News From ACFAS

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Don't miss your chance to serve as an ACFAS committee member, a Clinical Consensus Statement panelist or Scientific Literature reviewer for 2018. If you would like to volunteer with ACFAS, visit acfas.org/volunteer to apply. ACFAS must receive all applications by Tuesday, December 12, 2017. Fellow and Associate members, if you have not done so already, please pay your dues by December 31 at acfas.org/paymydues or by mail or fax so your ACFAS membership does not lapse and you do not incur a late fee.

Dues reminders for 2018 were both mailed and emailed to you. If you have any questions or require another statement, contact Terry Wilkinson in the Membership Department. No need to put your year-end practice marketing efforts on ice. Download the latest issue of FootNotes from the ACFAS Marketing Toolbox and use it to educate your patients while increasing your practice’s reach and visibility.

Articles in this issue include:

• Keep Boot Heels Low This Winter to Prevent Foot and Ankle Injuries
• Cold Weather Tips for Diabetic Foot Care
• Low Vitamin D Levels Can Increase Your Risk of Foot Fractures

Customize page 2 of FootNotes with your office contact information then distribute copies to your patients or post FootNotes to your website and social media pages.

Visit acfas.org/marketing for many other free resources, including infographics, PowerPoint presentations and healthcare provider referral tools, to promote your practice any time of year. The Residency Directors Forum is returning in 2018 and will be jam-packed with information to assist in the overall growth of every residency program.

This year’s Forum, held in advance of ACFAS 2018 on Wednesday, March 21 from 1:30–5:30pm and cohosted by the Council of Teaching Hospitals (COTH), will provide updates from COTH, AACPM, CPME and PRR.

Through direct interaction with the invited panelists, you will be provided with the tools needed to make a positive impact on residency education and training at your institution.

Not-to-be missed discussions include:

• accessing GME funding
• the DPM Mentors Network
• social media paths and pitfalls
• admission benchmarks of students and how this affects incoming residents

Residency program codirectors, faculty and chief residents are invited to attend, with up to two attendees per program. Chief residents must attend alongside their program director. School deans are also invited. Registration closes on March 2, 2018. Space is limited, so don’t delay!

Visit acfas.org/rdc for the complete schedule and registration form. For this month's poll, we would like to know which of the ACFAS Member Benefit Partners you use most often in your practice. Share your input in the new poll at right, and visit acfas.org for real-time results throughout December.

Foot and Ankle Surgery

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A study was conducted to assess the hindfoot alignment measured on standing HAV radiographs (Saltzman view) compared with nonweightbearing coronal magnetic resonance imaging (MRI). The apparent moment arm was measured with both modalities in 50 consecutive patients, with evaluation conducted independently by three readers using analogous reference points for both methods. Positive values were assigned when the deepest point of the calcaneus was lateral to the tibial axis and labeled as valgus, negative values as varus. The means of apparent moment arms of the three readers were more than 2.0 mm, more than 1.5 mm and less than 1.4 mm on HAV radiographs, and more than 4.6 mm, more than 6.3 mm and more than 5.4 mm on MRI. Bland-Altman analysis observed a systematic bias for all three readers, corresponding to an overestimation of measurements with MRI. The intertechnique correlation was determined to be moderate to high. The Pearson coefficients for the readers were 0.75, 0.64 and 0.65. The interobserver agreement among the readers was 0.72, 0.77 and 0.68 for HAV, MRI and both protocols combined, respectively.


A study was conducted to explain clarified foot pressure patterns and hindfoot deformities in individuals with advanced knee osteoarthritis (OA) and to analyze their associations with foot pain. Sixty-four persons with unilateral knee OA who underwent total knee arthroplasty (TKA) were split into groups with no foot pain, foot pain resolved following TKA and foot pain remaining following TKA. Seniors without pain or deformity in either knee served as controls. Navicular height ratio of the medial longitudinal arch, leg-heel angle and partial foot pressure as the percentage of body weight (%PFP) were estimated, and %PFPs of the medial and lateral heel regions prior to TKA were significantly lower for the no foot pain group than for controls. Twelve months after TKA, %PFP improved significantly. In the foot pain resolved group, prior to TKA, the leg-heel angle was significantly higher, and %PFPs of the medial and lateral heel regions and navicular height ratio before TKA were significantly lower than those of controls. One year following TKA, all parameters improved significantly. In the foot pain remaining group, similar abnormalities were seen before TKA, but significant improvement was only observed for %PFP of the medial heel region a year after TKA. More than 50 percent of the patients with advanced knee OA had foot pain, which improved in approximately 33 percent a year after TKA. Hindfoot deformities are likely associated with foot pain in individuals with advanced knee OA.


A study was conducted to present a case series demonstrating possible benefits from a combination of minimally invasive plate osteosynthesis (MIPO), plastic surgery and antibiotic therapy for treatment and eradication of infection in patients with tibial pilon or calcaneal fractures. The study involved 11 consecutive patients with dehiscence of the surgical wound in outcomes after MIPO using a Locking Compression Plate for tibial pilon or calcaneus fractures. The patients had developed a documented infection of the surgical wound. Average time of wound closure was 109 days plus or minus 60 days. The antibiotics employed were selected based on the antibiogram. The antibiotic therapy had a duration of four to six months, and after six weeks, the therapy transitioned to oral administration. At the three-month follow-up, all patients had excellent outcomes and had returned to their normal routines of daily living.

Practice Management

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A notice published in the Federal Register from the National Institute for Occupational Safety and Health (NIOSH) proposes an extension to its Workplace Violence Prevention Programs in NJ Healthcare Facilities. The project was initially sanctioned to assess nursing communities' compliance with the New Jersey Violence Prevention in Health Care Facilities Act and the efficacy of the law's regulations for reducing assault injuries to community employees. It was NIOSH's intention to evaluate these at 50 hospitals and 40 nursing communities, to poll nurses and to perform a home healthcare aide survey. NIOSH completed the data collection activities for the hospitals, the nurse survey and the aide survey, but it concluded only 20 out of 40 community interviews. It is now asking for the extension to complete it by having a contractor conduct face-to-face interviews with the chairs of the Violence Prevention Committees in 20 nursing communities, including 10 in New Jersey and 10 in Virginia, who oversee compliance efforts. According to the NIOSH notice, the interviews would quantify compliance with those states' regulations, including violence prevention policies, reporting systems for violent events, a violence prevention panel, a written violence prevention plan, violence risk evaluations and postincident response and violence prevention training. NIOSH notes healthcare employees are almost five times more likely to become victims of violence than those from all other industries combined, and almost 60 percent of all nonfatal assaults in private industry occur in healthcare.


The Medical Economics 2017 EHR Report reveals that 35 percent of medical practices surveyed outsource their information technology (IT) services. Of that group, 47 percent of both solo practices and those with two to five physicians rely on someone who is not on their staff to deal with technology issues. Thirty-one percent of solo practices also said they have no designated IT department or employee. Joe Capko at consulting firm Capko & Morgan says practices can take proactive steps to ensure they are prepared if an IT emergency occurs. For instance, the practice should find someone eager to expand his or her role and to take on more job responsibilities, such as working with technology vendors like electronic health records (EHRs) and billing and collections. This person will be responsible for forming the practice's action plan and for ensuring that everyone knows about it. In addition, the point person will gather the adequate information for what to do for a short-term or long-term emergency. Many software applications, including EHRs, have user groups online or in the same state as the practice. Practices also need to back up everything and to have a stand-in for the IT point person who is familiar with the plan. A practice will not be able to access its cloud-based record without a stable connection. And if practices make physical copies of vital data, it is a good idea to store them somewhere safe, perhaps away from the practice's physical location. At least twice a year, the practice point person should revisit the plan, ensure contact names and numbers are still accurate and update if needed.


Physicians who are considering the revenue-generating potential of ancillary services need to first determine if Medicare and Medicaid patients are being contemplated. If so, the next question is whether the service is a Designated Health Service (DHS), which includes clinical laboratory services; physical therapy services; occupational therapy services; outpatient speech-language pathology services; radiology and certain other imaging services; radiation therapy services and supplies; durable medical equipment and supplies; parenteral and enteral nutrients, equipment and supplies; prosthetics, orthotics and prosthetic devices and supplies; home health services; outpatient prescription drugs and inpatient and outpatient hospital services. If the referral is for a DHS and Medicare/Medicaid covers the claim, then Stark Law applies. Stark Law prohibits physicians from referring Medicare and Medicaid patients for designated health services to any entity with which the referring physician (or immediate family member) has any direct or indirect financial relationship unless an exception applies. When the Stark Law applies, the only safe way to make a referral is to fall into an exception. The most obvious exception is "in office ancillary services" under 42 U.S.C. Section 1395nn(b)(2). If the practice is actually a group, then it will be necessary to apply the "group practice" exception under 42 C.F.R. Section 411.352. This means the ancillary services must be performed in the office or in the same building, and the people performing the services must be directly supervised by a physician in the practice. The services must be billed by the physician, or his or her group, under the same NPI number or by an entity that is wholly owned by such physician or such group practice.

Health Policy and Reimbursement

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The U.S. Centers for Medicare and Medicaid Services (CMS) struck a blow to the 340B drug discount program when it announced a final rule to cut Medicare payments for hospitals enrolled in the program by 28 percent, or about $1.6 billion. The American Hospital Association and others quickly filed suit, arguing that the agency lacks the authority to slash the payments and that the rule undermines the intent Congress had when creating the program. Approximately 40 percent of U.S. hospitals now buy drugs through the program, according to a 2015 report from the Government Accountability Office. Richard Sorian, of the hospital lobbying group 340B Health, said that for some small, rural hospitals the funding cut "could actually be the difference between staying open and closing." Supporters of the CMS rule, including drugmakers, argue that the program has grown beyond its original intent because hospitals have pocketed the discounts to increase profits and not to help indigent patients. Stephen Ubl, president of the Pharmaceutical Research and Manufacturers of America, said the program "needs fundamental reform" and that the latest rule change is merely a good first step. His group is calling for changes, such as limiting which hospitals should be eligible for 340B price breaks and making sure needy patients benefit when hospitals buy discounted drugs.


Many state insurance commissioners are concerned that repealing the Affordable Care Act's (ACA) individual mandate in the GOP tax-reform bill would damage their markets. Wyoming Insurance Commissioner Tom Glause said that the damage would be most notable among those who make too much income to qualify for subsidies. "If the mandate is repealed in the tax bill, you'll see a lot of those people going without coverage," he said. Oklahoma Deputy Insurance Commissioner Mike Rhodes added that without a mandate, only sicker people would remain enrolled, which "manifests itself in a price increase." Meanwhile, the Utah Insurance Department said in a statement, "A simple repeal done without implementing any cost-control measures will drive premiums up because without a mandate individuals will only purchase insurance when care is needed. ... Over time, premium increases coupled with fewer healthy participants will cause the deterioration of the individual market pools."


The U.S. Congressional Budget Office (CBO) estimates that repealing the Affordable Care Act's individual mandate could result in an estimated 13 million more people without insurance within 10 years while also leading to federal savings of $338 billion. About 6.7 million tax filers (4.5 percent) paid the penalty for not having qualifying insurance in 2015, down from 8.1 million in 2014. Preliminary estimates show that filers paying the penalty continued to decrease in 2016 and 2017, likely due to a combination of more people getting insurance and more submitting "silent returns," or leaving blank whether they had healthcare coverage that year. In many instances, the places with the highest rates of uninsured people, such as Texas, also had the highest share of people who paid the penalty for not obtaining insurance. Other factors contributing to the variation in penalty payments include people who have income below a certain threshold or would be eligible for Medicaid if their state had expanded its program.

Medicine, Drugs and Devices

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Now that federal officials have quashed the mega-mergers proposed by the biggest insurers and blocked a deal between two large community pharmacy chains, established players in the healthcare industry are venturing beyond their traditional lines of business. Companies are actively looking for partners that will provide an entree into new businesses or a new supply of customers. CVS Health, which started as a community pharmacy chain, operates a large pharmacy benefit manager (PBM) as well as walk-in clinics in its stores. By combining with Aetna, which covers about 22 million people, CVS would be able to direct members to its own mail-order and pharmacy business and to its walk-in clinics, located in its stores, for much of their care. By sharing in the profits or losses of these ventures, the parties say they work more closely to make sure a patient gets the right medicine or has access to a doctor at a nearby clinic instead of resorting to an emergency room. However, employers that purchase coverage on behalf of their workers may have difficulty determining how much they are paying for a given medicine or a particular service, says Edward Kaplan, a senior vice president at Segal Consulting. There is already a lack of transparency when it comes to drug prices, and employers may have even less information if the insurer and the PBM are the same entity.


Alex Azar, the Trump administration's nominee to become the next secretary of the U.S. Department of Health and Human Services (HHS), testified that prescription drug prices are too high and that the federal government has a role in trying to make medicine more affordable for consumers. The focus on costs during Azar's hearing before the Senate Health, Education, Labor and Pensions Committee reflected an attempt to get ahead of criticism that the decade he spent as a top executive at Eli Lilly makes him ill-equipped to address the issue of drug prices. "I think there are constructive things we can do" to bring down the price of medicines, Azar said. He said he favors fostering competition between brand-name drugs and generic equivalents—an issue he worked on in the early 2000s while he was the HHS general counsel during the George W. Bush administration. "We have to fight gaming in the system by patents and exclusivity agreements." Azar also indicated he supports wider use of drug rebates, although he did not mention any potential constraints on the prices that pharmaceutical companies set.


House Republicans have proposed eliminating the orphan drug tax credits, which Congress passed as part of a basket of financial incentives for drugmakers in the 1983 Orphan Drug Act. The law gives seven years of market exclusivity for drugs that treat a specific condition that affects fewer than 200,000 people. The U.S. Senate Finance Committee, led by Sen. Orrin Hatch (R-UT), put the tax credit back into the current tax legislation. After some negotiations, the committee settled on reducing the credit to 27.5 percent of the costs of preapproved clinical research, compared with the current 50 percent. The committee also restored a provision that would have eliminated any credits for drugmakers who repurpose a mass-market drug as an orphan. The pharmaceutical industry has had a muted response to the tax bill, which includes a corporate tax cut. A group of patient advocates rallied—wearing bright-orange shirts that read "Save the Orphan Drug Tax Credit"—and planned to meet with a couple of dozen lawmakers.