locations via email, an oncology practice saved over $100,000.

Other efforts also have the potential to save practices thousands of dollars in savings. These include negotiating new contracts, consolidating medical and general office supply vendors, improving energy efficiency, reducing red bag waste, restructuring professional liability insurance and having employees sign a sustainability pledge to reduce waste in the organization.


The best way doctors can adapt to patient feedback online is to actively participate in the online review process, says Thomas Lee, MD, chief medical officer of Indiana-based Press Ganey Associates and a practicing primary care physician. If physicians do not post reviews on their websites, someone else will post reviews that skew negative. Another reason for physicians to post their reviews online is good marketing, he says. Google and other search engines prioritize the websites that have more data, so if you take control of online reviews, your website gets pulled to the top.

However, the best reason to post reviews online is it makes physicians better. "It's a vivid reminder that every interaction with a patient is a high-stakes interaction," Lee says. "All you have to do is be the kind of clinician who patients are hoping for—and the kind of clinician you want to be. Transparency puts the focus on the future. It nudges physicians to be reliably at their best."

Regarding negative reviews, Lee warns that if no negative feedback is posted, it will not look credible. When there is negative patient feedback, the best response for physicians is to learn from the experience.

Health Policy and Reimbursement

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The Affordable Care Act's (ACA) insurance marketplaces are opening for a sixth year with more stable health plan choices and rates. This enrollment season—which lasts six weeks, half as long as it used to be—will be a test of recent Republican efforts to undercut parts of the law. This is the first enrollment since Congress removed the law's penalty for people who fail to carry health insurance. With that federal fine slated to disappear in January, this year's marketplaces will provide evidence for a longstanding debate: How much of the country's gains in health coverage have happened because of the law's insurance mandate, and will coverage decline without it?

This enrollment season will also be the first since the Trump administration has been taking steps to circumvent the ACA's insurance requirements, making it easier for individuals to purchase two inexpensive types of insurance that cover less care and lack certain popular consumer protections. Administration officials argue that this alternative coverage, short-term health plans and "association health plans," expands affordable options, while critics say it will confuse consumers, causing some to buy less coverage than they need. In a major switch, federal health officials recently announced they are open to states using the ACA's subsidies to help people afford insurance premiums for these health plans, but states have not had time to get permission for this enrollment period.

Another big change this year is the amount of neutral guidance insurance shoppers will be able to find. The ACA created grants for grassroots organizations known as navigators in the states using the federal exchange, and the Trump administration has curbed funding for such groups from roughly $63 million in 2016 to $10 million this year.


The U.S. Department of Health and Human Services (HHS) has released a notice announcing its intention to implement a long-delayed rule to set price caps and monetary penalties in the 340B program rule on January 1, 2019, seven months earlier than the previously announced July 1 start date. Earlier delays in implementation were needed to ensure proper deployment and full investigation of possible alternatives or supplemental regulations, according to the Health Resources and Services Administration (HRSA).

The most recent delay was due in part to HHS's push to prioritize the rising cost of drugs, and officials were worried that implementing the rule could affect actions taken under the "American Patients First" plan. The January 1 rescheduling was made because the HRSA "determined that the finalization of the 340B ceiling price and civil monetary penalty rule will not interfere with the department's development of these comprehensive policies."


The U.S. Centers for Medicare and Medicaid Services (CMS) has proposed a rule that would allow Medicare Advantage (MA) plans to offer government-funded telehealth services to older adults beginning in 2020. Under the proposed rule, MA plans would be able to offer telehealth services to all plan members, regardless of where they live, and would have greater flexibility in how they pay for telehealth benefits. It would also allow MA members to receive telehealth at home.

The traditional fee-for-service Medicare program restricts telehealth services to certain sites in rural areas. MA plans can currently offer telehealth as a supplemental benefit, but the proposed rule would allow as part of the basic benefits package telehealth services beyond what is available in the traditional Medicare program. The change means telehealth benefits would be accounted for in CMS's payments to Advantage plans.

Beyond the telehealth changes, the proposed rule would consolidate the appeals processes across Medicare and Medicaid to make it easier for enrollees in certain dual-eligible special needs plans to navigate the system. It would also require health plans to more seamlessly integrate benefits across the two programs for more coordinated care, and would update the methodology for calculating MA plan star ratings to improve stability and predictability for plans and adjust how the ratings are set during uncontrollable events, such as hurricanes.

Medicine, Drugs and Devices

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The U.S. Centers for Disease Control and Prevention (CDC) offers a variety of tools and information to help providers better understand the opioid crisis and the role they can play in addressing the problem.

Earlier this year, CDC released Guideline for Prescribing Opioids for Chronic Pain, which gives recommendations for prescribing opioids for patients age 18 or older mostly in the primary care setting and offers clinical reminders providers can use when making care decisions. The guideline explains:

• How to determine when to initiate or continue opioids for chronic pain
• Opioid selection, dosage, duration, follow-up and discontinuation
• How to assess risk and address harms of opioid use

Compared to previous guidelines, the dosage recommendations for exercising caution are lower, safety precautions now apply to all patients rather than just "high risk patients" and recommendations are more specific on monitoring and discontinuing opioids when risks and harms outweigh benefits.

For more information, visit cdc.gov.


The medical device sector is lobbying for revisions to the federal anti-kickback law so that companies can fully participate in the migration from fee-for-service medicine to value-based care. The industry wants "safe harbors" to prevent medical device makers from breaking healthcare fraud laws that impose penalties if individuals knowingly pay for or induce a sale or referral. Such rules are applicable to medical care providers, insurers and other firms whose services, products and devices are covered by federal health insurance.

"Device makers cannot currently enter into certain value-based partnerships because federal rules prevent them from providing any incentives unless they fall within safe harbor or a waiver," said Advanced Medical Technology Association (AdvaMed) CEO Scott Whitaker. The device industry's push comes as insurers pay half or more of their medical claims via value-based payment models.

AdvaMed has proposed three "value-based safe harbors." The first is a value-based pricing arrangements safe harbor allowing for price adjustments based on whether or not specified clinical and/or cost outcome targets were realized. The second is a value-based warranties safe harbor permitting manufacturers to make clinical and/or cost outcome assurances and to provide an appropriate remedy where such results are not achieved. The final one is a value-based risk-sharing arrangements safe harbor allowing for risk-sharing arrangements on outcomes-based terms among more diverse participants—such as payers, data aggregators or multiple device companies—in a scheme separate from the sale of products reimbursed by a federal healthcare program.


The Congressional Diabetes Caucus, a bipartisan group of more than 290 lawmakers, has issued a report aimed at reducing the price of insulin. Their proposals include a measure requiring drug companies to disclose how they set their prices and legislation punishing drug makers that cannot prove a new version of insulin is more effective than an older one.

"This country must get the skyrocketing cost of insulin under control," said Rep. Diana DeGette (D-Colo.). The average list price for insulin almost tripled between 2002 and 2013, according to the American Diabetes Association. More than 30 million Americans have some type of diabetes. DeGette, who led the effort, said the report was a bipartisan initiative. "This isn't a red or blue, Republican or Democratic issue, it's [a] life or death issue for millions of Americans," she said.

A group as large and bipartisan as the Diabetes Caucus addressing highly charged drug pricing topics could spell trouble for drug makers. The report also highlights Capitol Hill's growing interest in the issue of high insulin prices, including two recent committee hearings in which insulin was a central theme. Meanwhile, more modest ideas proposed in the report include directing the U.S. Food and Drug Administration to expedite approval of biosimilar insulins and convening a discussion group on developing a patient-centric appeals process for changes to insurance formularies.