News From ACFAS

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Associate and Fellow members—dues reminders for the 2017 calendar year of membership have been mailed to you. Pay your dues online now or via mail or fax once you receive your reminder. Payment is due by December 31, 2016.

Visit the Member Center to connect with ACFAS members and to learn more about the many benefits your membership provides. Don't miss your chance to serve as an ACFAS committee member, a Clinical Consensus Statement panelist or Scientific Literature reviewer. If you would like to volunteer with ACFAS, visit acfas.org/volunteer to apply. ACFAS must receive all applications by November 23, 2016. All DPMs are invited to submit a clinical case for presentation at the 75^th Anniversary Scientific Conference at The Mirage in Las Vegas, February 27–March 2. Cases should highlight an interesting teaching point in foot and ankle surgery and should facilitate discussion of correct diagnosis. We have found many a future speaker in this session, so submit your case soon.

Download and complete the Doctors’ Lounge Case Form from acfas.org/vegas and email it to Marilyn Wallace by December 30, 2016. ACFAS will notify you if your case is selected for presentation. Have you looked at the clinical practice improvement activities in which you can participate? Eligible physicians must gain 40 points in improvement activities to receive the full credit in this performance category. Improvement activities include expanded practice access, population management, care coordination, beneficiary engagement, practice safety and practice assessment and behavioral and mental health.

Visit cms.gov for a full list of activity descriptions.

Foot and Ankle Surgery

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A study aimed to compare the clinical and radiologic outcomes between an all-inside arthroscropic modified Brostrom operation (MBO) and an open MBO. Forty-eight patients with lateral ankle instability were included in the study; all-inside arthroscopic MBO was performed on 25 patients and open MBO was performed on 23 patients. Clinical outcomes were evaluated using the American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score, visual analog scale (VAS) score and Karlsson score. Anterior talar translation and talar tilt were used to assess radiologic outcomes. At the one-year follow-up, the AOFAS, VAS and Karlsson scores improved significantly in both groups. There were no differences in the AOFAS, VAS or Karllson scores, anterior talar translation or talar tilt between the two groups.


Researchers examined whether perforator flaps can accommodate growth in children following foot and ankle reconstruction. The study included 28 children under 14 years of age who had foot and ankle soft tissue defects. Researchers compared flap/foot dimensions using the photo-anthropometric technique defined as proportionality index (PI) and compared the PI ratio of flap to foot area at intervals (ΔPI). There was a positive correlation in Pearson’s correlation analysis between flap and foot after growth, indicating flap expansion as the foot grows. The mean intraoperative and postoperative PI was 0.3 and 0.2475, respectively. No patients experienced growth disturbance or functional impairment. No correlation was found between ΔPI and motor power grade or range of motion.


A study aimed to evaluate the arthrodesis of the first metatarsophalangeal joint using an oblique interfragmentary lag screw and dorsal plate as a treatment for hallux rigidus. Researchers performed a retrospective review of 60 patients who had undergone arthrodesis with an average follow-up of 47.3 months. A fusion rate of 93.3 percent was recorded, and 6.7 percent of cases resulted in painless pseudoarthrosis that required no additional surgery. Pedobarographic measurements demonstrated first ray weightbearing function restoration. The American Orthopaedic Foot and Ankle Society Hallux Metatarsophalangeal-Interphalangeal Scale increased from 40.9 to 79.3. More than 71 percent of patients were very satisfied with postoperative outcomes.

Practice Management

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Medical practice acquisitions can be a source of contention between the two parties, so practices should plan ahead for the logistical and emotional challenges. Before agreeing to any acquisition, practices should negotiate details regarding billing, recruitment and compensation and ensure the mission and values of the two organizations are aligned. Practices being acquired should make sure no lawsuits or other legal actions are pending against the other entity. The negotiation process will require compromise, and practices should carefully consider the long-term consequences of seemingly beneficial arrangements that may create challenges later on. Before the acquisition is finalized, administrators should begin to work on reconciling practice management systems, electronic health records and other systems. Opposition to the acquisition can come from any direction, including patients, vendors and healthcare workers, and physicians in particular may struggle to change the way they practice. Administrators should address these concerns in advance.


As health insurance deductibles continue to rise, collecting payments from patients can become costly and time intensive for practices. Thirty percent to 50 percent of the financial obligation now lies with the patient, whose deductible can be as much as $6,000. Findings from ACA International show that non-hospital practices have just a 21.8 percent collection success rate among patients. Healthcare consumers are less likely to pay bills promptly if they only receive paper statements a few times per month or if they do not fully understand the charges. The Medical Group Management Association states that as many as 3.4 paper bills must be issued before any payment is received. By switching to online statements, the payment cycle could be cut to as little as one-tenth the time experienced with paper bills. According to Deloitte’s Survey of U.S. Healthcare Consumers, 70 percent of respondents would prefer to pay their healthcare bills in digital form. Practices should also seek a billing solution that aligns charges with an Explanation of Benefits and eliminates confusion as to what is being charged, what has been paid and what remains to be paid.


Using a free wi-fi service in airports, hotel rooms and other public places may be convenient, but unsecured wireless networks can put protected health information (PHI) at risk and threaten the security of a practice’s computer network. Without taking precautions, a third party could access a mobile device connected to a public wi-fi, potentially allowing them to view and download sensitive PHI. Healthcare organizations can establish a secure connection if they have an electronic health records system that is accessed through a Citrix app, but that may not be possible for a small practice. The U.S. Department of Health and Human Services recommends using a virtual private network because it encrypts information that is sent and received. Additionally, all sensitive data on mobile devices should be encrypted.

Health Policy and Reimbursement

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The U.S. Centers for Medicare and Medicaid Services (CMS) released the final version of its Medicare fee schedule for 2017. CMS reaffirmed its plan to have surgeons code their postoperative work during a global billing period but has significantly relaxed the requirements. In the proposed fee schedule, surgeons would use eight new “G” billing codes to track their work in 10-minute increments during surgical packages spanning either 10 days or 90 days. After receiving pushback from surgical societies, CMS reduced the burden on surgeons by limiting the reporting of postoperative visits to high-volume and high-cost procedures and requiring only surgeons in practices of 10 or more clinicians to report postoperative visits. CMS has pushed back the start date for reporting from January 1 to July 1 next year. The new fee schedule also expands payment for diabetes prevention programs and the treatment of patients with chronic illnesses.


The U.S. Federal Trade Commission (FTC) has won a handful of appeals to block anti-competitive healthcare consolidations despite lacking the resources and political support needed to effectively police the recent surge of mergers. The antitrust cases pursued by FTC represent a small percentage of mergers and are chosen to deliver wins that may deter other providers from pursuing similar mergers, according to Tim Greaney, co-director of the Center for Health Law Studies at Saint Louis University School of Law. FTC has been focusing exclusively on stopping consolidations of healthcare organizations that share the same geographic market, but the agency has not addressed the impacts of vertical mergers, which have increased 86 percent in the last three years. To weaken the incentives for consolidation, the Medicare Payment Advisory Commission is considering taking aim at the higher payments hospital-owned facilities receive for the same services delivered in other settings.


The U.S. Centers for Medicare and Medicaid Services (CMS) have announced a delay in enforcement of new Medicare Part D prescriber enrollment requirements until January 1, 2019. The rule requires doctors to enroll in Medicare to prescribe drugs that are paid for by Part D plans. CMS issued the rule to address the number of unqualified individuals prescribing Part D drugs; in 2016, as many as 250,000 unenrolled providers wrote prescriptions for 5.25 million beneficiaries. If a provider is not enrolled by the enforcement deadline, their patients will be notified that Part D prescriptions will not be covered. The enforcement date has been pushed back at least four times since the initiative was finalized in March 2014. CMS has implied that the delays have been partly because of concerns that providers may not know about the requirements.

Medicine, Drugs and Devices

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A recent study presented at the annual IDWeek meeting evaluated the risk of sepsis in discharged patients following exposure to antibiotics in the hospital. Researchers obtained data on 12.7 million hospital stays in 516 facilities. Antibiotics determined to be high risk included later-generation cephalosporins, fluoroquinolones, lincosamides, beta-lactam/beta-lactamase inhibitor combinations, oral vancomycin and carbapenems. Earlier cephalosporins, tetracycline and sulfa drugs were defined as low-risk, while control antibiotics, such as penicillin, were thought to have limited risks. Patients received high-risk drugs in 28 percent of the stays, low-risk drugs in 24 percent of stays and no-risk drugs in 5 percent of stays. Compared with no antibiotics, the odds ratio for sepsis was 1.78 after high-risk drugs, 1.10 after low-risk drugs and 1.22 after no-risk drugs. Regardless of drug type, patients treated for more than 14 days doubled their risk of sepsis.


Proposition 61, which would prohibit state agencies from buying prescriptions drugs at prices higher than those paid by the Department of Veterans Affairs, will be on the ballot in California November 8. The AIDS Healthcare Foundation and the California Nurses Association, the leading supporters of the initiative to restrict drug prices, argue that drugmakers are overcharging consumers and taxpayers. More than 30 drug companies, including Merck & Co. and Pfizer Inc., have contributed $109 million to defeat the initiative, which they say could lead to higher costs by invalidating current discounts. A poll of likely California voters found that 50 percent are in favor of Proposition 61 and 16% are against. About 34 percent are undecided.


Drug manufacturers are increasingly turning cheap generic drugs into expensive medicines. For example, a pack of Treximet, a combination of sumatriptan and naproxen that is intended to treat migraines, could cost $750 if it is not covered by an insurer. In contrast, sumatriptan and naproxen are two generic drugs that can be taken for migraines in the form of separate pills. Industry experts say that the drugs are an example of inefficiencies within the healthcare system. An added problem is that patients and doctors often do not know that cheaper alternatives are available. Further, the combination drugs may use different doses than cheaper alternatives.