News From ACFAS

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The ACFAS Nominating Committee is looking for the best and brightest to participate in the upcoming election to serve on the College’s Board of Directors. If you are an ACFAS Fellow, believe you are qualified and would like to help lead the profession, submit your nomination application by September 23, 2022. Visit acfas.org/nominations for more information, including complete details on the recommended criteria for election candidates.

The Nominating Committee will announce recommended candidates to the membership on October 26. Online voting for members will start no later than November 28 and will end on December 14. The elected directors will be announced shortly thereafter and will start their term of service at the ACFAS 2023 Scientific Conference on February 9-12, 2023 in Los Angeles. The ACFAS Clinical & Scientific Research Grant Program is accepting applications! 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 tomorrow, 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. The ACFAS Fellowship Committee recently determined the following two fellowships exceed the minimal requirements to be upgraded to full Recognized Status with the College after their first successful year:

Advanced Foot and Ankle Reconstructive Limb Salvage Fellowship
Salt Lake City
Program Director: Scott Clark, DPM, FACFAS and David Seegmiller, DPM, FACFAS

Virginia Mason Franciscan Health Foot and Ankle Sports Medicine Fellowship
Seattle
Program Director: Eric Heit, DPM, FACFAS

ACFAS highly recommends taking on a specialized fellowship for the continuation of foot and ankle surgical education after residency. If you are considering a fellowship, visit acfas.org to review a complete listing of programs and requirements. Have you recently moved or gotten a new phone number? Keep your contact information current to gain new patients from FootHealthFacts.org, connect with your colleagues through the ACFAS Member Directory, and get the latest news from ACFAS and JFAS.

Log into your account at acfas.org to access your profile to:

• Check and update your work and personal email addresses, fax number and your work, home or cell numbers.
• Opt in to include yourself in the “Find an ACFAS Physician” search tool on FootHealthFacts.org and in the ACFAS Membership Directory.
• Confirm your preferred mailing address for JFAS and ACFAS Update.

Log in to acfas.org and update your profile whenever you have a change in address or information. Reach out to the Membership Department if you have any questions.

Foot and Ankle Surgery

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Researchers reviewed cases of patients treated using endoscopic plantar fascia release (PFR) with calcaneal spur resection (CSR) to determine the reasons for complications. Forty patients and 40 feet (22 females, 18 males) were enrolled, and average age and body mass index were 51.1 years and 24.7 kilograms/square meter, respectively. The mean follow-up duration was 5.7 years. The visual analog scale for pain improved from 80.7 to 8.8 millimeters, while the Japanese Society for Surgery of the Foot score improved from 44.7 to 95.6 points. Complications were seen in eight patients, of whom three had flatfoot, three had an injury to the first branch of the lateral plantar nerve, one had scar pain and one had a wound infection. The 40 patients who underwent endoscopic PFR with CSR for plantar fasciitis had good outcomes with a high complication rate, and the invasiveness of creating the working space for the combined procedures was believed to be responsible.


A retrospective study was held to determine if bone mineral density (BMD) contributes to the number of fractured malleoli versus soft tissue injury in adult ankle fractures. Data was obtained from a registry of ankle fractures that were surgically treated by the foot and ankle team from July 2017 to August 2019 and in which a preoperative computerized tomography (CT) scan was conducted. Regional bone mineral density was quantified by calculating the average Hounsfield Unit (HU) on axial CT images of the distal fibula and tibia. The average HU was then compared to the number of fractured malleoli. A total of 108 patients met the study criteria. A statistically significant relationships was observed between decreased BMD with increasing age and male gender. After adjustment for the covariates age and gender, no statistically significant relationship was seen between BMD and the number of malleoli involved in a given ankle fracture. The implication is that increased age and biologic female gender is significantly related to lower BMD as identified through HU.


Researchers examined the short- and long-term outcomes of severe hallux valgus (HV) treated with a L-Reverse osteotomy, with 28 patients assessed preoperatively, at three months and four or more years postoperatively. Pre-operative intermetatarsal angle (IMA) changed from 18.1 degrees to 7 degrees and HV angle (HVA) from 38.5 degrees to 10.0 degrees at three-month follow up. Long-term follow up was of 5.6 years, and IMA value was 7.5 degrees and HVA was 10.1 degrees with no statistical difference with initial correction. Median American Orthopaedic Foot and Ankle Society score was 92.7.

Practice Management

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Analysis of 578 private equity (PE)-acquired dermatology, gastroenterology and ophthalmology physician practices and 2,874 similar independent practices found spending, new and unique patient volume and total encounters rose differentially versus controls. In comparison with the control practices, the PE-acquired physician practices saw an average increase of $71 charged per claim and $23 in the allowed amount per claim. The PE-acquired practices also boosted numbers of unique patients seen by 25.8 percent compared with control practices, fueled by a 37.9 percent gain in visits by new patients. Cumulatively, their volume of encounters increased by 16.3 percent versus the control group, with a 9.4 percent expansion in the share of office visits for established patients billed as longer than 30 minutes. Modest differences along key outcomes were noted within specialties.


The American Medical Association's Marie Brown, MD, suggests up to 50 percent of a physician's electronic health record (EHR) workload could be eliminated through eight changes. The first change is to reduce inbox notifications, with Brown noting many such alerts are of no value to the doctor and do not improve patient care. Only notifications with a favorable cost-benefit ratio should be retained, while simplifying logins and extending time before auto-logout are also recommended. Practices should also consider extending intervals for password reset requirements and using password-keeper programs; reducing clicks and hard-stops in ordering; removing requirements for password revalidation and cutting down on note bloat. Order-entry processes can also be streamlined by auto-populating necessary discreet data fields if the information already exists in the EHR.


A member of a medical practice insulting and silencing another creates the feeling that anyone feeling "lesser" in the group may stay quiet to defend themselves from those with higher perceived rank or privilege. But speaking up is critical, especially if the issues raised relate to safe patient care. The practice leader can help the injured colleague by arranging a confidential one-to-one dialogue with them, asking focused questions that invite them to speak. The next step is to brainstorm what can be done to support that colleague's voice, their belonging and their success. The leader should tell this member what they will do this week to support them and others' participation and then express appreciation for the value they bring to the group while arranging a follow-up conversation. Leaders should also begin each meeting by inviting and listening to contributions from all participants, appreciate each person after their first contribution, acknowledge their ideas without judging their value and consciously wait to let others respond to comments.

Health Policy and Reimbursement

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A new analysis of fee-for-service Medicare claims from the US Department of Health and Human Services' Office of the Inspector General (OIG) indicates only a small number of telehealth providers are billing for virtual care in a potentially fraudulent manner. The report estimates that roughly 1,714 out of 742,000 Medicare-certified providers billed for telehealth in a way suggesting high risk of fraud, waste or abuse in the first year of the pandemic. Approximately 672 providers billed both a site fee and a telehealth service fee for more than 75 percent of their visits, a practice banned by Medicare coverage. The researchers suggested some practices may be doing this "to inappropriately maximize their Medicare payments for each visit." While only 41 of the providers billing in a potentially fraudulent way appeared to be associated with telehealth companies, OIG could not identify them from Medicare claims data. These findings, in combination with another recent OIG analysis determining that urban Medicare beneficiaries were more likely to use telehealth than rural counterparts, are giving lawmakers a clearer idea of telehealth users and what risks the billing process presents. OIG advised the US Centers for Medicare and Medicaid to closely watch the risky providers, instill more transparency in cases where clinicians might bill under another supervisor's authority and fortify efforts to monitor such billing practices.


According to the US Census Bureau's Household Pulse Survey, of the 8.1 percent of uninsured Americans aged 18 and older, 6 percent are non-Hispanic whites, 9.2 percent are non-Hispanic Black individuals and 17.1 percent are Hispanics. The Household Pulse Survey also found that coverage rates varied across income levels, with 13 percent of adults with annual incomes below $50,000 lacking insurance, compared to 3.2 percent of those with incomes of $75,000 or more. Most uninsured adults cited health insurance costs as a main reason why they are uninsured.


The US Federal Trade Commission (FTC) is looking into Amazon's $3.9 billion purchase of One Medical. Both companies received requests on Friday for additional information in connection with an FTC review of the deal, according to a securities filing made by 1Life Healthcare Inc., One Medical's parent company. Amazon's acquisition of the concierge-type medical service, which has about 190 medical offices in 25 markets, was announced in late July. However, some groups have called on the FTC to block the deal, saying it would further expand Amazon's enormous market reach. Krista Brown, a senior policy analyst with the American Economic Liberties Project, asserted: "Allowing Amazon to control the health care data for another 700,000 plus individuals is terrifying. Amazon has no business being a major player in the health care space, and regulators should block this $4 billion deal to ensure it does not become one."

Medicine, Drugs and Devices

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New ways of paying for Medicare Part B drugs need to be examined, according to members of the Medicare Payment Advisory Commission (MedPAC). Part B-covered drugs are those that are dispensed in physicians' offices or other outpatient facilities. At MedPAC's September meeting, the group's principal policy analyst, Nancy Ray, MS, noted that price has been the largest driver of Part B spending growth, with Medicare spending $40.7 billion on Part B drugs in 2020. Of that total, 52 percent came from 20 drugs. Medicare currently pays for Part B-covered drugs based on the average sales price (ASP) of the drug plus a 6 percent administration fee. MedPAC staff proposed that Medicare could pay the ASP plus the lesser of three options for the administration fee: 6 percent, 3 percent plus $21 or $175 per drug per day, although other figures could be considered, Ray said. She also proposed using reference pricing in cases where higher-priced drugs have a lower-priced therapeutic alternative. At present, the economic incentive is to select a higher-priced drug that will result in a larger reimbursement because the administrative fee is based on a percentage of the drug's price. Ray suggested such alternative payment options as using the lowest ASP of the products in the reference group, the volume-weighted ASP of all products in the reference group or the lower of the volume-weighted ASP and the ASP of the drug being administered.


Researchers sought to gauge the safety and effectiveness of an open-source automated insulin delivery (AID) system among people with type one diabetes. They conducted the randomized, controlled CREATE (Community Derived Automated Insulin Delivery) trial to assess an open-source AID system as compared with sensor-augmented insulin-pump therapy in children and adults with type one diabetes. The trial was conducted at four sites in New Zealand and funded by the country's Health Research Council. Eligible patients were aged seven to 70 years, had received a diagnosis of type one diabetes at least one year earlier, had at least six months of experience with insulin-pump therapy and had a mean glycated hemoglobin level of less than 10.5 percent. In all, 48 children and 49 adults underwent randomization, with 44 assigned to open-source AID and 53 to the control group. At 24 weeks, the researchers found that the use of an open-source AID system resulted in a significantly higher percentage of time in the target glucose range compared with the use of a sensor-augmented insulin pump. Patients in the AID groups spent over three hours longer in the target range per day compared with patients in the control group. There were no reports of severe hypoglycemia or diabetic ketoacidosis in either group.


An analysis in Health Affairs found that cancer drugs recently approved through the US Food and Drug Administration's (FDA) accelerated approval pathway did not receive a price increase after they went through a confirmatory trial to demonstrate evidence of clinical benefit. Such absence of a price increase indicates there is little financial benefit for sponsors to quickly move forward with confirmatory trials, according to the study authors. Richard G. Frank, PhD, of the Brookings Institute in Washington, DC, and colleagues examined the price changes of 16 drugs approved through the accelerated approval pathway using surrogate endpoints that subsequently received coverage under Medicare Part B between 2012 and 2018. Of 16 drugs analyzed, most (69 percent) were biologics and 13 drugs were unique applicants. The researchers analyzed the status of each drug in June 2021 and found 16 of 39 indications (41 percent) were converted to regular approval following a confirmatory trial, 19 indications (49 percent) had confirmatory trials underway, and four indications (10 percent) were withdrawn. Overall, no drug was priced under $5,500, and one-third of the drugs were priced above $65,000 for a 28-day prescription. Because a positive trial result did not significantly affect the price of a drug on the market and a negative outcome can decrease the drug's market price, companies have "very little incentive" to conduct confirmatory trials, the authors concluded. One potential solution would be to have the US Centers for Medicare and Medicaid create an "economic incentive" for companies that promptly complete confirmatory trials, such as a price adjustment under Medicare Part B. Another solution could be to have FDA enforce the timely completion of confirmatory trials through federal legislation.