News From ACFAS

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Profiles and position statements for the four candidates recommended by the Nominating Committee to fill three vacancies on the ACFAS Board of Directors are now available at acfas.org/nominations: Christopher D. Lotufo, DPM, FACFAS; Alan Ng, DPM, FACFAS; Ryan T. Scott, DPM, FACFAS; and Matthew Williams, DPM, FACFAS.

Two, three-year terms and one, two-year term will be filled by electronic voting conducted December 6-22. Members will also have the opportunity to vote on proposed bylaw changes. Watch your email for balloting details next week. Plan to spend Tuesday, February 18 at Residents’ Day designed to usher you into ACFAS as a peer and make the transition to decision-maker—from resident to doctor.

Networking opportunities with speakers will be available throughout the day – our seasoned professionals are eager to share their experiences and their “First and Worst” stories as they welcome residents to ACFAS and the exciting profession they’ve chosen. Walk away with helpful tips on everything from job search and interview prep, practice types and managing difficult cases. Participate in Q&A over lunch and end the day with an informal networking reception.

Visit acfas.org/sanantonio to register and see this year’s schedule, it is sure to fill up fast! Need another patient education resource? ACFAS Infographics are the perfect place to start!

Visit the ACFAS Marketing Toolbox and choose from several customized colorful graphics to help educate patients on various topics in foot and ankle. Topics include keeping feet safe at the gym, healthy holiday feet tips, preventing foot and ankle injuries and more. The infographics can be displayed in exam rooms, printed out for waiting rooms, posted on social media or your practice website or printed out as flyers to include with billing statements or handed out at community health events.

Visit the ACFAS Marketing Toolbox at acfas.org/marketing to access the full infographic library.

Foot and Ankle Surgery

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The abductor digiti minimi (ADM) muscle flap is used to treat small- to moderate-sized defects that have exposed bone, joint or tendons in the lateral malleolar area. This study looks at eight patients who were reconstructed with an ADM, which obliterated the dead space and provided a vascularized muscle over the debrided ankle joint. When it is needed, the flap is covered with a small split-thickness skin graft. In all cases, complete healing was achieved, and the muscle flap functioned well as a versatile and shock absorbent coverage without ulcer recurrence during the mean follow-up period of around two years. The findings suggest that using ADM muscle is a viable method of treatment for wounds with exposed bone or neurovascular structures in the lateral malleolar area. The ADM offers no donor site morbidity, good soft tissue, coverage and an effective healing process.


The study investigates the safety of managing isolated ankle fractures in an outpatient setting. Researchers queried the 2007 to 2014 Humana Administrative Claims database to identify patients undergoing open reduction internal fixation for unimalleolar, bimalleolar, or trimalleolar isolated closed ankle fractures. A total of 5,317 inpatient-treated and 6,941 outpatient-treated closed ankle fractures were included in the final cohort. Regression analyses were performed to report independent impact of outpatient-treated ankle fracture surgery on 90-day complications, readmission and emergency department visit rates. Patients with outpatient ankle fractures had statistically lower rates of pneumonia, myocardial infarction, acute renal failure, urinary tract infections and pressure ulcers than those with inpatient ankle fractures. Outpatient ankle fractures also had lower rates of 90-day readmissions and emergency department visits, and overall 90-day costs for outpatient ankle fractures were nearly $9,000 lower than costs for inpatient ankle fractures. The findings suggest that outpatient treatment of ankle fractures can be deemed safe and feasible in a select patient cohort.


The study aimed to predict patients who would or would not benefit from bunion surgery by using Patient-Reported Outcomes Measurement Information System (PROMIS) values to determine bunionectomy-specific thresholds. PROMIS physical function (PF), pain interference and depression assessments were prospectively collected, and 42 patients were included the study. Minimally clinically important differences (MCID), receiver operating characteristic (ROC) curves and area under the curve (AUC) analyses were performed to determine whether preoperative PROMIS scores predicted achieving MCID with 95 percent specificity or failing to achieve an MCID with 95 percent sensitivity. PROMIS PF demonstrated a significant AUC and likelihood ratio. The preoperative threshold score for failing to achieve MCID for PF was 49.6, which is nearly one standard deviation higher than previously published. This suggests that if a patient is hoping to improve PF, a patient with a preoperative t score under 49.6 may not benefit from surgery.

Practice Management

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The article lists five key features of successful quality collaboratives: routine communication, a shared mission, achievable timelines, efficient data exchanges and incentivized outcomes. Promoting an open dialogue and routine communication between care managers and provider relations means assigning and maintaining a consistent point-person who is well-versed in medical terminology, healthcare practices and value-based purchasing. While the ultimate shared mission is improving healthcare outcomes, there are many ways to achieve that, so it is important to establish a consensus between payers and providers on what paths and end-goals will have the most positive impact.

It is also important to establish realistic timelines that account for the details of connecting and setting up data transfer and reporting systems. Having a Health Insurance Portability and Accountability Act-compliant system with efficient import and expert functionalities can greatly contribute to the success of a quality collaborative. Incentivized outcomes are also critical in driving a results-driven culture and go beyond merely reporting measurable outcomes. Contract renewals are an ideal time to engage and incentivize health facilities in aligning with specific quality initiatives.


Attorney David Williams provides nine tips for responding to medical board complaints, the first of which is to get proper insurance for the event. A medical board complaint defense can present a heavy cost burden at a time when income is often disrupted. Physicians should be represented by experienced legal counsel and inform their insurance carriers, employers, partners and/or organization about the complaint. It is also important to respond to any board complaint in a complete and timely manner. Never destroy or conceal evidence and do not reveal evidence or answer questions without counsel. Do not make any statements that may be used against you and above all else, do not panic. It is important to have an asset protection plan in place before the complaint, as acting to protect your assets after the complaint is received can be considered a fraudulent conveyance.


The U.S. House of Representatives has voted to approve The Workplace Violence Prevention for Health Care and Social Services Act of 2019. The bill ensures that healthcare employers, including hospitals, take specific steps to prevent workplace violence and ensure the safety of patients and workers. It directs the U.S. Secretary of Labor to require these employers to develop and implement workplace violence prevention plans that are worker-driven and comprehensive. The bill now moves to the Senate for consideration.

Health Policy and Reimbursement

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A RAND Corp. study finds that creating a Medicare buy-in program for individuals between the ages of 50 and 64 would lower premiums for that age group but increase premiums for younger consumers on the individual market. In the base scenario, about six million people would move to Medicare from the individual markets. This buy-in model would serve as a continuation of the existing ACA structure and cater to a select group of consumers without access to employer-based coverage. Researchers estimate that in these conditions, an average 50-year-old buying into Medicare would save $2,500 compared to buying a gold-level plan on the insurance exchanges established by the Affordable Care Act (ACA), while a 60-year-old would save $8,000 per year for the same plan.

While most Medicare premium costs for older Americans would be $10,000 per year in 2022 under a buy-in program, premiums would rise between three and 9 percent for younger consumers. Researchers say that older individuals constitute a sizable portion of the insurance exchanges, which would suffer if a Medicare buy-in was available. Additionally, researchers note that under this scenario, hospital executives would have to contend with extended Medicare reimbursement rates for part of their patient populations. The study's findings did not have a significant impact on the total number of people with insurance, as approximately 246 million people under the age of 65 would be insured in a Medicare buy-in scenario.


The U.S. Centers for Medicare and Medicaid Services reports that the improper payment rate for Medicare fee-for-service declined $7 billion from fiscal years 2017-2019 to $28.9 billion, its lowest level since 2010. In 2018 alone, the Medicare fee-for-service improper payment rate fell from 8.12 percent to 7.25 percent. Corrective actions in home health led to a $5.32 billion decrease in improper payments from 2016 to 2019, while durable medical equipment, prosthetics, orthotics and supplies fell about $1.29 billion in the same period. Other Medicare Part B services saw a $1.82 billion decrease in estimated improper payments over the last year.


According to an eHealth analysis of consumer behavior and average costs from the first half of the open enrollment period, 83 percent of Medicare consumers are selecting Medicare Advantage plans with $0 premiums, up from 76 percent last year. Data from between October 15 and November 8 found that $5.47 is the average monthly premium for Medicare Advantage plans selected by those enrolling in coverage, down 43 percent from the same period last year. Monthly Part D premiums are down 15 percent year-over-year to $19.76, while Medicare Supplement premiums increased by 8 percent to $157.48. According to the U.S. Centers for Medicare and Medicaid Services, the average monthly premium for 2020 Medicare Advantage plans available nationwide is $23, down 14 percent from 2019.

Ninety percent of all Medicare beneficiaries in 46 states now have access to Medicare Advantage plans with a $0 monthly premium. A new national poll conducted by Morning Consult shows that 94 percent of beneficiaries said they were satisfied with Medicare Advantage, topping the previous best of 92 percent. The poll also found that 62 percent of seniors call Medicare Advantage a "better choice" than traditional Medicare.

Medicine, Drugs and Devices

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The U.S. Centers for Disease Control and Prevention (CDC) has released updated guidance to help optimize antibiotic use in U.S. hospitals. The new version of CDC's Core Elements of Hospital Stewardship Programs emphasizes the need for more commitment from hospital leadership, prioritizes specific antibiotic stewardship programs (ASPs) and calls for more efforts to educate patients about antibiotic use. The 2014 Core Elements laid out seven components associated with successful ASPs: hospital leadership commitment, accountability, drug expertise, action, tracking, reporting and education. The 2019 update retains the original Core Elements but provides more specifics and detail on the individual components.


Record numbers of generic drugs have received U.S. approval in recent years, but a Wall Street Journal review found that many of the lower-price medicines have not hit the market, forcing many patients to take high-price medicines. Pharmaceutical industry officials and other researchers say delays in releasing generic drugs sometimes stem from businesses changing their strategies, but they mostly blame protracted legal tie-ups, such as brand-name drugmakers aggressively defending their products by filing additional patents and suing generic-drug companies. Since 2016, the U.S. Food and Drug Administration has approved 2,492 generic versions of 617 brand name drugs, according to Iqvia. The number of generic approvals has set records each of the past three fiscal years, but less than two-thirds of generic drugs approved between 2016 and 2018, or 1,249 of the copies, were launched into the market, according to Iqvia.

Through June, just 30 percent—or 134—of the 442 approvals this year have gone on sale. Approximately 40 percent of last year's 689 approvals have not been launched. The breakdown is especially acute for the most expensive medicines, biologic drugs for ailments such as cancer and rheumatoid arthritis that often list for hundreds of thousands of dollars a year. Biosimilars are also being launched less frequently. Only 11 products are available commercially, despite more than two dozen approvals since 2015.


University Hospitals Birmingham (UHB) in the U.K. conducted a live demonstration, in which a doctor at a hospital workstation remotely diagnosed a patient in an ambulance two miles away in real time over a 5G network, via camera. The clinician used a joystick to manipulate the hand of the paramedic in the ambulance, who wore a glove that vibrated, in response to joystick signals. Both doctor and paramedic also wore virtual reality headsets, so the doctor could see live videos and close-up images from inside the vehicle. UHB's Tom Clutton-Block said the success of this service hinges on ensuring the technology is safe to use and on patient buy-in. Said Clutton-Block, "This will only work if patients want it to work. But I think people are beginning to accept that we need to move forward with healthcare."