News From ACFAS

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Voting for the ACFAS Board of Directors closes next Monday, December 27. 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 last Friday, December 17, from acfas.ballot@intelliscaninc.net containing your unique link to the election.

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

Please contact our independent election firm at kwier@intelliscaninc.com or (484) 920-8106 if you are unable to locate your unique link or have questions about accessing the ballot site. We can’t wait to get back together in person for ACFAS 2022! Join your friends and colleagues in Austin to take advantage of the many networking opportunities throughout the week.

Premier Connection Opening Event at the Hilton Austin
Thursday, February 24
Relax and reconnect with your colleagues before heading out to explore Austin for the evening. Meet and greet classmates, colleagues, and new friends, while enjoying great food, beverages, and music.

Wrap Party at the Lustre Pearl Austin
Saturday, February 26
Close down another great meeting with colleagues and friends at one of Austin’s most popular musical venues. Tickets are selling out fast, so act now to celebrate one last evening in the Lone Star State with us.

In addition to the Welcome Reception and Wrap Party there will also be a variety of ACFAS-sponsored member events, as well as industry sponsored labs and receptions. Keep an eye on acfas.org/Austin for more details on industry events soon. The American Board of Foot and Ankle Surgery (ABFAS) is making a major change to the way its Diplomates will keep their Board Certified status current.

Launching in January 2022, the new program LEAD: Longitudinal Education and Assessment for Diplomates will replace ABFAS’ traditional, once-every-ten-years recertification and self-assessment examinations. All Diplomates will begin participating in the LEAD program in January 2022, regardless of certification expiration date.

LEAD will allow Diplomates to participate in a self-paced online assessment of 30 questions per quarter, anytime and from anyplace, on any device. In addition, Diplomates will receive instant feedback on questions, as well as references and rationales, resulting in a process of continuous learning with no need to travel to a testing center.

Both holders of Time-limited Certificates (certified after 1990) and holders of Lifetime Certificates (certified before 1991) will participate in the LEAD program.

Diplomates will periodically participate in LEAD throughout their entire ten-year certification cycles. The LEAD program does not change a Diplomate's existing certification expiration dates. ABFAS does not require Diplomates to participate every single quarter; rather, each Diplomate will participate in periodic assessment based on their own certification cycle.

ABFAS Diplomates can learn more by visiting abfas.org/lead. That webpage includes an introductory video explaining the program's flexibility, as well as an interactive Program Requirements tool for Diplomates to learn how they will participate. After reviewing these resources, Diplomates who still have questions about the transition to the LEAD program are welcome to contact ABFAS at lead@abfas.org or (415) 553-7800.
Give your patients the gift of good foot health this year with the newest issue of our patient education newsletter. FootNotes Winter issue has arrived and is full of seasonal tips to keep your patients' feet and ankles healthy and happy throughout the winter.

Get tips to keep feet healthy and happy throughout the winter months, encouraging a mid-year foot check for your children and ways to avoid painful gout attacks with an increase in overindulgence for the holidays.

This new issue is available in the ACFAS Marketing Toolbox and is ready for you to use as you wish, whether it’s handing it out in your practice, sharing it to your social media accounts or posting it on your practice website. Visit acfas.org/Marketing to access this and all the other free resources to help up your marketing game.

Foot and Ankle Surgery

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This study was conducted to determine associations between having chronic plantar heel pain (CPHP) and bone density and microarchitecture of the calcaneus. We assessed 220 participants with CPHP and 100 age- and sex-matched population-based controls. Researchers assessed for potential effect modification of CPHP on these covariates using interaction terms. Associations with bone outcomes were assessed using multivariable linear regression adjusting for age, sex, physical activity, BMI and ankle plantarflexor strength. There were univariable associations at the plantar calcaneus where higher trabecular bone density, BV/TV and thickness and lower trabecular separation were associated with CPHP. In multivariable models, having CPHP was not independently associated with any bone outcome, but modified associations of BMI and ankle plantarflexor strength with mid-calcaneal and plantar bone outcomes, respectively. Beneficial associations of BMI with mid-calcaneal trabecular density and BV/TV -0.009 were reduced in people with CPHP. Beneficial associations of ankle plantarflexor strength with plantar trabecular density (ankle plantarflexor strength -case interaction -11.9, thickness -0.003, separation -0.003 and BV/TV -0.010 were also reduced. CPHP may have consequences for calcaneal bone density and microarchitecture by modifying associations of BMI and ankle plantarflexor strength with calcaneal bone outcomes. Researchers say the reasons for these case-control differences are uncertain but could include a bone response to entheseal stress, altered loading habits and/or pain mechanisms.


Research was conducted to determine environmental and physiological risk factors for Achilles tendon (AT) tears, given the minimal amount of research on AT ruptures in the National Football League (NFL). NFL players with a diagnosed AT tear between 2009 and 2016 were selected as the study population for this retrospective analysis. Between 2009 and 2016, there were 101 documented AT tears. Of these, 64 percent occurred before the official season, including preseason games. Of the 36 tears that occurred in-season, 34 were during games. Overall, 29 percent of the preseason tears occurred in rookies and 100 percent of the in-season tears affected nonrookies. Of the rookies with AT ruptures, 42.11 percent returned to play in the NFL, while 62.20 percent of the nonrookies came back to partake in future seasons. Despite an average age of 26.7 years, the tear distribution was bimodal with players aged 24 and 36 years exhibiting the highest rates of tear. The study concluded that a large percentage of the tears occurred in rookie players, especially during the preseason. We also found that tears during the season occurred in only nonrookies, suggesting that the preseason is when rookies experience the greatest risk for injury.


Researchers evaluated the results of knotted and knotless double-row suture systems for Achilles reattachment. Perioperative and postoperative records were reviewed and telephone interviews were conducted to assess patient satisfaction, functional status, postoperative pain and information regarding surgical complications. At a mean follow-up of 32.5 months, 35 patients reported satisfaction with the outcome. Decreased pain levels were reported in 38 ankles, with 21 ankles being rated pain-free postoperatively. Of the patients working prior to surgery, 20 were able to return to normal work duties, and all 11 patients who engaged in sports preoperatively were able to return to the same level of activity. Two patients developed postoperative infections, one of which required operative debridement. No Achilles avulsions were encountered. No significant differences were noted between the two operative techniques. The research concluded that double-row repair offers a viable option for recalcitrant insertional Achilles tendinopathy.

Practice Management

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A study in Health Affairs suggests selling a practice will likely not improve doctors' income significantly and might even cause a slight decline. The authors combined national survey data on medical practice ownership with income data on 41,648 physicians between 2014 and 2018, when hospital and health system ownership of practices, or vertical integration, increased from 24.1 percent to 45.6 percent of all physicians in the sample. Vertical integration led to an average income drop of $2,987, or a relative difference of 0.8 percent, even though other studies found a hospital's revenue increased by 19 percent following vertical integration. For primary care physicians, vertical integration saw an average income uptick of $3,179, or 1.2 percent relative difference, in a time when the percentage working in practices owned by a hospital or health system rose from 28.6 percent to 47.7 percent; nonsurgical specialists, however, saw a 2.4 percent slippage in income. Physicians in practices that vertically integrated with nonprofit hospitals had 1.9 percent lower annual incomes, and no statistically significant income changes were observed for doctors in practices acquired by for-profit hospitals.


Doctors should carefully evaluate five contact areas in their employment contract, starting with their duties and responsibilities, which include where they will work, how often they will work and what is expected of them at work. An unwitting doctor might sign a contract that they will agree to work at any of the hospitals within the health system, even far-off locations; the number of shifts per month and hours per shift also should be understood. Contract terms and termination is a second focus area, as an unspecified term makes the doctor an employee in perpetuity, without any recourse to reconsider salary or other aspects of the job at a logical and natural timepoint. Doctors in a termination-without-cause contract should study that provision and specify that they receive at least 90 days' notice. Non-compete provisions should also be carefully studied, and doctors should attempt to alleviate some of their more onerous aspects through negotiation. Also worth reviewing is education loan debt assistance, while the fifth area to consider is bonus compensation. In both cases, doctors are less likely to obtain those items if they do not ask for them.

Health Policy and Reimbursement

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A poll of 1,745 public and private companies from benefits company Mercer found employers' health insurance costs rose to a 10-year high in 2021 as Americans resumed non-urgent procedures postponed by the pandemic. Companies employing about 118 million people saw the average cost of employer-sponsored health insurance per employee rising 6.3 percent this year to $14,542, the biggest increase since 2010. The gain was only 3.4 percent last year when the pandemic had strained hospital capacity and forced people to delay elective procedures. Mercer's Center for Health Innovation Leader Kate Brown said claims related to the treatment of long-term effects of COVID-19 and specialty drug pricing could also be contributing to the rise in costs, which may continue into 2022. Employers expect a "fairly typical" cost increase of 4.4 percent then, yet most were unwilling to try to lower the cost hike as they recommit to more affordable healthcare for employees. The poll indicated that adding or expanding programs to boost access to behavioral healthcare was one the three leading priorities for all large employers.


A study published in JAMA Health Forum found nearly 10 percent of Medicare beneficiaries accrue debt due to medical expenses, despite receiving health coverage. About 8 percent of beneficiaries have ongoing medical debt, have been contacted by a collection agency or both. Enrollees age 65 and up with annual incomes of $15,000 to $25,000 were three times as likely to report difficulties paying medical bills than those with incomes exceeding $50,000. Moreover, older adults with four to 10 chronic health conditions covered under Medicare were more than twice as likely to have problems paying bills as those with zero or one chronic condition. Slightly more than 30 percent of older respondents had annual incomes of less than $25,000, compared to about two-thirds of the younger respondents. Approximately 8 percent of older respondents said they delayed medical care because of cost, versus 25 percent of younger respondents. "Unaffordability is really concentrated among people who have very low incomes or who have poor health and high health care needs [as] the former don't have enough money to pay, and the latter have great needs that overwhelm their ability to pay," said Northeastern University Professor Jeanne M. Madden.


The Office of the Actuary at the US Centers for Medicare and Medicaid Services (CMS) reported in Health Affairs that US healthcare spending increased 9.7 percent in 2020 to $4.1 trillion, or $12,530 per person. This exceeded the roughly 5 percent growth in recent years, with the authors citing the 36 percent increase in government healthcare spending in response to the pandemic. Included in that estimate is the $122 billion Congress apportioned for the Provider Relief Fund to help hospitals deal with the pandemic, plus higher Medicaid spending. "New federal estimates show that even as healthcare use declined during the pandemic, health spending grew by 9.7 percent in 2020," tweeted Larry Levitt at the Kaiser Family Foundation. "It's remarkable how much the government has propped up the health system during the crisis, financing a majority of health spending for the first time."

Medicine, Drugs and Devices

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Large US hospital chains including the Cleveland Clinic, HCA Healthcare and Intermountain Healthcare have stopped requiring employees to be vaccinated for COVID-19 until the courts rule on the legitimacy of a federal mandate. This will likely decelerate campaigns to curtail the latest surge in cases, potentially exacerbated by holiday travel, large indoor gatherings and the emergence of the omicron variant. The suspension will also complicate hospitals' efforts to meet the government's early January deadline for vaccinating all eligible staff if the courts support the mandate. It remains uncertain how many hospitals have halted the mandate, with HCA noting it would continue the requirement in places where there is a state directive. Several large hospital groups implemented their own requirements earlier this year after seeing a spike in cases from the delta variant. About 40 percent of US hospitals required vaccinations for staffers, and the US Centers for Medicaid and Medicare Services (CMS) said many facilities have already gotten workers vaccinated. "While the current CMS vaccine requirement may be delayed, hospitals and health systems are not delaying their efforts to vaccinate staff," said the American Hospital Association.


House Democrats and Republicans issued conflicting reports on the forces underpinning high prescription drug prices and what actions should be taken. In unveiling the results of the Democrats' probe, House Oversight Committee Chair Rep. Carolyn Maloney (D-NY) refuted drugmakers' claims that the drug price controls the Democrats are chasing would limit efforts to develop new cures and treatments. "The largest drug companies spend more on payouts for investors and executives than on research and development," she wrote. "And many blockbuster drugs rely on scientific discoveries from research funded by taxpayers, while drug companies' R&D spending often focuses on minor changes to extend patent protection and block lower-priced competitors." The Pharmaceutical Research and Manufacturers of America countered that the committee's research failed to account for insurers and supply-chain intermediaries' role in pricing. Republicans cited pharmacy benefit managers (PBMs) who negotiate drug prices for employer-sponsored health plans, alleging they engage in anti-competitive practices and manipulate drug formularies in ways that drive up patients' out-of-pocket costs. A spokesperson for the panel's Democrats commented, "It is curious that Republicans are focusing on PBMs at the same time big pharma is staring down one of the most meaningful checks on its abusive pricing practices in years—Medicare negotiation."


The Biden administration wants to improve how the federal government delivers healthcare services, according to an executive order issued Dec. 13. The directive will expand patients' ability to use telehealth services, connecting rural residents, disabled residents and others who want telehealth options, although the White House has not specified how this will happen or the ramifications for provider reimbursement. Meanwhile, Medicare beneficiaries will be allowed to access online tools to help manage their care, provide customer support options and reduce drug costs; beneficiaries will also be able to enroll more easily in Social Security Administration benefits. Also authorized is streamlining of the Department of Veterans Affairs digital health services and other benefits, allowing virtual services to be accessed via an integrated platform both online and through a mobile app. Finally, the order designates the US Centers for Medicare and Medicaid Services a high-impact service provider within the US Health and Human Services Department.