News From ACFAS

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On behalf of the The Podiatry Foundation, please see the below opportunity for ACFAS members:

As a member of ACFAS, you appreciate the value of research in the field of podiatric medicine. To stimulate the interest in this critical area, The Podiatry Foundation has developed a Request For Proposals for research covering most areas of podiatry.

We invite you to review this proposal and apply online through your IRS approved not-for-profit organization (as either a 501c3 or 501c6) for a research grant. Submit your intention to participate by November 30, 2022. Proposals received between October 1, 2022 and June 30, 2023 will be considered for support.

If you have any comments, questions, or concerns, please email david@thepodiatry.foundation. Practice Management Webinar Wednesday is back with tips to help your practice succeed!

Join us tonight for How Do I Know If My Practice is Doing Well? at 7:00 pm CT. Bela Pandit, DPM, FACFAS and Heraj Patel, DPM, FACFAS will show you how to do a deep dive analysis of your practice by accurately determining and measuring your top revenue makers and losers, along with how to adjust accordingly—all without hiring an outside consulting company! Register now to join us and earn 1.5 CME credits.

The series continues next week with:

Malpractice Preparation: Because it Happens to Everyone
October 26 | 7-8:30pm CT | 1.5 CME
Ellianne Nasser, DPM, FACFAS; Ross Taubman, DPM; Al Ng, DPM, FACFAS; Barry Rosenblum, DPM, FACFAS and Maryellen Brucato, DPM, FACFAS
While nobody can fully exempt themselves from a possible malpractice case, experts share some tools to help you avoid getting into litigation with patients. You’ll also hear tips and pearls for documentation, peri-operative management and discussions on complications with patients.

Visit acfas.org/practicemanagementeducation to ensure you don't miss out! Are you currently a first-year resident interested in getting more involved with ACFAS? Are you interested in helping to advance the profession, patient care and the future of the College by volunteering to serve on an ACFAS committee? The College is looking for members like you!

For 2023, there are a very limited number of volunteer positions available for first-year residents on the following ACFAS committees: Consumer Education, Health Policy, Membership, Post Graduate Affairs, Practice Management and Research/EBM. You can find information about each committee at acfas.org/volunteer.

Interested in being considered? Submit the online application with your CV and a short statement of interest. Applications are due by October 31, and committee selections will be notified by the end of the year.

Please contact Michelle Kennedy, Director of Member Engagement & Post Graduate Affairs with any questions.
Get ready for College’s annual Residency Directors Forum at ACFAS 2023! Co-sponsored by the Council of Teaching Hospitals (COTH), this year’s forum is happening Wednesday, February 8 from 12:30 - 6:30 pm.

The Residency Directors Forum is geared to assist resident educators in optimizing their resident review and oversight such as social media dos and don’ts, CPME mock site-visits, DEI advancement within our residency learning environments, and curriculum building – for residents and for faculty. Hear from a roundtable of deans, residency and fellowship educators. The day will conclude with an update on the CPME 320/330 re-write status.

Onsite registrations are not accepted, so visit acfas.org/asc to register and save your spot today! We’re rolling out the red carpet for residents with Residents Day at ACFAS 2023! Head to Los Angeles a day early to join us on Wednesday, February 8 from 9:00 am - 2:00 pm. This year’s Residents Day is generously sponsored by Organogenesis.

Pick up tips from the experts as you complete your post graduate education and make plans for your career as a foot and ankle surgeon – and do it in style! Learn from experienced foot and ankle surgeons on those important transitional non-surgical topics including:

• The Simple Rules of Achieving Board Certification
• The Art of Negotiation: From CVs to Interviews and Contracts
• Why Can’t We All Just Get Along? Conflict Resolution
• Post-Residency Bazinga: Making the Next Step the Right One

Gain the tools to help with post-residency life such as promoting yourself properly, illustrating the importance of proper documentation and informed consent and give you advice on how to find a job. Visit acfas.org/asc to learn more and register today!

Foot and Ankle Surgery

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An observational study sought to measurably determine the degrees of improvement of a dysmetric phalanx following incomplete phalangeal osteotomy with minimally invasive surgery. The points of improvement were determined using the American Orthopaedic Foot and Ankle Society (AOFAS) scale score. Thirty patients with curly toes received nicortical osteotomy of the affected phalanx between May 2021 and June 2022, with 33 toes treated in all. The average reduction of the convergence angle was nine degrees, while the average improvement in the AOFAS scale score was 53 points at six months and reached nearly 90 points.


A study was held to compare the clinical outcomes of neurectomy in treating Morton’s neuroma through plantar and dorsal approaches. Twenty patients with a mean age of 48.5 ± 13.0 years who underwent excision of a Morton’s neuroma that was unresponsive to conservative treatment were retrospectively analyzed from June 2014 to June 2021. All neurectomies were conducted via a plantar or dorsal approach, with eight patients receiving dorsal surgery and 12 undergoing plantar surgery. The average follow-up time was 28.9 ± 12.9 month, and no statistically significant difference was observed between the dorsal and plantar approach groups in terms of postoperative pain measured by the visual analogue scale score. Postoperative American Orthopaedic Foot and Ankle Society scores and Foot and Ankle Ability Measure outcomes did not significantly differ between the groups. Complications reported in the dorsal approach cohort were less than those of the plantar cohort, mainly limited to discomfort in wearing shoes. The appearance index differed significantly between both groups.


A single-site, non-randomized observational study used Optical Coherence Tomography (OCT) to obtain skin images at 1,305 nanometers, generating real-time image of 17 patients' skin and wounds 1-2 millimeters (mm) under the surface. Vertical B-scan, en-face and three-dimensional images were rendered to calculate surface and Dermal-Epidermal Junction roughness, the optical attenuation coefficient, light absorption and scattering and blood flow metrics. Diabetic and non-diabetic subjects had increases in both the Ra and Rz of the wounded compared the control skin. There was an average decrease in blood flow of 63 percent from control to wounded skin at a depth of 0.6 mm across all subjects, which rose to 76 percent in those with diabetes and fell to 55 percent in those without diabetes. An increase in the Ra and Rz values and a decrease in blood flow between the wounded skin and control was seen.

Practice Management

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The pandemic has squeezed many independent doctors out of business by driving the expansion of big hospital systems. Personal risks and fatigue have played a role in doctors' decisions to retire or sell their practices to hospital systems, but North Carolina-based clinician Andrew Bush wants to avoid such a fate for his Central Carolina Orthopaedic Associates practice. Some doctors and experts say the trend highlights how billions in federal aid at the beginning of the pandemic benefited large hospital systems. Bush said patient visits to his practice have reverted only to half of pre-pandemic levels because high inflation makes appointments unaffordable. Meanwhile, reports from two states and interviews with academics and doctors indicated that a disproportionate number of wealthy hospitals received grants, loans and other financial aid they did not need as much as independent practices and rural hospitals. According to North Carolina's treasurer, seven large hospital systems in the state received $1.5 billion in COVID relief while their cash and investments cumulatively grew by $7.1 billion from 2019 to 2021.

Bush said COVID relief helped him keep his 13 employees on the payroll but did not cover losses from canceled surgeries and office visits. He advises against opening an independent practice, saying the burden of sparring with insurers for payment and the low federal reimbursement rates for treating low-income patients are insurmountable obstacles. Duke University Professor Barak Richman said the loss of independent physician practices could reframe the doctor-patient relationship,as physicians working for hospital systems tend to refer patients for extra testing and more aggressive treatment, which raises the hospitals' profits.


Medical office staff should prioritize a number of areas when cleaning the office. Furniture and other surfaces in high-traffic areas should be sanitized with EPA-registered disinfectants. Items to clean in the reception area include phones, computer equipment, clipboards, door handles and counters. Surfaces should also be dusted regularly, while feather dusters should be avoided in favor of a dampened cloth, a handheld vacuum or a microfiber duster; staff should not wait until dust becomes visible on surfaces. Examining rooms should be thoroughly cleaned after each use with proper disinfectants,. All doorknobs, cabinets, light switches and other high-touch zones should be wiped after patients leave. Bathroom cleanliness is also critical. Practices should schedule for cleaning countertops, disinfecting toilets, sinks and other fixtures. Restrooms also must be constantly stocked with soap, paper towels and toilet paper.


It is easier to run a direct care practice than to run a conventional medical practice. A good starting point is incorporating "direct care" or "DPC" in the practice's name. The owner should also make sure the name is not already taken and purchase the domain name immediately if the price is reasonable. The practice should next set up a website, while a presence on Facebook, LinkedIn, Google Business, Instagram and elsewhere increases the likelihood that search engines will help patients find the practice. Website development need not be expensive, as current website builders are highly affordable. An email address and logo are also essential. Most direct practices are run as an LLC or S corporation, which offer tax advantages over sole proprietorships. Direct practices should also register their business in compliance with the mandates of their state, as well as register with the IRS and secure an employer identification number.

Workman's Compensation insurance is needed for staffers in the event of accidents or injuries on the job as required by the state. Practices must also change their address with their state medical board and acquire a dispensing practitioner license if their state permits medication dispensation. Adherence to the state Department of Health's process for medical waste disposal is required. Malpractice insurance is also a necessity, which for direct care practices is usually less costly.

Health Policy and Reimbursement

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Most large insurers participating in the Medicare Advantage program have been charged with fraud by allegedly incentivizing doctors to diagnose diseases that might have been nonexistent. A New York Times review of dozens of fraud lawsuits, inspector general audits and probes by regulators indicates widespread exploitation. The government allocates Medicare Advantage insurers a set amount of payment for each enrollee, with higher rates awarded for sicker patients; the lawsuits alleged that insurers have set up intricate systems to make their patients appear as ill as possible, often without providing additional treatment. Federal audits showed eight of the 10 biggest Medicare Advantage insurers have submitted inflated bills, while four of the five largest companies have faced federal litigation claiming that efforts to overdiagnose their customers constituted fraud.

Although Congress empowered the Centers for Medicare and Medicaid Services (CMS) to lower insurers' rates in response to evidence of systematic overbilling, the agency has opted not to take such action. Several experts have urged reducing all Medicare plans' payments, but few analysts expect major legislative or regulatory revisions. "The big healthcare plans know it's wrong, and they know how to fix it, but they're making too much money to stop," says former Medicare regulator Richard Gilfillan. "Their CEOs should come to the table with Medicare as they did for the Affordable Care Act, end the coding frenzy and let providers focus on better care, not more dollars for plans."


The US Centers for Medicare and Medicaid Services (CMS) is soliciting public feedback on establishing a centralized, nationwide directory of healthcare providers and services, according to an unpublished notice in the Federal Register and a release from the agency. CMS said the directory would be a resource for patients seeking provider services like spoken language or comparing health plan networks; it could replace the current "fragmented" database ecosystem. The notice cited a 2019 provider survey from the Council for Affordable Quality Healthcare indicating that physician practices collectively spend $2.76 billion a year, or $998.84 per month per practice, on directory maintenance. Switching data collection to one platform would cumulatively save $1.1 billion annually, or $4,746 annually per practice. CMS added that an interoperable platform could support provider and payer organizations by eliminating workloads in updating their own directories, sharing health information and disclosing public health data. The agency requested comments on what data should be included, a potential technical scheme for the directory, priorities if a phased implementation is undertaken and other prerequisites and actions.


The Biden administration issued a final rule to fix the "family glitch" in the Affordable Care Act (ACA) that pertains to the affordability of employer coverage ahead of the 2023 open enrollment period that begins November 1. The rule will ensure more families can receive ACA subsidies if employer-based health insurance options are not affordable after adding family members to the policy. Employer-based insurance is "affordable" if it accounts for less than 10 percent of an employee's income for single coverage. The Kaiser Family Foundation estimated approximately 5.1 million Americans, most of whom are children, are impacted by ACA's family glitch. The White House expects nearly 1 million people to either gain coverage or see reductions in premiums under the final rule.


The Medical Group Management Association's (MGMA) 2022 Annual Regulatory Burden Report estimates that 89 percent of over 500 surveyed medical group practices said their overall regulatory burden has intensified during the past year. The poll ranked prior authorization requirements as the leading burden for providers, with mandates stemming from the No Surprises Act and Medicare's Quality Payment Program in second and third place. Nearly all respondents, 97 percent, felt a reduction in regulatory burden would allow their practice to redirect resources into patient care. "Medical groups continue to face growing challenges with prior authorization, including delays in prior authorization decisions, inconsistent payer payment policies and processing prior authorizations for routinely approved items and services," the survey stated. Such factors reportedly prompted 89 percent of respondents' practices to hire or redistribute staff to work on prior authorizations.

"The increase in prior authorization requirements year after year is simply unsustainable," said MGMA's Anders Gilberg. "Practices are being forced to divert resources away from delivering care to contend with these onerous and ever-changing requirements. It is time that Congress acts to put commonsense guardrails around prior authorization programs. We urge the expedient passage of the Improving Seniors' Timely Access to Care Act before the end of this year."

Medicine, Drugs and Devices

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Researchers found that the rheumatoid arthritis drug auranofin can potentially be repurposed to improve diabetes-associated symptoms. Although scientists have identified definitive associations between inflammation in white adipose tissue and insulin resistance in humans and rodents, broad anti-inflammatory treatments lack durable clinical efficacy on diabetes. In the current study, the researchers explored in more detail this association between inflammation and diabetes by looking for existing drugs that might affect both conditions. Their findings were published in Cell Metabolism.


Stanford University engineers have constructed an untethered exoskeleton that helps users walk and run faster, with less exertion. Stanford's Steve Collins said the device "personalizes assistance as people walk normally through the real world," and has yielded "exceptional improvements in walking speed and energy economy." The "robotic boot's" motor interacts with calf muscles to give the wearer an extra push with each step, while a machine learning-based model trained over years on exoskeleton emulators adds personalization. Stanford's Patrick Slade said the exoskeleton saves twice as much energy as previous exoskeletons in treadmill tests. The researchers calculated that the device's energy savings and speed upgrade were equivalent to "taking off a 30-pound backpack."