News From ACFAS

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With 2019 just days away, ACFAS would like to thank you—our dedicated members and volunteer leaders—for your commitment and service this past year. Your hard work helped ACFAS achieve the following in 2018:

• ACFAS membership peaked at more than 7,600 members for the first time ever.
  
  
• A Clinical Consensus Statement on gout was developed in partnership with the American Association of Nurse Practitioners and published in The Journal of Foot & Ankle Surgery and the Journal of Nurse Practitioners.
  
  
• Attendance at ACFAS 2018 in Nashville matched an all-time high set in 2017.
  
  
• A joint DPM and Ortho MD task force was launched to enhance parity cooperation.
  
  
• ACFAS engaged in 21 media pitches on stories about who you are and what you do and secured placements in USA Today and Rheumatology Advisor.
  
  
• Two brand-new programs will roll out in 2019—Residents’ Day at ACFAS 2019 in New Orleans and the course Revision Surgery: Managing Complications, thanks to an Educational task force.
  
  
• Triennial membership and practice surveys were conducted.
  
  
• The Take a New Look email campaign sent 30 emails in 2018, reaching many diabetes educators, family physicians and nurse practitioners.
  
  
• The College successfully challenged a grievous DPM discrimination case.
  
  
• Clinical Consensus Statements on Achilles Tendon and Ankle Arthritis are in development and will be released in early 2019.
  
  
• Six new fellowship programs received status through ACFAS’ Recognized Fellowship Initiative, bringing the total number of programs with status to 47.
  
  
• A research survey on consumer behavior was conducted to help us gain insights on promoting foot and ankle surgeons to our most engaged audiences.
  
  
• Three mat releases generated 11,264 news articles, with a combined 218.8 million impressions.
  
  
• Comments regarding the U.S. Centers for Medicare and Medicaid Services’ (CMS) proposed changes to evaluation and management codes were submitted to CMS, and the proposed rule was not accepted by the agency.
  
  
• Eleven press releases were distributed nationally to help raise awareness of the profession and the College.
  
  
• The ACFAS Research Committee submitted a draft Research Strategy and Implementation Plan to the Board of Directors for review and approval in 2019.

Sign up for free, personalized one-hour media training sessions at ACFAS 2019 in New Orleans and get pro tips on how to:

• Publicize your practice
• Speak to the media on behalf of the College
• Become a more confident speaker, both on and off camera

A professional media trainer will work one-on-one with you and will show you how just a few simple PR tools and strategies can make all the difference in how you market your practice.

Contact Melissa Matusek, ACFAS director of Marketing and Communications, at melissa.matusek@acfas.org to reserve your session. Time slots are limited, so sign up now!

Foot and Ankle Surgery

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A study was conducted to compare arthrodesis of the proximal interphalangeal joint with shortening osteotomy of the proximal phalanx neck in the treatment of hammer toes. In most cases, both procedures have been associated with elongation of the extensor apparatus, capsulotomy of the metatarsophalangeal joint and stabilization with a Kirschner wire. To experiment with a technique that respects the anatomy and joint function, a distal subtraction osteotomy of the proximal phalanx neck was employed. The researchers compared a series of 78 patients, aged 22 to 78 years, divided into two groups; arthrodesis (38 patients) and osteotomy (40 patients). The mean final follow-up period was 56.6 months. The American Orthopaedic Foot and Ankle Society score, Foot and Ankle Outcome Score and a subjective rating scale were used for clinical assessment. Results were comparable between the two techniques, but faster functional recovery was observed in the cohort treated with shortening osteotomy, with an adjunctive advantage of preserving the integrity of the proximal interphalangeal joint.


A study was conducted to assess the results of second-ray pathology after distal chevron osteotomy (DCO) with Weil osteotomy to correct metatarsal parabola. Concomitant Weil osteotomy of the second metatarsal was carried out with DCO of the first metatarsal as part of hallux valgus with second-ray pathology correction surgery in 45 feet. Second-ray pathologies included claw toe deformity, painful plantar callosity, second metatarsophalangeal joint (MTPJ) dislocation and osteoarthritis (OA) of the second MTPJ. Projection of the second metatarsal (PSM), metatarsal protrusion index (MPI) and metatarsal protrusion distance (MPD) were measured, with second-ray surgery outcome evaluated by patient satisfaction. Satisfaction was good in claw toe deformity and OA pathology, and fair in painful plantar callosity and second MTP joint dislocation pathology. Total patient satisfaction rate was higher when the PSM, MPI and MPD ranged between 7 mm and 12 mm, -5 mm and 0 mm and 0 and 4 mm, respectively. Simultaneous performance of hallux valgus correction and Weil osteotomy in patients with second-ray pathologies associated with hallux valgus was determined to be safe and effective.


A study was conducted to determine if deformity can predict the outcome of operative correction for patients treated for Charcot foot arthropathy involving the ankle joint. Over the course of the study, 56 consecutive patients underwent operative reconstruction of Charcot foot deformity involving the ankle joint by a single surgeon over 14 years. Preoperative patient characteristics and tibiotalar alignment were recorded. Treatment included single-stage debridement of active infection and ankle arthrodesis with application of a circular external fixator when infection was present or retrograde locked intramedullary nailing in the absence of infection. One patient died at 134.3 weeks following surgery of unrelated causes, while eight underwent amputation. Twenty-eight patients had a favorable clinical outcome. No significant association between pre- or postoperative alignment and clinical outcomes was observed, and patients who were living with diabetes and insulin-dependent were about three times more likely to have a poor clinical outcome.

Practice Management

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Physicians can transition from full-time clinical work in several ways, including working part-time at one particular institution. A second option is to become credentialed for different facilities, opting to work in multiple hospitals or clinics doing different types of work. Doctors will be able to set their own schedule, typically months in advance, and to easily arrange extended time off, if desired. This will reduce the need to travel long distances or to be away from home for extended periods, provided doctors take advantage of all the likely existing local opportunities.

A key issue concerns maximizing the tax incentives that become available as a small business owner. Clinicians who truly want to become independent contractor physicians, with a game plan to make this feasible, can form their own LLC or corporation and choose to be an independent contractor. This gives them access to multiple small business tax breaks. Obtaining benefits, such as health insurance, will depend on the clinician's individual circumstances and where he or she resides.


In the weeks leading up to the New Year, practices encounter the dreaded end-of-year crunch, when patients start coming out of the woodwork trying to squeeze in appointments and schedule surgeries before December ends. With the added pressure of the holiday season, it is standard for staff to feel more tightly wound. Starla Fitch, MD, an ophthalmologist, personal coach and the author of Remedy for Burnout: 7 Prescriptions Doctors Use to Find Meaning in Medicine, recommends putting the phone down and expressing gratitude for the people around you. An estimated 80 percent of people reach for their phone first thing every morning, while research shows that expressing gratitude can improve our health and reduce stress.

A few years ago, Fitch changed her morning routine: instead of reaching for her phone, she decided to send out a small note of gratitude to colleagues via email or text. She found that she got responses immediately and that both the recipients and Fitch herself felt better. Fitch had her operating room staff start a gratitude practice as well. Over time, the practice of naming three things each person in the room was grateful for became a welcome part of the day and helped overcome low morale. Fitch recommends putting a gratitude jar at the checkout desk to get the whole office involved and keeping the flame of gratitude lit during this busy time of year.


Practices can apply four strategies to improve cash flow while adhering to the Medicare Access and CHIP Reauthorization Act's (MACRA) Merit-based Incentive Payment System (MIPS) reporting requirements. The first tip is to prepare for major participation eligibility changes in MACRA's Quality Payment Program final rule for MIPS Year 3. Physical therapists, occupational therapists, speech-language pathologists, audiologists, clinical psychologists and registered dietitians or nutrition professionals have been added for eligibility in Year 3; exempt parties must either have $90,000 or less in Part B allowed charges for covered professional services, supply care to 200 or fewer Part B beneficiaries or provide 200 or fewer covered professional services under the Physician Fee Schedule.

A second tip is to strategize MIPS performance category submissions. The MIPS Promoting Interoperability (PI) and Improvement Activities (IA) categories expanded last year and adjusted reporting activity options to make meaningful participation easier for more practices. In showing improvement to existing activities for easy comparison and documentation, 2018 MIPS participants should document IA starting points and activity measurement progress and leverage opportunities. A third tip is to guarantee more conscientious registration processes, with staff confirming insurance information for all scheduled encounters at least a week prior to appointment. The final tip is to encourage patient participation in online portals for test results, secure communication and payments.

Health Policy and Reimbursement

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U.S. District Judge Reed O'Connor of Texas has ruled that the entirety of the Affordable Care Act (ACA) is unconstitutional because of a recent change in federal tax law. The ruling upheld a lawsuit initiated by Texas Attorney General Ken Paxton; the plaintiffs' contention that the ACA is invalid stems from the Supreme Court's 2012 ruling in which Chief Justice John G. Roberts Jr. wrote for the majority that the penalty the law created for Americans who do not carry health insurance is constitutional because Congress "does have the power to impose a tax on those without health insurance." Congressional Republicans pushed through a change in which that penalty will be eliminated, starting in January, as part of the tax overhaul earlier this year. The lawsuit argues that, with the enforcement of the insurance requirement stripped, a tax no longer exists so the law is no longer constitutional.

If the ruling stands, it would create widespread disruption across the U.S. healthcare system. The White House released a statement concerning the ruling, saying, "We expect this ruling will be appealed to the Supreme Court. Pending the appeal process, the law remains in place." Congressional Democrats decried O'Connor's ruling, as did major healthcare industry segments. America's Health Insurance Plans promised consumers that their health coverage would remain "strong and stable" while the ruling is appealed.


The U.S. Centers for Medicare and Medicaid Services (CMS) has proposed to phase in changes to the way it estimates risk adjustment payment to Medicare Advantage plans. Beginning in 2020, CMS will calculate payments with a combination of 50 percent of the risk adjustment model first used for payment in 2017 and 50 percent of the new risk adjustment model proposed, but not finalized, in the 2019 rate announcement. The new model adds factors that count the number of conditions a beneficiary may have, including additional condition categories for mental health, substance use disorder and chronic kidney disease. It also features technical updates, such as calibrating the model with more recent data and selecting diagnoses with the same technique used for encounter data.

Furthermore, CMS is presenting an alternate payment condition count model that includes additional condition categories for pressure ulcers and dementia. Under the 21^st Century Cures Act, CMS must report to Congress on the Part C risk adjustment model and the end-stage renal disease risk adjustment model every three years, starting with a report due no later than December 31. The initial report on risk adjustment in Medicare Advantage required by the 21^st Century Cures Act is being issued at the same time as Part I of the 2020 Advance Notice.


U.S. Centers for Medicare and Medicaid Services (CMS) Administrator Seema Verma announced that she is moving to establish an office for regulatory reform as one of her priorities for next year. Verma said the office would seek to reduce "regulatory burden" created by the agency, criticizing how CMS's regulations have hampered providers and beneficiaries. CMS already has committed a team to its "Patients over Paperwork" initiative, and Verma aims to make that effort permanent.

Verma also lauded staff for quickly responding to a recent court decision that the Affordable Care Act (ACA) is unconstitutional, suggesting the ruling did not impede ACA sign-ups. "We were able to have a very successful close to open enrollment," she said. Verma restated that Medicare Advantage is the model for how she views the overall Medicare program. Her goals include modernizing Medicare into a beneficiary-oriented program, with affordable choices based on market principles, that encourages innovation.

Medicine, Drugs and Devices

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Naloxone should be prescribed alongside opioids for patients considered at risk for overdosing, according to new guidance released by the U.S. Department of Health and Human Services (HHS). "Given the scope of the opioid crisis, it's critically important that healthcare providers and patients discuss the risks of opioids and how naloxone should be used in the event of an overdose," said Adm. Brett Giroir, MD, assistant secretary for health and senior advisor for opioid policy at HHS. "Co-prescribing naloxone when a patient is considered to be at high risk of an overdose is an essential element of our national effort to reduce overdose deaths and should be practiced widely," he added.

The guidance recommends that clinicians prescribe or co-prescribe naloxone to individuals at risk for opioid overdose, including those who are on relatively high doses of opioids, take other medications that enhance opioid complications or have underlying health conditions. Clinicians should also educate patients and those who are likely to respond to an overdose on when and how to use naloxone in its variety of forms, the statement said. The HHS announcement came a few days after a U.S. Food and Drug Administration advisory committee voted 12-11 in favor of adding language to opioid drug labels recommending naloxone co-prescribing for all or some patients.


Nearly 30 drugmakers have taken steps to raise the U.S. prices of their medicines in January, ending a self-declared halt to increases made under pressure from the Trump administration. Twenty-eight drugmakers filed notifications with California agencies in early November disclosing that they planned to raise prices in 60 days or longer. Under a state law passed last year, companies are required to notify payers in California if they intend to raise the U.S. list price on any drug by more than 16 percent over a two-year period. The details were revealed in response to a public records request to California Correctional Health Care Services, which provides healthcare services to the state's corrections department. The department spends more than $3 billion annually on drugs for inmates, more than any other state. The California corrections department documents indicate that the companies plan to increase prices as early as January 1.


Artificial intelligence (AI) and machine learning are poised to transform the healthcare industry in the upcoming years. In the view of Yann Fleureau, co-founder and CEO of Cardiologs, 2017 and 2018 were the years of regulatory validation for AI, with companies breaking down regulatory barriers with diagnostics programs and other applications that proved their effectiveness. Now, he predicts that 2019 will be the year of commercial and clinical validation, meaning the solutions that emerge can be effectively used to manage patients.

One of the reasons the AI market is primed to take off in healthcare is that it holds the potential to automate mundane reporting requirements, which have held back clinicians from patient care and forced them to spend hours reviewing information that could be better left to machine learning. "By bringing a deep learning-enabled technology, which is radically superior, you demonstrate you have the same level of safety—no false negatives—while reducing the administrative burden," Fleureau said. "You save caregivers' time so they can focus on the true items that require medical attention." Workflow improvement and drug discovery are two use cases for AI that will become even more evident as AI in healthcare advances, he added. When it comes to clinical support, the areas likely to lead the way to large-scale adoption are imaging and diagnostics.