News From ACFAS

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We have stars in our eyes and we’re heading to Los Angeles! Register now to join your peers for ACFAS 2023 February 9-12 in L.A.'s largest entertainment district, L.A. LIVE.

Don’t miss four days of enhancing your knowledge with more cutting-edge sessions, hands-on workshops, new topics in the HUB, more international research, and the chance to reconnect with your friends and colleagues.

New this year:

• You can now register separately for Pre-Conference Workshops through registration
• We’ve added a full-day Surgical Pre-Conference Session
• You can now register ahead for the Residency Directors Forum
• Physician Staff, Allied Health, and other groups who previously couldn't can now register online

Visit annualconference.acfas.org for more information on this year’s meeting and to register today. Have a passion to get involved and give back to the profession? Volunteer to serve on a 2023 ACFAS committee, Clinical Consensus Statement panel or as a reviewer of Scientific Literature. ACFAS is looking for members who are leaders, thinkers, team players, and hard workers to work with the College to shape your future.

To volunteer, visit acfas.org/volunteer. Don’t delay - the application deadline is October 31.
The Alliance of Wound Care Stakeholders, of which ACFAS is an active participant, recently submitted two comment letters to the Centers for Medicare and Medicaid Services (CMS). The first was regarding the proposed 2023 Physician Fee Schedule (PFS) which included changes to the way cellular and/or tissue-based products for skin wounds (CTPs), or “skin substitutes”, are coded and paid for in the physician office. The second letter addresses CMS’ proposed FY 2023 Hospital Outpatient Prospective Payment System (HOPPS) and its impacts to wound care.

The proposed 2023 Physician Fee Schedule contains provisions that would reclassify all CTPs as “supplies incident to a physician service,” and package payment for these “supplies” into the practice expense associated with that service. The Alliance’s comments on the PFS discuss how the impacts to physician office based wound care providers and their patients are significant and could create barriers to care that would ultimately lead to increased amputations and infections for patients with chronic non-healing wounds. Specifically:

1. Payments wouldn’t match costs, challenging physician office’s ability to offer CTP treatments. Under this proposed policy, payments for CTPs and their application will simply not cover the costs to physician offices. Without adequate payment many physicians may not be able to afford to provide these medically necessary treatments to their patients.
2. These policy changes may create barriers to patient access and deprive patients these treatment options which, in turn, could ultimately result in an increase in infections as well as amputations.
3. Limited access in the physician setting is particularly concerning, as previous CMS policies have already created barriers to CTPs in Provider Based Departments (PBDs). Many PBDs as a result have not been offering these treatments and more frequently refer these patients to physician’s offices. Now, physicians’ office would also face Medicare payments for CTP products that won’t match their costs, resulting in the reduced ability to offer CTP treatments in this site of service as well and exacerbating patient access issues.

In subsequent comments in response to the proposed HOPPS, the Alliance urged CMS to update inadequate payment methodologies for cellular and/or tissue-based products for CTPs, or “skin substitutes) to ensure appropriate access to care in the hospital outpatient/provider-based department (PBD) site of service. In addition to reiterating the concerns stated in the PFS letter that cross-over into the HOPPS, these recently submitted comments elevate specific recommendations to remove barriers to care by fixing inadequate payments for CTPs in provider-based departments/hospital outpatient settings. Specifically, the Alliance requested that CMS:

1. Enable Provider-Based Departments to be reimbursed for an adequate amount of CTP products for larger wounds. To do this, the Alliance advised CMS to make the following policy change: assign the existing CPT add-on codes (15272 and 15276; 15274 and 15278) to an appropriate ambulatory payment classification (APC) group allowing for payment and issue an exception for the payment of CTP add-on codes.
2. Equalize payment for the application of CTPs on wounds/ulcers of the same size. The Alliance recommended that CMS assign APCs for the same size wound regardless of anatomical location.

ACFAS continues to be an active member of the Alliance of Wound Care Stakeholders and will provide relevant input to aid in the practice of podiatric foot and ankle surgery and our patients. Congratulations to Associate Members who are newly Board Certified by ABFAS this year! Those newly-certified members are encouraged to upgrade their ACFAS membership status to Fellow.

Fellow membership with ACFAS is the highest pinnacle in your career as a DPM. It's time to show your colleagues and patients you are now a Fellow Member with the FACFAS designation, which is only available to ABFAS Board Certified DPMs who are members of ACFAS.

The change of status includes one Fellow certificate that is suitable for framing, the upgrade of your designation to FACFAS, recognition at ACFAS 2023 in Los Angeles including presentation of a Fellow lapel pin, and eligibility to serve on committees and the Board.

The upgrade from Associate to Fellow membership is not automatic. To upgrade, please download the Change of Status application from the ACFAS website.

Foot and Ankle Surgery

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A study sought to assess patient-reported outcomes following first metatarsophalangeal joint (MTPJ) arthrodesis in obese patients compared to non-obese patients. The research involved 94 patients undergoing first MTPJ fusion over the age of 18 with a diagnosis of hallux valgus or hallux rigidus. The average overall Visual Analog Pain scale and Short Form 36 physical component scores showed significant improvement at six-month and 12-month postoperative visits, with no deviations in survey scores, outcomes or complications between weight groups. First MTPJ fusion was demonstrated to improve short-term pain and physical quality-of-life in arthritic obese and non-obese patients.


A retrospective cohort study reviewing 39 limbs that received a partial calcanectomy from 2012 to 2018 was held to assess the proportion of patients healed, time to healing, ulcer recurrence and postoperative functional level versus preoperative state. Age, gender, body mass index, smoking status, coronary artery disease, diabetes mellitus, renal insufficiency, dialysis, peripheral arterial disease, method of closure and percent of calcaneus resected also were evaluated. The cohort has a mean follow-up of 2.3 years. A on-year mortality rate of 11 percent and a major amputation rate of 18 percent were observed. The outcomes indicated a 77 percent healing rate with a median time to healing of 162 days. Patients who were closed primarily healed faster than those who underwent closure by secondary intention. Ulcer recurrence was seen 57 percent of healed limbs, while 76 percent of patients were ambulatory postoperatively.


Researchers analyzed how preaxial polydactyly of the foot affected health-related quality of life (HR-QoL), focusing on 20 children and 15 adults with the condition, 15 children with postaxial polydactyly and 62 healthy controls. Worse outcomes in all Oxford Ankle and Foot Questionnaire (OxAFQ-c) domains were noted among children with preaxial polydactyly and healthy controls and postaxial polydactyly. Children with preaxial polydactyly also scored significantly worse on five foot-specific visual analogue scales than those with postaxial polydactyly and controls. Only the Pediatric Quality of Life Inventory (PedsQL) physical domain indicated a lower outcome in children with preaxial polydactyly than in those with postaxial polydactyly and controls. Children and adults with preaxial polydactyly scored the same across all domains, while the OxAFQ-c and the PedsQL physical domain indicated significantly worse outcomes in children with preaxial polydactyly versus healthy controls and postaxial polydactyly. The presence of large variation suggests major differences between patients. Foot and scar appearance seems to be the biggest issue among children and adults, compared to diminished foot function.

Practice Management

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A statement in Infection Control & Hospital Epidemiology by the Society for Healthcare Epidemiology of America (SHEA) provides recommendations to healthcare providers on ways to decrease inappropriate antibiotic use in future pandemics and how to avoid some of the missteps that occurred during the COVID-19 pandemic. Tamar Barlam, MD, an infectious diseases expert at the Boston Medical Center who led the development of the SHEA white paper, observed: "Dealing with uncertainty, exhaustion, critical illness in often young, otherwise healthy patients, meant doctors wanted to do something for their patients," which often translated into prescribing antibiotics despite there not being a clear indication they were required. The statement addresses what tests to order during a respiratory viral pandemic, when to prescribe antibiotics and when to reduce or discontinue the treatment. Healthcare providers are also advised not to rely on inflammatory markers as key indicators of bacterial or fungal infection and to not use procalcitonin routinely to aid in decision-making to initiate antibiotics. Barlam emphasized that providers should trust their own impressions and avoid resorting to antimicrobials "just in case." In addition, antibiotic stewardship programs should track prescribing during pandemics, gather new information on bacterial co-infections and ensure clinicians have access to this information in a clear format. The US Centers for Disease Control and Prevention estimated that infections and deaths caused by resistant bacteria and fungi increased by 15 percent during the COVID-19 pandemic. For carbapenem-resistant Acinetobacter, that number increased up to 78 percent.


Practices can follow several strategies for dealing with chronically late patients. They should first establish a concise written policy regarding lateness that clearly states the position of the office and the physicians, and advise patients to arrive early to complete their paperwork or to complete the paperwork online; patients should be informed that if they arrive late they will be seen at the end of the day or must reschedule their appointment. Being on time also applies to doctors, who if chronically late should identify the issues and problems that affect arrival. Doctors should also avoid overbooking, while the front office staff should listen to patients' reasons for tardiness, as they may be legitimate. Because charging patients late fees is ineffective, a better recourse is to warn them that they will not be seen or will be moved to the end of the schedule if they are tardy. If chronic lateness continues, doctors should consider sending patients a letter suggesting they get their healthcare elsewhere.


Medications play a prominent role in accidental deaths in the US, and providers should focus on three core areas to prevent such mistakes: engaging patients in medication safety, keeping up to date and implementing safety protocols and practicing collaboration and communication. Efforts in the first domain include evaluating patients' medical history; making targeted queries to determine patient adherence to medications; resolving any healthcare literacy issues and acquiring informed consent for medications prescribed and documenting patients' understanding of the risks. Protocols to follow in the second area include querying state prescription drug monitoring programs to identify others who may be prescribing the same or similar drugs; aggressive screening of patients at each visit; an office tracking process for patients on drugs that require periodic monitoring with specific lab tests and additional monitoring and oversight in cases of polypharmacy. Guidance for the last area includes sharing information with others caring for patients concomitantly; standardizing practices for delivering instructions and counseling to patients related to taking medications and possible side effects to watch for and cultivating trust and collaboration in the practice.

Health Policy and Reimbursement

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A Georgetown University analysis of US Census Bureau data found that during the COVID-19 pandemic, the number of uninsured children declined, likely due to the passage of a provision that prevented states from cutting their Medicaid programs during the public health emergency. The uninsured rate among children declined from 5.7 percent in 2019 to 5.4 percent in 2021, which researchers say equates to 200,000 more children having health insurance. The analysis found nearly 4.2 million children overall were uninsured in 2021. Of those with health insurance, over 50 percent are either enrolled in Medicaid or the Children's Health Insurance Program (CHIP). Between February 2020 and May 2022, enrollment in Medicaid and CHIP grew by 5.6 million, according to the analysis.


A study published in JAMA Open Network analyzed differences in reimbursement for medical decision-making (MDM) billing and time-based billing. MDM billing is applied via a fee-for-service model, which reimburses providers for evaluation and management (E/M) services based on the number and complexity of problems addressed in patient visits. Medical record review, documentation and coordination of care are excluded, which leaves doctors with uncompensated hours for after-hours work. Meanwhile, time-based billing reimburses physicians based on the length of visit, which previously only covered time spent face-to-face with patients. Revisions made last year to time-based billing guidelines now let physicians also receive remuneration for time spent on medical record review, documentation and coordination of care on the day of the visit. The authors associated time-based billing with higher reimbursement for longer evaluation and management (E/M) visits, and MDM billing with higher reimbursement for shorter visits. Because MDM billing still produces the most revenue when visits are shorter, physicians have an incentive to increase volume. "Previous studies have shown that physicians with time constraints are less likely to complete preventive medicine tasks," the authors noted. "Therefore, the flexibility in patient scheduling afforded by time-based billing could help physicians better address preventive medicine."


According to a new report from the Urban Institute, nonelderly adults who lack health insurance or are enrolled in public coverage are over five times more likely than privately insured adults to report unfair treatment in healthcare settings. The report indicates that unfair treatment due to coverage type was reported by 9.6 percent of uninsured adults and 7.4 percent of publicly insured adults, compared to just 1.3 percent of privately insured adults. "Experiences of unfair treatment in healthcare settings have been associated with unmet health needs that can result in poorer healthcare quality and contribute to health inequities," said the report. "The higher rates of unfair treatment experienced by publicly insured and uninsured adults could have many causes, including providers' and office staff members' biases, payment and administrative barriers in Medicaid and affordability issues facing uninsured people."

Medicine, Drugs and Devices

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During a recent webinar sponsored by the US Food and Drug Administration's (FDA) Small Business and Industry Assistance program, FDA Commissioner Robert Califf examined ways to improve abbreviated new drug application (ANDA) submissions. Califf said the agency is developing alternative avenues for evaluating a drug's bioequivalence in an effort to curb the number of unnecessary human studies. The agency is also overhauling its policies to help industry maximize the use of the 505(j) pathway for ANDAs and hopes to offer more clarity in guidances on developing generic versions of drug-device combination products. Califf further said FDA is revising its policies to increase interaction with industry to ensure that submissions are complete. A recent success story for a complex generic cited by Califf was the approval of the first generic version of Allergan's cyclosporine ophthalmic emulsion (Restasis), which is used as single-use eye drops for increasing tear production in patients with dry eye syndrome. The generic approval followed 10 years of research funded under the Generic Drug User Fee Amendments (GDUFA) to develop bioequivalence recommendations for the drug. FDA is also working on "enhancements" to its complex generics program through the third GDUFA iteration. Those enhancements include additional science meetings with industry before and after submission to allow sponsors to have appropriate feedback about their development programs and to encourage higher quality ANDA submissions.


The latest University of Michigan National Poll on Healthy Aging finds 70 percent of older US adults report joint pain or arthritis, with nearly half saying it constrains daily activities. Researchers surveyed 2,277 older adults aged 50 to 80 years, and 45 percent of those with arthritis symptoms said they experience pain every day. Meanwhile, 49 percent of those with joint pain said the pain limits their usual activities at least somewhat, compared to 36 percent who said it interferes with their day-to-day living. Three-quarters consider arthritis and joint pain a normal part of aging and two-thirds | take over-the-counter pain relievers; 26 percent said they take supplements, while 11 percent use cannabidiol and 9 percent use marijuana. Fewer than one in five respondents use prescription-based treatments, including prescription-only nonopioid pain relievers, steroid joint injections, oral steroids, opioids and disease-modifying antirheumatic drugs. "Older adults with fair or poor physical or mental health were much more likely to agree with the statement that there's nothing that someone with joint pain can do to ease their symptoms, which we now know to be untrue," said the University of Michigan Institute for Healthcare Policy and Innovation's Preet Malani. "Health providers need to raise the topic of joint pain with their older patients and help them make a plan for care that might work for them."


A National Institute of Diabetes and Digestive and Kidney Diseases-funded clinical trial compared four drugs commonly used for treating type 2 diabetes, to determine that insulin glargine and liraglutide were most effective in maintaining blood glucose levels in the recommended range. All four drugs were added to treatment with metformin, the first-line type 2 diabetes medication. Study participants taking metformin in conjunction with liraglutide or insulin glargine realized and maintained their target blood levels for the longest time compared to sitagliptin or glimepiride. However, no combination overwhelmingly bested the others, and nearly three quarters of participants could not maintain the blood glucose target over four years. The researchers also observed that severe hypoglycemia was generally uncommon among subjects, but impacted more participants assigned to glimepiride. Moreover, gastrointestinal symptoms occurred more frequently with liraglutide than with the other three treatment cohorts.