News From ACFAS

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The ACFAS Board of Directors election closes Monday, December 17. If you are an eligible voter and have not yet voted, a reminder email with the subject line: ACFAS Board of Directors Election. We Need Your Vote! was sent to you last Friday (December 7) from acfas.ballot@intelliscaninc.net with your unique link to the election.

Members without an email address or whose email system rejected our test email were sent voting instructions by U.S. mail earlier this month. If you do not see the email and did not receive a letter, check your junk mail folder.

Please contact our independent election firm at kwier@intelliscan.com or (484) 920-8106 if you are unable to locate your unique link or have questions about accessing the ballot site.
Sign up now for free, formal media training at ACFAS 2019 in New Orleans and learn how to be your own publicist for your practice and be a spokesperson for the College.

A professional media trainer will offer personalized one-hour training sessions to help you speak confidently to the media both on and off camera and will also equip you with PR tools you can easily implement to promote your practice.

Time slots are filling fast, so contact Melissa Matusek, ACFAS director of Marketing and Communications, at melissa.matusek@acfas.org to reserve your session now. The Residency Directors Forum will once again be held in advance of ACFAS 2019 in New Orleans on Wednesday, February 13 from 1:30–5:30pm and is cohosted by the Council of Teaching Hospitals (COTH). This year’s program focuses on best practices in residency training.

The Forum will also provide time for open Q&A with all of the residency-related organizations, including AACPM, PRR, COTH, CPME, ABFAS, ABPM and ACFAS. New this year: the Forum will offer attendees 2.5 CME hours.

Forum sessions will include:

• CPME and ACGME: Sharing Best Practices in Resident Education
• Slaying the Three-Headed Monster: Patient Safety, Physician Well-Being and Resident Remediation
• Research: The Next Frontier
• Get on Board! Preparing Your Residents for In-Training Exams and How This Correlates with ABFAS Board Qualification Rates
• Mix It Up Like Jambalaya: Organizational Oversight Updates

Residency program directors, codirectors and faculty are invited to attend, with up to two attendees per program. School deans are also invited.

Visit acfas.org for further details and to register.
This week, the U.S. Centers for Disease Control and Prevention (CDC) released two new online training modules, Determining Whether to Initiate Opioids for Chronic Pain and Implementing CDC’s Opioid Prescribing Guideline into Clinical Practice, to help providers, including foot and ankle surgeons, use CDC’s opioid prescribing guidelines in their practice.

The first module helps providers identify and consider relevant patient factors when determining whether or not to start or continue opioid therapy. The second focuses on the quality improvement process and highlights 16 clinical measures useful in monitoring opioid prescribing at the practice level.

Access these and all training modules CDC has released to date at cdc.gov.

Foot and Ankle Surgery

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A study was conducted to compare arthroscopic ankle stabilization and open stabilization with suture tape augmentation. A retrospective comparative trial was performed with a follow-up satisfaction poll involving 55 patients, including 43 arthroscopic patients and 12 suture tape augmentation patients. The average follow-up period was 24.2 months in the arthroscopic group and 21 months in the open group. A statistically significantly faster return to activity/sports was observed in the arthroscopic group. A trend favoring the open group in terms of revision surgery and patient satisfaction was also noted, with the results suggesting both methods of stabilization are reasonable for ankle instability repair.


The purpose of this study was to assess function of 10-year-old children initially treated nonoperatively for clubfoot with either the Ponseti or French physiotherapy program and to compare outcomes in feet that had undergone only nonoperative treatment with those that required subsequent surgery. Of 263 treated clubfeet in 175 patients, 148 had only been treated nonoperatively, 29 underwent extra-articular surgery and 86 underwent intra-articular surgery (posterior release in 42 and posteromedial release in 44). Significant abnormalities were found in ankle kinetics and isokinetic ankle strength in the feet treated with intra-articular surgery compared with the nonoperatively treated feet. Compared with controls, all groups showed reduced ankle plantar flexion during gait, resulting in a deficit of 9 percent to 14 percent for dynamic range of motion, 13 percent to 20 percent for ankle moment and 13 percent to 23 percent for power. Within the intra-articular group, feet that underwent posteromedial release had decreased plantar flexion strength, dorsiflexion strength and parent-reported global function scores compared with the posterior release group. The patients with clubfoot took 10 percent fewer steps and had 11 percent less total ambulatory time than the controls.


A study was conducted to ascertain the advisable screw entry point and direction of intercuneiform arthrodesis using intraoperatively detectable landmarks. The computed tomography (CT) scan data of feet was reformatted using OsiriX software multiplanar reconstruction. Based on the data of 10 CT scans of normal feet, the researchers determined the advisable screw entry point at the upper one third in the dorsoplantar direction and center in the anteroposterior direction on the medial aspect of the medial cuneiform and insertion direction toward the outermost point of the base of the fifth metatarsal in the axial plane and parallel to the plantar surface in the coronal plane. The team then examined the accuracy of these newly designed guideposts in the simulation using other CT scan data of the other 27 normal feet and 12 flat feet. The simulated trajectory penetrated the mid three fifths of all three cuneiforms in 97 percent of the normal feet and 92 percent of the flat feet without any cortical wall violation.

Practice Management

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The end of the year often creates anticipation among medical practice employees of holiday bonuses. Done properly, bonuses are an important way of demonstrating to employees that their services are sincerely valued and remembered. With a relatively greater proportion of practice revenues being tied to physician performance as measured by patient outcomes, it can be wise to link employee bonuses to their own performance-based measures. In doing so, a holiday bonus program can further the practice's quality goals and objectives.

It is also important for physicians and practice administrator to sit down and create a detailed holiday bonus budget. Furthermore, the timing and manner in which the gift is given can also enhance the meaning of the gesture. Two customary ways of delivering the bonus generally should be avoided: waiting to give the bonus on December 24^th or simply adding the bonus into one pay cycle's direct deposit. Instead, when a physician takes the time to take an employee aside and deliver a personalized message of appreciation, the true meaning and spirit of the gift shine through with much greater clarity.

Some practices have a tradition of giving nonmonetary gifts, but this can be risky. Handing out flashy items or pulling staff names out of a hat for receiving such gifts detracts from the meaning of the season and the reasons for giving a bonus. Doing so may also create negativity among employees. Practices should remember that the purpose of giving a bonus is to reflect respect for your staff, express thanks for their services and perhaps recognize the meaning of the season.


Practices can improve their billing and collections process by educating patients, using strategies, such as flyers explaining billing basics as applicable to any insurance plan, and highlighting customer service numbers on the back of patients' insurance cards. Another tactic is having staff speak with patients about billing more effectively, and a third tip is not to lag behind claims through timely filing and by deploying a routine system for checking open claims. Practices should commit to insurance verification on the phone prior to and at every visit, avoid sending statements to the wrong address and ensure a follow-up procedure if patients do not pay to avoid payment delays.

Reviewing contracts with payers is another good approach and one practices should do at the first of the year. They must be aware of any changes from the prior year, especially if they demand shifts in workflow, process or staff training. Finally, practices should have at least one staffer well-versed in billing who can address any questions or issues from personnel and patients.


Communicating with patients and families about what is happening with their care could help curb dangerous medical errors, according to a new study published in The BMJ. "Families are a really valuable, but sometimes underrecognized, part of care," said Dr. Alisa Khan, a Boston Children's Hospital pediatrician and Harvard Medical School professor who led the study.

The Patient and Family Center I-PASS intervention focuses on starting rounds by asking if the patient or family has any questions or concerns. Then, healthcare providers give updates and review the treatment plan in a way that minimizes medical jargon and makes everything clear. At the end, patients and families are asked to "read back" what they understood about the care plan. "We often assume understanding without confirming it," Khan said.

Khan and her colleagues taught providers at seven academic medical centers in the United States about the program. Then they reviewed patient charts and the hospital's incident reporting system for medical errors, asked staff about any errors they observed and interviewed families. The rate of harmful errors, or preventable adverse events, declined by 38 percent in the three months after the intervention was implemented. Those errors can range from incorrect drug doses and lost patient samples to delays in consultations with specialists. Families were also more likely to share concerns, and more people felt like they were part of the care team, Khan said. The researchers are hopeful the intervention could help reduce the rate of medical errors elsewhere. But making that happen requires a shift in thinking that rounds are not just for physicians, Khan said, but "about the patient and the family."

Health Policy and Reimbursement

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Sens. Chuck Grassley (R-Iowa) and Ron Wyden (D-Ore.) have introduced the Right Rebate Act of 2018, which would establish monetary penalties and strengthen oversight of pharmaceutical companies that knowingly misclassify their drugs within the Medicaid system. The legislation comes just over a year after Mylan settled a federal lawsuit for $465 million alleging the company classified its EpiPen treatment as a generic drug to avoid paying higher rebates to Medicaid. The bill designates 25 percent of the penalty money to help improve drug data reporting and oversight of drug classification info and compliance. It would also require annual reports describing these misclassified drugs and related government actions.

The bill could potentially affect hundreds of drugs. About 3 percent of the roughly 30,000 drugs in Medicaid's rebate program may have been misclassified in 2016, according to a December 2017 report from the U.S. Department of Health and Human Services Office of Inspector General. The 10 potentially misclassified drugs with the highest total reimbursement could have cost Medicaid an additional $1.3 billion from 2012 to 2016 compared to what those products would have cost if properly classified. That report also stressed that while the U.S. Centers for Medicare and Medicaid Services can ask manufacturers to change classification data, it cannot require those corrections. This bill would grant that explicit authority.


The next wave of state actions against the opioid epidemic may focus on taxing them, depending on the outcome of an industry lawsuit against New York. Most of the bills that have been proposed would tax opioids and use the money for addiction treatment and prevention. But the healthcare industry argues that they are bad policy and, at least in the New York law's case, illegal. More than a dozen states saw the introduction of bills to tax opioids last year, but only New York's made it into law.

The New York law will collect $600 million over six years from drugmakers and distributors and use it to fund addiction treatment and prevention. These industry groups have responded with three different lawsuits arguing that the law is unconstitutional. If the industry is successful in its attempt to derail the law, that could influence whether other states follow New York's lead or how they write legislation.

Proponents of opioid taxes argue that their value goes beyond just raising money. "If the actual price for these products reflected their true costs, I think we'd see a greater emphasis on reducing opioid use and encouraging use of pain treatments that are much safer and more effective," said Andrew Kolodny of Brandeis University. Opponents say these taxes could make it tougher for patients to get the pain medication they need. "We do not believe levying a tax on prescribed medicines that meet legitimate medical needs is an appropriate funding mechanism for a state's budget," said a spokeswoman for Pharmaceutical Research and Manufacturers of America.


The American Hospital Association (AHA) and the Association of American Medical Colleges (AAMC) are suing the Trump administration over the U.S. Centers for Medicare and Medicaid Services' (CMS) finalized 2019 Outpatient Prospective Payment System rule to gradually impose site-neutral payments for clinic visits in the Medicare program over the next two years. CMS officials claimed that site-neutral payments for clinic visits will reduce out-of-pocket costs for beneficiaries and will save Medicare up to $380 million next year. AHA and AAMC countered in their complaint that the rule would lead to access difficulties as hospitals cut services, hurting vulnerable patients.

Both plaintiffs argued that the administration is overstepping its legal authority, with AHA CEO Rick Pollack stressing, "These cuts directly undercut the clear intent of Congress to protect hospital outpatient departments because of the real and crucial differences between them and other sites of care." He also said patients who receive care in outpatient departments tend to be poorer and have more severe chronic problems than patients treated in an independent physician office. "In addition, only hospitals provide 24/7 access to care for patients, regardless of their ability to pay, hospitals are held to far higher regulatory requirements, and hospital outpatient departments in inner cities and rural areas are often the only sites of care that provide the services they do," Pollack warned.

Medicine, Drugs and Devices

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An increasing number of doctors around the United States are able to direct a patient to Amazon.com to purchase medical supplies via an app embedded in the patient's private medical record. Hospitals that use the app say the goal is to replace the handwritten shopping lists doctors often hand people, which are easy to lose, and to spare patients lengthy searches through pharmacy shelves. "We're looking for ways to make that more convenient," says Glenn Updike, an obstetrician and technology official at the UPMC health system in Pittsburgh who has sent the digital referrals.

Privacy experts say the app, and Amazon's involvement, represent the latest example of new and unanticipated issues arising as doctors, retailers and software developers take advantage of the digitization of medical data and tap patients' growing comfort with the internet. The app enables doctors to choose which supplies to recommend and then to email the list of products to a patient. The email directs the patient to a website with photos of recommended products, descriptions and links for purchasing on Amazon. Privacy experts express concern that patients could unwittingly share personal and potentially sensitive health information with Amazon, giving the company more data points about a shopper that it could use to tailor how it sells.


A coalition of healthcare groups is calling on the federal government to take steps to address the ongoing shortages of critical medications across the country. Among the groups that formulated the recommendations are the American Hospital Association, the American Society of Health-System Pharmacists and the Institute for Safe Medication Practices. The coalition's 19 proposals were issued the day before a public meeting held by the U.S. Food and Drug Administration (FDA) and the Duke-Margolis Center for Health Policy that was designed to get stakeholder input on the root causes of drug shortages and what to do about them.

The coalition recommends strategies that would allow healthcare providers to prepare for an imminent shortage of certain drugs. The group wants FDA to share information on the types of products that may be affected during a public health emergency and the expected duration of the impact on the drug supply chain. These communications, the coalition says, would "allow healthcare organizations to assess their inventories ... and would give manufacturers the time needed to manage their supplies to ensure equitable distribution and guard against potential hoarding of drugs." The coalition also recommends that the U.S. Government Accountability Office be commissioned to report on the new and emerging factors that contribute to shortages.


Aetna and Ascension have partnered with five other healthcare companies to test the use of blockchain technology to fix provider network lists. The Synaptic Health Alliance will help pilot a blockchain-enabled initiative to enhance data quality and to reduce time and costs associated with changes to provider demographic data. Aetna and Ascension join alliance founders Humana, UnitedHealthcare, UnitedHealth Group's Optum, MultiPlan and Quest Diagnostics.

This development coincides with a recent U.S. Centers for Medicare and Medicaid Services finding that almost 49 percent of Medicare Advantage organizations' online directories contain at least one provider location error. Within each directory, the percentage of locations with inaccuracies ranged from 4.6 percent to 93 percent, with the median being 45 percent. Directory errors can be costly for payers, as plans that fail to keep directories accurate can be fined up to $25,000 per error per physician and up to $100 per physician for errors in plans sold on HealthCare.gov. The alliance's pilot employs a multicompany, multisite, permissioned blockchain, allowing each member to determine how its nodes are deployed.