News From ACFAS

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You have until July 25 to book your hotel at special rates when you register to join the experts at ACFAS’ Coding and Billing Education Series. Register for just one course or both with special bundle pricing and see the coding and billing process come to life with actual patient cases and coding scenarios at the Walt Disney World Dolphin Resort in Orlando August 25-27.

Start with Coding Fundamentals and stay for Coding and Billing for the Foot and Ankle Surgeon with your newly established foundation.

Coding Fundamentals
August 25
3.5 CECH

Coding and Billing for the Foot and Ankle Surgeon
August 26-27
12 CECH

Don’t leave money on the table! Register now to get the tools you need to simplify your coding and reimbursement practices. Special hotel rates and discounted Walt Disney World admission tickets are also available when you register. Visit acfas.org/PracticeManagement for more information. The ACFAS Clinical & Scientific Research Grant Program is now open! Thanks to support from PICA and the ACFAS Regions, the College will again be offering funding of up to $75,000 for an established investigator and $25,000 for a new researcher.

Letters of intent should be submitted by September 15 at 5pm CT and final applications are due by October 15 at 5pm CT. Awards will be announced in December and funding will be provided in January 2023. All applications must follow a modified NIH R21 format.

Visit acfas.org/ResearchGrant for more information. Mark your calendars! ACFAS is heading to the City of Angels February 9-12 for the 2023 Annual Scientific Conference.

Planning is underway to bring you more cutting-edge, scientific educational programming including pre-conference workshops, new topics in the HUB, international research, hands-on workshops, a wrap party and so much more!

Registration is set to open in August. Head to acfas.org/asc to get the latest news on ACFAS 2023. Program information will be posted as it becomes available, so check back to learn more.

Foot and Ankle Surgery

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A single-center, retrospective database study reviewed patients administered arthroscopic microfracture with or without atelocollagen-induced chondrogenesis (ACIC) for osteochondral lesions of the talus (OLTs). Eighty-seven patients underwent microfracture only and 31 patients received ACIC between 2010 and 2019. No differences in baseline characteristics between groups were observed after matching, and both cohorts had similar improvements to Visual Analog Scale, American Orthopaedic Foot & Ankle Society and Short Form-36 scores up to 12 months. There were significant one-year improvements to physical functioning, physical limitations in usual role activities, pain and social functioning domains in both groups, but the ACIC group also saw significant improvements to general health, vitality and mental health. Subjects in the ACIC cohort were also more satisfied than the microfracture group at all time points. ACIC-treated patients reported superior satisfaction and improvements to quality of life, although clinical outcomes were similar to those who underwent microfracture alone at 12 months.


Researchers theorized that a treatment algorithm based on the correction of symptomatic metatarsus adductus (MA) associated with hallux abducto-valgo (HAV) via tarsometatarsal joint (TMTJ) 2-3 shortening arthrodesis induces realignment of the forefoot rays from two to five and reduction of the talonavicular coverage angle with positive clinical and radiographic results. Clinical and radiographic assessments were conducted before and after surgery at one-year follow-up on 46 consecutive adult patients with MA, midfoot pain, HAV and osteoarthritis and/or instability of the TMTJ 2-3 in whom shortening of the second and third TMT joint adhering to MAA and treatment of the hallux valgus according to deformity was undertaken. The talus-first metatarsal angle was the sole parameter which did not statistically or significantly change following surgery. All other clinical and radiological outcomes indicated significant postoperative improvement. The subsequent application of the algorithm and adequate correction of the HAV enable the realization of good clinical and radiographic results.


A randomized study was held to assess abobotulinumtoxinA's (aboBoNT-A) ability to reduce pain in the treatment of adult patients with hallux valgus (HV). The analysis included a double-blind phase and an open-label aboBoNT-A treatment regimen in participants with an HV diagnosis and no HV surgery. Sixty-three participants received 300U of apaboBoNT-A, 60 received 500U of the drug and 63 were given placebo. The researchers did not observe superiority to placebo with either aboBoNT-A dose in the eighth week, thus the primary endpoint of a change from baseline in numeric pain rating scale (NPRS) was unrealized. At week 12, trending effectiveness was noted with aboBoNT-A 500U versus placebo, while responder rates were greater with aboBoNT-A 500U than placebo. Participants in the aboBoNT-A 500U cohort spent more days with lower NPRS than their lowest baseline score and with NPRS =2 points lower than their mean baseline NPRS at weeks eight and 12 versus placebo. Further clinical assessment is necessary to determine whether botulinum toxins are a workable non-operative treatment option for HV-associated pain.

Practice Management

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Physician practices should consult with legal experts when negotiating a billing agreement in order to ensure the terms are as fair as possible. Issues to take under consideration include having the agreement outline the exact services to be rendered by the billing company, the schedule in which the services are to be provided and any items or services which are excluded. The practice should also attempt to spell out in the written agreement its expectations that preferred teams are assigned to its account. Also critical is making sure the agreement specifies the exact termination and/or remedy process if the practice believes the billing company is not performing as expected. The compliance aspects of the agreement should be clearly understood, and the agreement should also spell out precisely what is included in the fee and when the practice will be charged extra. Finally, the contract should outline a seamless process for transitioning to a new billing company once the billing agreement concludes or is terminated.


Health system executives at a recent HealthLeaders roundtable recommended strategies for creating an effective and sustainable remote patient monitoring (RPM) program. Such programs are becoming increasingly popular as healthcare organizations seek to connect with patients outside the facility to develop better care management protocols. The panel said RPM programs can include digital health tools that gather important data and enable patients and providers to communicate on an as-needed basis, while also allowing providers to modify treatments on demand. Houston Methodist's Sarah Pletcher said [RPM] "can be much more efficient, allowing us to better use hospital, nurse and doctor resources, and there's more freedom, convenience, independence and wellness for the patient, and the technology can allow us to be more proactive."


McKinsey & Co. reports that rising inflation could cost the healthcare sector $70 billion or more in profits this year, while physicians and healthcare systems must cultivate operational excellence and resilience. The global management consultant estimates that inflation topped 5.8 percent from December 2020 to December 2021, and worse may be coming. The healthcare industry's price shifts tend to trail the overall rate since prices, reimbursement rates, labor contracts and other costs typically are set two or three years in advance. "A typical health system could see a 1.2 to 2.8 percentage point decline in profit margin, assuming that its ability to raise prices is typically limited to about 3 percent," the analysis indicates. Assuming a 1.5 percentage point increase on top of current levels, healthcare profits could shrink by 12 percent or $70 billion, while a 3 percent hike could entail a 24 percent drop, or $140 billion lost. Solutions proposed by study authors include boosting productivity by using technology to slash administrative costs; optimizing labor through strategies like workforce health and well-being and flexibility; optimizing supply chains via partnerships with distributors and vendor diversification and expediting the migration to value-based care.

Health Policy and Reimbursement

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The US Centers for Medicare and Medicaid Services (CMS) published its 2023 Physician Fee Schedule proposed rule, recommending lower payments for physicians under fee-for-service Medicare plans, plus expansions related to behavioral health, cancer screenings, dental care and patient access to accountable care organizations (ACOs). The revisions include a reduction in the fee-for-service conversion factor of $33.08, a decrease of $1.53 from 2021; CMS said this accounts for the statutorily mandated update of 0 percent, the expiration of a 3 percent hike in physician payments required by Congress and the required budget neutrality adjustment to count for changes in relative value units. American Medical Association President Jack Resneck Jr. reflected that the proposed fee schedule "would create long-term financial instability in the Medicare physician payment system and threaten patient access to Medicare-participating physicians."

The Medical Group Management Association also said it "is incredibly concerned about the likely impact of the proposed 4.42 percent reduction to the conversion factor, especially in light of the financial uncertainty which medical groups have faced over the past two years stemming from the COVID-19 pandemic, inflation and the staffing crisis." Moreover, CMS wants to incorporate advance shared savings payments into certain ACOs, which can be applied to Medicare patients' social needs.


Individual health insurance rate proposals have so far been filed by insurers in about 12 states, with acasignups.net reporting an average increase of around 10 percent. The increases for 2023 plans come amid pressure for the US Congress to extend enhanced subsidies that are due to expire at the end of this year. State insurance regulators must still approve the rates, and observers expect they will push back on substantial rate hikes. A March study by the US Department of Health and Human Services forecast that the expiration of the enhanced subsidies would prompt around 3 million people to cancel their insurance. Most insurers have not cited the subsidy expiration as a reason for increasing rates, according to the National Association of Insurance Commissioners.


A study conducted by Avalere found more than half of Medicare Part D beneficiaries were liable for paying the full out-of-pocket cost of their generic prescription medication in 2020. Three years before, 45 percent of beneficiaries paid the total cost of a generic at least once, which by 2020 had risen to 63 percent. There were also greater numbers of thyroid, cardiotonic, antianxiety and musculoskeletal therapy agents associated with enrollees paying the full cost. Furthermore, more enrollees in prescription drug plans (64 percent) paid their entire prescription drug costs than those with Medicare Advantage prescription drug plans (62 percent). In addition, 68 percent of beneficiaries with low-income subsidy benchmark plans paid full price compared with 62 percent of those in non-benchmark plans. The Build Back Better Act features provisions designed to reduce Medicare Part D drug spending by allowing the federal government to negotiate prices for expensive medications without generic alternatives, limit cost-sharing for insulin, mandate that Medicare Part D plans cover Advisory Committee on Immunization Practices-recommended vaccines for free and overturn the drug rebate rule.

Medicine, Drugs and Devices

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The US Food and Drug Administration (FDA) in June released a proposed rule to make it easier for drugmakers to designate products from prescription-only to over the counter (OTC) while still retaining a prescription version. The rule would allow OTC drugs to have the same active ingredient, dosage form, strength, route of administration and indication as its prescription-only counterpart. The rule would not form a third class of drugs not requiring a prescription but be available only "behind-the-counter" and could be purchased after consultation with a pharmacist. FDA's rule would create an Additional Condition for Nonprescription Use (ACNU) category for prescription products. Under an ACNU, a drugmaker would need to adhere to multiple FDA-approved conditions to ensure that consumers can correctly self-select and/or use a medication without the supervision of a health care practitioner. FDA has kept the definition broad of what fulfilling an ACNU may involve, but patient education is essential. FDA in particular has suggested that patients view a video or complete a questionnaire, both with assessments to confirm patients' understanding of the medication. In addition to widely defining an ACNU, FDA appears to be offering drugmakers considerable leeway in determining how to deploy it. Examples provided in the proposed rule include providing information through in-pharmacy apps, kiosks and online.


Hospital "superbug" infections, which declined almost 30 percent during 2012–17, made a comeback during the COVID-19 pandemic, according to a new analysis from the US Centers for Disease Control and Prevention (CDC). The downward trend reversed in 2020 as the public health emergency got underway, with infections and deaths among several serious pathogens rising about 15 percent overall from prior-year levels as hospitals were overrun with sicker patients. A shortage of personal protective equipment for staff at the onset of the crisis also helped the drug-resistant pathogens thrive, but the report noted additional contributors. Infection-control protocols often lapsed, for example, with all able bodies at short-staffed facilities assigned to care for COVID patients. Meanwhile, overreliance and inappropriate use of antibiotics prevailed in the absence of other treatments for sick patients. Sadly, noted Arjun Srinivasan, who leads CDC's prevention campaign against superbugs, some patients beat COVID-19 only to succumb to a deadly drug-resistant infection acquired while they were hospitalized. In particular, hospitals saw an increased in carbapenem-resistant Acinetobacter, Candida auris and carbapenem-resistant enterobacteriaceae.


The administration of US President Joe Biden is warning pharmacists that refusing to dispense medications used in abortions might violate federal protections against discrimination. The US Department of Health and Human Services’ Office for Civil Rights has prepared new guidelines that spell out examples when a pharmacist’s refusal to dispense a drug to a patient might be a violation of federal antidiscrimination law. Among the situations are cases involving patients seeking drug treatment after a miscarriage and for an ectopic pregnancy, in which a fertilized egg implants outside the uterus. The guidelines aim to address the challenge pharmacies are facing trying to abide by state laws restricting abortions while dispensing drugs like methotrexate and misoprostol, which can be used to end pregnancies but are prescribed for other uses such as treating rheumatoid arthritis.