News From ACFAS

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Kick of the 2023 Annual Scientific Conference with this year’s keynote speaker, Victoria Arlen. Victoria will discuss the perspective we give to obstacles in our lives, how to change it, and how to push off those roadblocks to achieve greater heights.

After developing two rare conditions at the age of 11, Victoria lost the ability to speak, eat or walk and spent four years in a vegetative state fighting for her life. She defied the odds with her recovery and went on to win a gold medal at the 2012 Paralympic Games in London, begin a broadcasting career with ESPN and compete as a finalist on Dancing With the Stars.

Don’t miss what’s sure to be a thrilling and heartwarming speech to kick off another great Annual Scientific Conference. Visit acfas.org/asc to register today and find out more about this year’s meeting. There’s still time to register and join us for our first-ever virtual symposium!

Held entirely online, the ACFAS First Ray Virtual Symposium will teach surgical options to correct first ray deformity, along with complication and revision options. Help drive the discussion as you interact with faculty and attendees during the live program, then continue the conversation after through an exclusive online discussion forum.

Can’t join us live on Saturday, November 19? All registrants also get access to the recordings of the sessions to access on-demand at your convenience. You’ll earn 4 CME no matter how you participate!

Save your spot now at acfas.org/firstrayvirtualsymposium. Get ahead in your coding and billing with the Coding and Billing for the Foot and Ankle Surgeon and Coding Fundamentals pre-conference programs at ACFAS 2023 in L.A.!

Coding and Billing for the Foot and Ankle Surgeon
Wednesday, February 8
8:00 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
Wednesday, February 8
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. Ideal for anyone
who wants to learn more of the basic coding and billing terminology and process.

Residents: Planning on attending Residents Day? Coding Fundamentals is a great next step to learn about coding and billing for your future practice. Register for Residents Day in the morning and Coding Fundamentals in the afternoon at a bundled rate!

Learn more about these coding courses and register today at acfas.org/asc. Stay current with the latest research relevant to foot and ankle surgery with the ACFAS Virtual Journal Club, returning on Tuesday, November 29 at 7:00 pm CT.

Reconstructive Foot and Ankle Surgery
Hosted by: North Jersey Reconstructive Foot and Ankle Fellowship
Fellowship Director: Michael Subik, DPM, FACFAS

Brought to you by the ACFAS Research Committee, the Virtual Journal Club is complimentary for ACFAS student and resident members and provides an informative and interactive way to learn about research. Monthly sessions will be presented by research experts from fellowship programs with ACFAS status.

Learn more and register at acfas.org/virtualjournalclub. We previously told you about a comment letter submitted by the Alliance of Wound Care Stakeholders, which ACFAS is an active participant, to the Centers for Medicare and Medicaid Services (CMS) regarding the proposed 2023 Physician Fee Schedule (PFS). The proposed rule 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’s office. Specifically, as proposed, the PFS 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. CMS had also proposed changing the name “skin substitutes” to “wound management products.”

The final rule has been released and we are excited to report that CMS has decided not to implement these changes. CMS will not be finalizing the payment approach outlined in the proposed rule where they proposed to package payment for CPTs under incident- to supplies and decided against changing the name “skin substitutes” to “wound management projects” currently. CMS plans to conduct a Town Hall meeting with all interested parties at the beginning of 2023 to discuss alternative payment approaches for skin substitute products before 2024 rulemaking.

ACFAS will be sure to keep members informed of these efforts as they move forward. We also continue to be an active member of the Alliance of Wound Care Stakeholder to ensure the voices of podiatric foot and ankle surgeons are included in these efforts.

Foot and Ankle Surgery

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Researchers adopted the extended lateral approach (ELA) for surgery of comminuted fractures of the calcaneus, in combination with circular external fixator assisted reduction. There were 61 cases of unilateral calcaneal fractures treated by the same surgeon over 64 months and followed up for 19.28 ± 5.28 months. During surgery, a circular external fixator was used to correct the midfoot and the distal end of the tibia and the calcaneal tubercle. The calcaneal tubercle was then distracted to restore the calcaneus' three-dimensional structure. The ELA was employed to reduce the articular surface fracture, and the fracture was fixated with a locking plate. All fractures healed. The mean preoperative Böhler's angle was 9.3 ± 10.1 degrees, the mean Gissane's angle was 110.5 ± 14.7 degrees, the immediate postoperative mean Böhler's angle was 31.3 ± 5.5 degrees and the mean Gissane's angle was 110.9 ± 5.9 degrees. Local superficial necrosis of surgical incision transpired in two cases, which healed well after dressing changes; there was skin necrosis in one case, treated with deridement and local flap transfer. The mean visual analogue scale score at final follow-up was 1.48 ± 1.30 and the mean American Orthopaedic Foot and Ankle Society Scoree was 90.16 ± 7.19.


A systematic review and meta-analysis of randomized controlled trials and prospective controlled studies sought to determine whether minimally invasive surgery for hallux valgus improves American Orthopaedic Foot and Ankle Society (AOFAS) scores and visual analog scale (VAS) scores for pain and yields radiologic outcomes, fewer complications or shorter length of surgery, compared with open surgery. The authors saw no clinically important difference between minimally invasive and open surgery for AOFAS score or VAS scores. No differences between the minimally invasive and open surgery groups were observed in terms of the hallux valgus angle, while radiographic measurements of the intermetatarsal angle did not diverge between the minimally invasive and open surgery groups. Moreover, the minimally invasive and open surgery groups did not differ in terms of the distal metatarsal articular angle. Qualitative analysis also indicated no disparity between frequency or severity of complications between the minimally invasive and the open surgery groups. Neither cohort differed in terms of surgery duration.


A study was held to assess the degree to which the signal intensity on magnetic resonance imaging (MRI) reflected the qualitative diagnostic capacity for anterior talofibular ligament (ATFL) and calcaneofibular ligament (CFL) injuries in patients with chronic lateral ankle instability (CLAI). Included were 38 and 20 ankles with and without CLAI, respectively, with regions of interest set in the ATFL, CFL and tibialis anterior tendon on MRI. The mean signal intensity ratio (SIR) of the ATFL in the CLAI group was much higher than that in the control, and the SIR of the ATFL was associated with the arthroscopic grading. The mean SIR of the CFL in the CLAI groups was significantly higher than that in the control, as was the SIR of the CFL in subjects with the requirement of the CFL repair compared to that without the CFL repair.

Practice Management

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Physician colleagues who are at odds over patient decisions are a common refrain in medical practices, which can sour their long-term relationship. The younger doctor wants an older colleagues to listen to and discuss patient treatment so they can gain knowledge and also wants better relationships, respect and fellowship from peers. To boost the chances of the relationship improving, the younger doctor should arrange a conversation later with the older clinician and concentrate on enlarging their common interests. The younger peer also should adopt a forward-looking approach that mutually benefits both colleagues and their patients. This dialog shows the older peer respect and reduces friction and refocuses the discussion on common intentions without casting criticism or blame. The younger colleague can also use this private opportunity to express their own views and raise the odds of them finding a productive place in the practice.


Burnout and health industry consolidation are driving more doctors and doctors-in-training to unionize to demand better pay, benefits and working conditions. For example, more than 1,200 resident physicians and interns at Montefiore Medical Center recently asked the Bronx, NY, hospital to recognize their bargaining unit after an organizing vote. There were more than 67,000 physician union members, or about 7 percent of all practicing US doctors, as of 2019, according to the American Medical Association. The numbers have likely increased since then, in response to hospital consolidation and more physicians working as employees of a health system or other provider. The average resident physician's salary in the United States in 2021 was $64,000, according to some reports. Younger doctors who are unionizing say that's not enough to contend with general inflation and the cost of living, especially in markets like New York and Los Angeles. The workload and residents with student loan debt are also factors. There are concerns that doctors taking collective action could undermine public trust and jeopardize patient safety. The prospect of physicians walking off the job nearly became reality over the summer, during a labor dispute involving 1,300 residents and fellows at three big Los Angeles County hospitals.


New research sought to define variance in patients' satisfaction with video telemedicine-based doctor visits according to patient characteristics and their comparison with in-person visits. Standardized patient experience surveys were analyzed to compare telemedicine and in-person clinic visits during the COVID-19 pandemic from July 1, 2020, to June 30, 2021. Surveys were sent to 1,521,398 patients over the study period, with a response rate of 20 percent (307,185). Despite the results indicating some trends, no significant differences in patient ratings of telemedicine visits and in-person clinic visits emerged. This indicated patient satisfaction with telemedicine visits was not lower than that of in-person outpatient visits during the timeframe.

Health Policy and Reimbursement

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Among standalone Medicare drug plans offering nationwide coverage, AARP's MedicareRx Preferred plan has the highest premiums. The plan, insured by UnitedHealth Group, has 1.74 million members and a 9 percent market share of the market for standalone Part D Medicare drug coverage. The AARP plan covers a higher percentage of both branded and generic drugs compared with its top four national competitors and does not have a deductible. Juliette Cubanski, co-author of a 2021 Kaiser report that noted the steady rise in premiums, observes that "it comes down to brand loyalty and beneficiary appeal. If people haven't had any problems, they may not feel that what they're paying is so outrageous that they're willing to go through the time and effort it takes to switch." AARP says it does not sell or manage the insurance plans directly, but licenses the use of its name by different companies. UnitedHealth, which has a leading 23 percent share of both Part D plan types, says two of its three AARP-branded drug plans are priced at or below the national average of $40 a month, and rate increases are steered primarily by higher drug costs and changes in use patterns. However, a report in June by the Medicare Payment Advisory Commission said that some drug-plan sponsors will "raise premiums more for established plans because their enrollees are unlikely to switch plans." Experts say AARP's plan mirrors a larger trend of major Medicare drug plans raising prices significantly. They says older adults should closely examine their plans from any brand to make sure they are not paying needlessly high premiums.


An alliance of advocacy groups and scholars is requesting lawmakers not to pass a proposed measure to reward drug companies for developing new treatments. It asserts that the legislation fails to require acceptable clinical trial standards and would essentially be a giveaway. The proposed Pasteur Act hopes to encourage drug development by creating a subscription-style business model in which the federal government offers upfront payments to drugmakers in exchange for unlimited access to their antibiotics. The aim is to allow drugmakers to recover their costs and make sufficient profit without having to sell large quantities of antibiotics. The measure is predicted to cost $11 billion price over 10 years because it calls for providing upfront payments to companies for developing novel antibiotics. The Collaboration for Regulatory Rigor, Integrity and Transparency at the Yale School of Medicine asserted that FDA has been approving antibiotics that "have not been proven to work against resistant infections or are not more beneficial than other available and less expensive alternative treatments." They also said the proposed legislation does not include stewardship measures designed to curb future antimicrobial resistance. Furthermore, the alliance said that studies of new drugs "intentionally exclude patients who are older or sicker, who are the exact types of patients for whom the drugs are intended." It added that "more patients die from bacteria that could be treated with existing prescription drugs rather than from bacteria that are resistant to prescription drugs."


The US Center for Medicare and Medicaid Innovation's (CMMI) update on its plan for implementing value-based care and progress made aims to elevate integration of care across doctors by offering incentivizing prevention and closer collaboration. The center is investigating the tools and data required to allow doctors to work better together across specialties and also intends to roll out an advanced primary care model for guaranteeing equitable access via recruitment of safety net and Medicaid providers. The ACO REACH model applies health equity benchmark adjustments to increase payments to providers that serve dual-eligible Medicare-Medicaid enrollees, while additional investments to the accountable care organization (ACO) benchmark seek to reduce start-up costs for providers joining an ACO and extend timeframes for testing the model.

Medicine, Drugs and Devices

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Researchers at Australia's RMIT University and Bolton Clarke Research Institute have demonstrated that a thermal-imaging tool can identify chronic leg wounds during the first home assessment. This builds on previous research by the team in which chronic leg wounds were identified by the second week after the baseline assessment. Powered by artificial intelligence, the tool uses thermal images captured during the first assessment to predict how these wounds will heal. By assessing spatial heat distribution in a wound, the tool was 78 percent accurate in determining whether venous leg ulcers in 56 patients would heal in 12 weeks without specialized treatment. Said RMIT's Dinesh Kumar, "Our new work that identifies chronic leg wounds during the first visit is a world-first achievement. This means that specialized treatment for slow-healing leg ulcers can begin up to four weeks earlier than the current gold standard." The research was published in Scientific Reports.


The Dragon Ambient eXperience (DAX) tool sold by Microsoft subsidiary Nuance Communications transcribes doctors' notes about patients into their computer systems, but requires health systems mandated to shield privacy to share patients' most sensitive data with companies trying to develop new products. A STAT review found health systems are split on whether that data-sharing makes DAX untenable or whether informing patients and getting their permission is possible and sufficient. SSM Health's Ann Cappellari said DAX presents a necessary exception to the hospital chain's policy of not allowing data retention by vendors, in order to access the benefits of machine learning. Adding to the uncertainty is that the permissibility of the data-sharing required by artificial intelligence-based automation is not specified under the Health Insurance Portability and Accountability Act. Several health systems said they procured DAX to help address clinician burnout, as the tool can reduce the amount of time physicians spend on documentation. Cappellari said increased automation will inflame the debate.


A recent report found that an estimated 1.3 million US adults with diabetes rationed their use of insulin in the past year, representing 16.5 percent of those who use prescribed insulin. People rationed their insulin by delaying when they refill their prescriptions, skipping doses or using a smaller dose. The report also indicated that rationing was more widespread among lower- and middle-income participants (15 percent and 20 percent, respectively) compared with higher income people (11 percent). Black participants were found to ration (23 percent) more frequently compared with White or Hispanic participants (16 percent). Rationing was most frequent among uninsured individuals, with 29 percent saying they had rationed insulin. Among people with private insurance, 19 percent rationed the drug, citing high copays, along with 14 percent of Medicare recipients and 12 percent of Medicaid recipients. The Annals of Internal Medicine report was based on data from an ongoing US Centers for Disease Control and Prevention health research project in which researchers are studying a nationally representative sample of 982 adults who use insulin to treat diabetes. The report said the rationing is linked to the high price of insulin and "inadequate" insurance coverage.


Researchers at the University of Pennsylvania's Perelman School of Medicine (Penn Medicine) associated texts sent automatically from patients' primary care office following hospitalization with a reduced likelihood of further hospital care. The researchers analyzed data on over 400 patients enrolled in a program providing automated check-in texts after discharge from emergency care visits with that of more than 1,000 non-participants. They observed a 55 percent drop in rehospitalization among patients who received such texts, as well as a 41 percent decline in their chances of requiring acute care over the next 30 days. "Contact from a primary care practice can help patients feel more connected and enable them to access care in a timely manner," said Penn Medicine's Anna U. Morgan.