News From ACFAS

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A confluence of old and new, San Antonio is a city rich in history, bursting with culture and booming with modern attractions. Register for ACFAS 2020 to discover why San Antonio was ranked fifth in Money magazine’s list of 20 Best Places to Go in 2019.

Join us February 19-22 for another can’t-miss educational program—advanced clinical sessions, hands-on surgical workshops and award-winning research with this vibrant city as the backdrop. Experience San Antonio’s colorful culture, spectacular architecture and storied history. From the famed River Walk, to the Alamo, to delicious local cuisine and lively music, the city has plenty to offer everyone.

Come see for yourself! Visit acfas.org/sanantonio to register for ACFAS 2020 and experience this lively city.
Attention residency directors and faculty—the Residency Directors Forum returns in 2020 and focuses on best practices in resident education and learning. As the profession of foot and ankle surgery evolves, directors need to ensure that they are keeping up with the highest educational standards and best practices in teaching the new generation. This Forum explores multiple topics to assist with those goals.

The Forum, co-hosted by ACFAS and the AACPM Council of Teaching Hospitals (COTH), is set for Tuesday, February 18 in advance of ACFAS 2020 in San Antonio. This year’s topics include human resources management decisions, social media, CPME standards and compliance, financial considerations for on- and off-campus providers, and top malpractice issues. Finally, by popular request, attendees have an opportunity to hear updates on the CASPR/CRIP and clerkship processes, College news, PRR revisions and the CPME 320 re-write.

Up to two representatives per program are invited to attend as are College Deans. The Forum is complimentary and provides up to 3.0 Continuing Education Contact Hours (CECH). Interested in attending? Visit acfas.org to download the registration form. Need holiday gift ideas for your colleagues, friends or office staff? Head to the ACFAS Logo Store and get inspired!

The ACFAS Logo Store has shirts, jackets, pullovers and scrubs in a wide range of colors and sizes. Don’t know what size you need? Choose from a selection of drink wear, pens and other one-size-fits-all items.

Place your order by Monday, December 3 to ensure you receive your shipment before the holidays. Visit acfas.org/logostore now to shop the full collection of ACFAS-branded merchandise.

Foot and Ankle Surgery

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The study aimed to identify the possible role of imaging in the delayed diagnosis of posterior ankle impingement syndrome (PAIS) and identify key findings on imaging to suggest PAIS in pediatric and adolescent patients. Researchers reviewed imaging and data from 38 patients, 51 ankles, with an average age of 12.9 years and an average 18-month delay in diagnosis. Twenty-seven of the 38 patients had previously seen multiple medical providers and were misdiagnosed multiple times. Radiographs were reported normal in 34 of 47 ankles. For the 30 patients that had magnetic resonance imaging (MRI), 94 percent were found to have an os trigonum/Stieda process with varying rates of associated oseus edema, flexor hallucis longus tenosynovitis and edena in Kager's fat pad. Though individual findings were noted, the impression in 16 of the 32 MRI reports did not mention PAIS as the likely diagnosis. There was a significant difference in the MRI findings of ankle impingement in the patient population when compared to the control group. All 51 ankles had a PAIS diagnosis confirmed during arthroscopy. After surgery, at an average follow-up of 10.2 months, there was improvement of visual analogue scale pain and American Orthopaedic Foot & Ankle Society ankle-hindfoot scores. The study indicates that radiologic misinterpretation is a contributing factor to the delayed diagnosis of PAIS in young patients.


The study investigated the prevalence and risk factors of postsurgical foot complaints (PFCs) following spinal surgery by using a modified pain drawing (PD) instrument. The study included 853 consecutive patients who underwent decompression with or without fusion. PFCs were defined as sensory foot symptoms that were not clearly due to spinal pathology. Patients who complained of postoperative foot symptoms at more than two consecutive visits were assigned to the PFC group, and the remaining patients were assigned to the asymptomatic group. In total, 176 of the 853 patients had PFCs. The duration of preoperative leg pain was significantly longer in the PFC group than in the asymptomatic group, and the proportions of preoperative foot symptoms and sensory deficits on the leg were significantly greater in the PFC group. Regression analysis revealed two independent risk factors: the presence of preoperative foot symptoms and preoperative sensory deficits on the leg. The study indicates that the PD instrument can help reduce the incidence of PFCs if patients are informed that preoperatively existing foot symptoms and sensory deficits on the leg are significant risk factors for PFC development.


The study describes the role and outcomes of surgical correction with a talectomy procedure in patients presenting severe foot and ankle deformity. Researchers completed a review of 45 patients undergoing talectomy by a single surgeon, accounting for the cause of deformity, history of infection, body mass index and relevant comorbidities in each case. Outcome measures of interest were minor or major complications and limb functionality at final follow-up. Limb salvage occurred in 38 of 45 patients, and patients with an infection history had 89 percent lower odds of a functional limb at final follow-up. Six of seven patients who ultimately underwent amputation had a history of prior infection, and women had 8.25 times higher odds of having a functional limb compared with men. All 13 patients with major complications had neuropathy. The study indicates that patients with chronic lower extremity deformities can be successfully treated with a talectomy as part of the reconstructive procedure, though patients with a history of infection should be counseled on the possibility of requiring major amputation.

Practice Management

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Independent practices have more power than they realize when it comes to negotiating with major payers on reimbursement. Before rushing into a breakup, practices should start with a comprehensive, data-based analysis of what would happen if the payer contract were terminated. This includes studying market conditions through the lens of a payer and considering whether one can replace the lost revenue. While the goal is to create an objective analysis, it is also worth considering whether a bullying payer is worth the trouble, as fighting one can bring down office morale and productivity.

Practices should then build consensus among stakeholders, including the physicians and administrators responsible for making critical business decisions. A comprehensive plan should be in place before a practice takes any action in the payer relationship. Independent practices should also remember that, ultimately, payers don't want to lose them, as they are critical to maintaining payer networks and provide more value than consolidated health systems. In many cases, a termination notice can spark negotiation that ends up in a more agreeable contract and a better relationship between both parties.


According to a recent KLAS survey, which looked at the net electronic health record (EHR) experience score for 30,000 physicians from 33 different specialties, physician satisfaction with their tools is highly variable. For example, pathology physicians scored their EHRs an average of 24.3 on a minus 100-to-100 point scale, while neurosurgery physicians scored EHRs a 2.2. The key factor appeared to be the quality of initial training, as the physicians that responded well and showed high satisfaction noted robust initial EHR training for their specialty. Nonetheless, some specialties do not have needed functionality in their EHR even with training. Smaller specialty providers said that the size of the EHR does not match up with the size of the practice, while other providers noted that the EHR does not align with or support specialty-specific clinical workflows.


Revenue cycle management can be difficult for new doctors setting up their medical practice and it is rarely discussed during medical school or residency. In the face of increasing conglomeration, a transition to value-based care and an entire generation of physicians set to retire, private practices have the most to lose when it comes to revenue cycle management. Physicians are constantly told to renegotiate contracts, but the author believes they should instead consider the phrase "mindset training." This means taking a detailed look at every step in the revenue cycle between rendering service and receiving payment. Practices should also ensure their staff is constantly being retrained and cross-trained. Front-desk employees and other staff are critical to handling the administrative nuances in the revenue cycle.

Health Policy and Reimbursement

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The U.S. Centers for Medicare and Medicaid Services (CMS) has published its first annual update to the Medicaid and Children's Health Insurance Program (CHIP) Scorecard, which provides transparency around Medicaid and CHIP programs. CMS released its first Medicaid and CHIP Scorecard in June 2018. The fall 2019 updates are part of a wider three-pillared strategy to better balance federal oversight and state flexibility, ensuring fiscal integrity and promoting accountability for the quality of care provided to beneficiaries. The Scorecard includes measures in three areas: State Health System Performance; State Administrative Accountability; and Federal Administrative Accountability. CMS is strengthening the Scorecard with better usability and more information in the national context, including a variety of new measures.

New national context data points include annual enrollment by payer, enrollment in any type of managed care plan by state, waivers for Home & Community Based Services by state and substance use disorders Section 1115 Demonstrations by state. In addition, the Scorecard includes the first set of T-MSIS based per capita Medicaid expenditures across a subset of states. The site will provide more functionality by allowing users to sort measures by performance rate or alphabetical order and toggle between screens to view measures that have multi-component rates.


Seema Verma, administrator of the U.S. Centers for Medicare and Medicaid Services (CMS), detailed a proposed rule that she says would crack down on impermissible financing arrangements that do not support the direct needs of Medicaid beneficiaries. In a speech, Verma described a proliferation of payment arrangements "that mask or circumvent the rules where shady recycling schemes drive up taxpayer costs and pervert the system." For example, one scheme uses a loophole to tax managed care facilities 25 times higher for Medicaid business than for similar business, then uses the additional tax revenue to generate additional payments without a commiserate increase in state spending. CMS says that as a result of these schemes, Medicaid supplemental payments have grown from 9.4 percent of all Medicaid payments in 2010 to 17.5 percent in 2017.

In response, the administration is proposing a Medicaid Fiscal Accountability Rule that would provide new definitions for Medicaid "base" and "supplemental" payments. The proposed rule would create new requirements for states to report provider-level information on Medicaid supplemental payments. The rule would also require states to sunset supplemental payments and tax waivers after no more than three years, with the option to request renewal. Provider groups and safety net hospitals panned the proposed rule, which they say "oversteps" the goal of transparency with damaging policies that would undermine the financial stability of state Medicaid programs and erode state flexibility. Some say the rules would harm states' ability to handle situations that require expanded services, such as the opioid epidemic.


The American Hospital Association (AHA) is urging U.S. District Judge Rosemary Collyer to enforce her ruling site-neutral payments for doctor's visits. The U.S. Centers for Medicare and Medicaid Services (CMS) is pressing forward with the payment changes, even though Collyer ruled against the policy in September. The AHA is asking Collyer to enforce her previous ruling, while the CMS insists that her decision cannot apply to the 2020 rule and that the court does not have jurisdiction over the new rule until payments begin next year. The site-neutral payment policy would pay doctors the same amount for basic visits in outpatient facilities and regular doctors' offices. The CMS is still considering whether to appeal Judge Collyer's decision, and it has about a week to decide. In their original complaint, hospitals projected payment cuts of about $380 million this year and $760 million in 2020. The CMS estimated the 2020 changes will cut copays for people on Medicare and slash federal spending by $800 million in 2020.

Medicine, Drugs and Devices

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According to a recent data brief from the U.S. National Center for Health Statistics, about 25 percent of adults who had diagnosed diabetes asked their physician if there was a lower-cost medication they could try, even if things were working for them, and 13 percent had not taken their medication as prescribed because of the cost. More than a third of uninsured patients, 18 percent of those with Medicaid, and 14 percent of those with private insurance went without their medication due to cost. Multiple studies show that patients are less likely to continue drug therapy when more cost sharing is involved, and it isn't limited to diabetes but applies to birth control and the treatment of high cholesterol, high blood pressure, cancer and other chronic conditions as well.


Google and the Ascension healthcare system have partnered on an initiative to collect the personal medical data of tens of millions of Americans. Project Nightingale gathers information like laboratory results, doctor diagnoses and hospitalization records, comprising complete health histories, without informing patients or doctors. One source said at least 150 Google employees currently have access to much of the data on these patients, although the companies claim Project Nightingale complies with federal health statutes and has strong safeguards for patient data. Google is using the data to partly design new software, driven by advanced artificial intelligence and machine learning, that focuses on individuals, to suggest treatment changes. Google's ultimate goal is to develop an omnibus search tool for aggregating and hosting patient data, in one place; Ascension hopes to enhance patient care, mining data to find additional tests for patients or other ways of boosting revenue.


A study in JAMA Surgery suggests that when surgeons reduce the number of opioid analgesics they prescribe by more than 50 percent, their patient-satisfaction scores do not suffer. In the study, researchers examined patient satisfaction results for 11 surgeons during the periods before and after they were given education and prescribing guidelines, resulting in a considerable decline in the number and duration of opioid analgesics they prescribed. The researchers at the prescribing practices and patient satisfaction for 11 surgeons who performed a total of 996 surgeries from May to December 2015 and July 2016 to June 2017. They focused on partial mastectomies with or without lymph node removal, minimally invasive gallbladder removal and either open or minimally invasive hernia repair.

The study found that 90.2 percent of patients were prescribed opioid analgesics in the first period, which fell to 72.8 percent in the second period after clinicians were educated at their institution about opioid prescribing guidelines. Moreover, 10 of the 11 physicians reduced the average number of doses by 50 percent or more. Satisfaction ratings from patients averaged 9.7 out of a possible positive rating of 10 before the intervention, and afterward, the average score was 9.65.