News From ACFAS

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After careful review of applicants applying to serve on the ACFAS Board of Directors, the Nominating Committee recommends these Fellows to run for three open seats in the upcoming election:

• Incumbent: Matthew E. Williams, DPM, FACFAS
• Jason A. Piraino, DPM, MS, FACFAS
• Ronald G. Ray, DPM, FACFAS, WCC, PT
• Brett D. Sachs, DPM, FACFAS

There are two (2) three-year terms that will be filled by election. Candidates will be posted on the ACFAS website and highlighted in the November 22 issue of This Week. Online voting will be open November 28 - December 14, 2022. Eligible voters will receive an email with a unique link to the election website when the election opens.

ACFAS sincerely thanks the 2022 Nominating Committee for their service on this important group: Chair Thanh Dinh, DPM, FACFAS; Michael Cornelison, DPM, FACFAS; Michael Lee, DPM, FACFAS; Erin Robles-Sherman, DPM, FACFAS; Jeff Baker, DPM, FACFAS; Roya Mirmiran, DPM, FACFAS and Mark Prissel, DPM, FACFAS. Register now to join us for the conclusion of Practice Management Webinar Wednesday!

Malpractice Preparation: Because it Happens to Everyone will be held tonight at 7:00 pm CT. Ellianne Nasser, DPM, FACFAS; Ross Taubman, DPM, FACFAS; Al Ng, DPM, FACFAS; Barry Rosenblum, DPM, FACFAS and Maryellen Brucato, DPM, FACFAS will share tools to help you avoid getting into litigation with patients. Earn 1.5 CME credits as you hear tips and pearls for documentation, peri-operative management and discussions on complications with patients.

Visit acfas.org/practicemanagementeducation to secure your spot! The deadline to volunteer to serve as an ACFAS committee member, Clinical Consensus Statement panelist or Scientific Literature reviewer is just around the corner. Don’t miss your chance to help the College shape the future of our profession in 2023. If you would like to apply to volunteer, visit acfas.org/volunteer by Monday, October 31. The Council on Podiatric Medical Education (CPME) seeks input as they undertake the rewrite of publications CPME 220, Criteria and Guidelines for Recognition of a Specialty Board for Podiatric Medical Practice and CPME 230, Procedures for Recognition of a Specialty Board for Podiatric Medical Practice.

CPME is conducting a survey to obtain the opinions of the podiatric community of interest regarding crucial elements of specialty certification by Tuesday, November 1.

To learn more and submit your comments, please visit https://www.surveymonkey.com/r/THFZ5MN. The First Ray Virtual Symposium is quickly approaching. Mark your calendar for Saturday, November 19 to learn surgical options to correct first ray deformity, along with complication and revision options – completely online!

You won’t want to miss this unique opportunity to interact with faculty and attendees during the live program with the ability to continue the conversation through an exclusive online discussion forum.

Register now and you’ll also get access to the recorded program. You’ll earn 4 CME whether you particpate live or on-demand! Learn more and register at acfas.org/firstrayvirtualsymposium. Whether you’re new to coding or need to refresh your skills, ACFAS has a course designed just for you! Get expert tips and insights when you attend the ACFAS 2023 pre-conference programs on Wednesday, February 8.

Coding and Billing for the Foot and Ankle Surgeon | 8 am - 5:30 pm
Get properly reimbursed for the care you provide! Hear what’s new in coding for 2023 as you participate in surgical coding scenarios including forefoot reconstruction, arthrodesis, office procedures, rearfoot and ankle reconstruction, tendon surgery, arthroscopy, trauma and diabetic foot surgery.

Coding Fundamentals | 2:30 - 6:15 pm
Start or refresh your coding and billing foundation! Walk away with an understanding of CPT and E&M codes, common modifiers and their use, and how to code minor in-office procedures. This course is ideal for residents, fellows, new practitioners, office staff of foot and ankle surgeons or anyone who wants to learn more of the basic coding and billing terminology and process. If you’re attending Residents Day in the morning, this is a great next step to learning more about coding and billing for your future practice.

Learn more and register at acfas.org/asc.

Foot and Ankle Surgery

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A comprehensive review and meta-analysis of randomized controlled trials (RCTs) in the PubMed, Cochrane Library and EMBASE databases was conducted to determine whether locked intramedullary nail (LIMN) fixation offers equal or superior treatment of acute ankle fracture to open reduction and internal fixation (ORIF). Four RCTs involving 359 participants with ankle fractures were included. Results showed that the LIMN fixation group had statistically superior functional outcomes at the three-month follow-up and wound-related complications. Patients in the LIMN fixation group saw no statistical advantage in terms of nonwound-related complications, total complications or mid-term follow-up functional outcomes. No statistical difference was observed between the LIMN and ORIF cohorts regarding operation time and quality of reduction.


Researchers characterized an arthroscopic ligament reconstruction protocol involving the use of the tendon allograft for patients with chronic lateral ankle instability (CLAI) as compared with open ligament reconstruction. Ten patients (four men and six women) with CLAI underwent arthroscopic ligament reconstruction with tendon allografting between November 2017 and June 2019, while a 10-patient control group received open tendon allograft reconstruction. The average surgical duration was 118 and 110 minutes in the arthroscopic and open groups, respectively. Scores on the American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot scale improved significantly compared with preoperatively on the two-year follow-up, from 71.3 to 96.4 in the arthroscopic group and from 68.6 to 96.7 in the open group. There were no significant differences between the two cohorts on post-operative AOFAS, pain visual analog scale, Karlsson Ankle Functional Score and 12-Item Short Form Health Survey scores. Yet the Tegner activity score was much higher in the arthroscopic reconstruction group versus the open group.


A quality improvement study sought to boost peripheral nerve block (PNB) administration for ankle fracture surgeries (AFSs) to more than 50 percent by Jan. 1, 2021. Seventy-eight and 157 patients were assigned to undergo PNB and not undergo PNB for AFS, respectively. PNB administration rose from <5 percent to 53 percent after implementation of the improvement bundle. Mean post-anesthesia care unit (PACU) and 24-hour opioid analgesic consumption was lower in the PNB group, and more patients in the PNB cohort did not require PACU opioids.

Practice Management

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A recent US Department of Health and Human Services (HHS) Office of the Inspector General data brief offers clues for revenue cycle leaders to correct telehealth billing errors. Epstein Becker Green's Amy Lerman recommends reading the brief, calling it "a useful compliance roadmap for providers and one that should inspire both providers and telemedicine companies to take a closer look at internal coding, billing, auditing and monitoring practices, which serve as important checks and balances in any healthcare organization." Revenue cycle staff are also urged to read HHS' list of common telehealth billing errors when reviewing claims, including wrong codes, documentation and time. Discovery of an error should be followed by an inquiry into its cause and scope and then remedial action. Lerman says a thorough root cause analysis should be conducted to see if bigger-picture solutions are warranted, while Sheppard Mullin partner Sara Shanti advises enlisting outside help if the problem's scale is significant. Finally, the revenue cycle should be fully documented in writing.


Harvard University Professor Lisa Iezzoni polled anonymous primary care physicians and specialists across the country in focus groups, learning that many do not want disabled patients. Some doctors said their office scales could not accommodate wheelchairs, so they had told patients to go elsewhere to be weighed, or they would inform new patients that the practice was closed. They also explained that the limited amount of time they are allotted to spend with individual patients discourages seeing patients with disabilities. Communication difficulties were cited, with one doctor saying he had hired a sign language interpreter for a deaf patient, which cost $30 for each visit. People with disabilities confirmed encountering the kind of care-limiting or exclusion practices described in Iezzoni's report. "Some will find every excuse not to see you. They will say, 'Our machinery isn't good enough for you. Maybe you shouldn't come in,'" said disabled transgender patient August Rocha. Northwestern University Professor Tara Lagu said addressing this problem requires changing the mindset about disability in the field of healthcare.

Health Policy and Reimbursement

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How much Americans will have to pay for health insurance will depend on how much of the cost will be covered by employers. History shows economic stress often leads to higher insurance premiums. The Kaiser Family Foundation's Employer Health Benefits Survey estimated that the average worker's contribution to their healthcare insurance premium rose 25 percent from 2008 to 2010, adding an inflation-adjusted $244 more to their yearly bill. Willis Towers Watson found three-quarters of health insurers believe their customers' bad habits and medical system overuse are elevating costs. Economic prosperity before the pandemic caused worker contributions to decline, on average, in 2015 and 2018. Kaiser's Matthew Rae attributes this to companies having to compete for workers in a tight labor market. If historical trends hold, a major hike in worker contributions in 2023 would be followed by a smaller increase in 2024.


The Biden administration is telling healthcare providers to prepare for the termination of the COVID public health emergency in January, which will significantly impact Medicaid and could potentially affect how hospitals operate. The Department of Health and Human Services (HHS) estimates that up to 15 million people will be disenrolled from Medicare and the Children's Health Insurance Program when the emergency ends. About 7 million will lose Medicaid coverage due to bureaucratic hurdles, even though they still qualify for the program. Meanwhile, the public health emergency expanded telehealth services for Medicare patients and gave hospitals more latitude in how they can deploy staff, where they can add beds and how they care for patients. The loss of these flexibilities will worsen severe staff shortages, and the American Hospital Association has urged the Biden administration to renew the public health emergency until a sustained period of low COVID transmission is realized.


In the United States, administrative costs account for up to 30 percent of healthcare spending, and about 50 percent of that is wasteful. A Health Affairs research brief says, "Even at the lower end of estimates, US spending on administrative costs annually account for twice the spending on care for cardiovascular disease and three times the spending for cancer care." Additionally, it says, "if administrative spending is about 15-30 percent of national health spending, then wasteful administrative spending comprises half of that, or 7.5-15 percent of national health spending ($285 billion to $570 billion in 2019)." Per capita spending on healthcare administrative costs is $1,055, the highest among the 12 countries studied, followed by Germany at $306.

Medicine, Drugs and Devices

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Drugmakers are trying to blunt Medicare’s newfound power to negotiate US medicine prices. Under the Inflation Reduction Act, the US Congress gave Medicare, the biggest buyer of prescription drugs in the United States, the authority to negotiate how much it pays for certain high-price therapies and to get rebates on treatments whose prices rise more than the rate of inflation. Drugmakers are seeking to ease the law’s impact as regulators begin to work on the details of implementing the provisions, say insiders.


New findings reveal that one in six Americans with insulin-dependent diabetes manage the high cost of the medicine by skipping doses, taking smaller amounts than prescribed and/or postponing insulin purchases. Researchers were surprised to learn that "insulin rationing" is common among the privately insured — who must navigate copays, deductibles and other hurdles. National Health Interview Survey 2021 data from nearly 1,000 insulin users with type one, type two or uncategorized diabetes also indicate that uninsured persons were even more likely to engage in the practice than people with commercial coverage or with Medicare/Medicaid benefits. Similarly, younger people ration more than adults aged 65 years and older, and Black participants are more likely than to do so than White or Hispanic patients who require insulin. "Insulin rationing is frequently harmful and sometimes deadly," warns Harvard Medical School physician Adam Gaffney, MD, lead author of the report in the Annals of Internal Medicine. The Inflation Reduction Act of 2022 might improve access to the treatment on some level, he and his co-authors acknowledge, but the federal law's $35 co-pay ceiling still might be too high for some patients. Moreover, the law does not apply to privately insured individuals or those with no insurance. Gaffney emphasizes that "universal access to insulin, without cost barriers, is urgently needed."


In August, health insurer Highmark started offering a policy that covers software-based treatments for psychiatric and other conditions. The policy aims to pay for claims only for prescription digital therapeutics approved by FDA when prescribed by a clinician within the appropriate specialty and used as indicated on product labels. Matt Fickie, a senior director at Highmark, says the insurer is now in talks with product developers regarding how much the company will pay for individual treatments, what comprises an "episode of care," and other details. Highmark currently has 6 million members in Pennsylvania, West Virginia, New York and Delaware. Andrey Ostrovsky, managing partner of Social Innovation Ventures, which has invested in two of the companies whose products Highmark intends to cover, says: "It's going to take a lot of resources because we have to do the studies and we have to go through the FDA, but you know what? At least we see the light at the end of the tunnel of how this gets paid for." The policy names eight products, including Pear Therapeutics' cognitive behavioral therapy (CBT) apps for the treatment of substance use disorder, opiate user disorder and insomnia and Akili Interactive's video game treatment for pediatric ADHD. The policy also includes treatments for chronic lower-back pain and childhood lazy eye delivered via virtual reality headsets; a treatment for nightmares using the Apple Watch; and a CBT app targeting irritable bowel syndrome.


A new analysis calculates that spending on prescription medications accounted for 27.2 percent of total healthcare spending among fee-for-service Medicare beneficiaries in 2019. That share, which includes retail prescription drugs under Part D and clinician-administered therapies under Part B and is inclusive of rebates and discounts, is up from approximately 24 percent in 2008. Total spending on a per-capita basis was $16,345 in 2008 and $20,117 in 2019. Part B drug spending over the study period increased from $720 to $1,641, while Part D net spending bumped up from $3,122 to $3,477. The analysis authors believe it is important to pinpoint the origin of the spending hikes, track how the Inflation Reduction Act and other policy changes affect Medicare spending on prescription drugs and consider how drug prices and spending influence the affordability of Medicare premiums.