This is a belated Thanksgiving message, but it has taken awhile for me to think through the sweeping changes that happened to CTP/CAMP/skin substitute payments on the last day of October. Here’s a list of what I think are the positive impacts and I hope you will send me your thoughts:
- Reduced Moral Hazard for Practitioners: Let’s be honest. The current system incentivizes practitioners to select products which maximize profit per cm2 as well as overuse. Even if the percentage of really “bad actors” among practitioners is low, the system has been a constant moral hazard for everyone.
- Increased Use of Low-Cost, Highly Effective Products: The new skin substitute payment model encourages the use of low cost products which have been on the market for years and are highly effective.
- Reduced Patient Copays: There were only 3 ways to handle soaring patient copays: 1) bill their secondary insurance (which has fostered increased private payer rates for everyone), 2) financially harm vulnerable patients, or 3) illegally wave the patient copays. One physician self-righteously messaged me on Linked In that his patients were not harmed by high copays because his high profit margin on skin subs allowed him to waive the patient copay. He was apparently unaware that this behavior violated the Anti-Kickback Statue (AKS).
- Reduced Likelihood of AKS Violations: The opportunities to violate the AKS are many under the current payment scheme. More than one person is in prison thanks to the dangerous combination of “Greed + skin subs” and more prosecutions are underway. We will never know the “It’s a Wonderful Life” version of this story – meaning we will never know how many practitioners’ lives will NOT be destroyed because the rules changed – but I am certain that payment reform will save many from destroying their lives.
- Reduced Medicare Payment Denials due to Product Choice: Medicare auditors have clawed back payments based on specious arguments around the FDA status of human placental tissue. Although Medicare post-payment denials for this reason are almost certainly improper, the lack of published studies among the tidal wave of new and high-priced products has made it hard for clinicians to defend their product choices to auditors. In contrast, all the low priced products (some of which are also human tissue derived) have years of clinical evidence behind them. Now there’s one less uphill battle in the Medicare audits around skin subs.
- HOPDs Can Use Skin Substitutes Without Losing Money: I think my HOPD was one of the few in the country that did NOT lose money on skin subs thanks to badly implemented package pricing, and it was not possible for any HOPD to treat large wounds because large sizes were unaffordable. Patients being treated in the HOPD can finally get the treatment they need with skin subs.
- Reduced Risk to Accountable Care Organizations (ACOs): ACOs have taken a huge financial hit thanks to abuse of CTPs/skin subs. Your tax dollars are probably going to be needed bail them out since the financial impact is going to take years to correct. ACOs have also been following data that suggest their patients are not benefitting from home use of skin subs.
- Increased Opportunities for Innovation: Thanks to the “skin sub market boom,” there has been almost zero opportunity for medical innovation in the field of wound care. The “next big advance in wound care”(whatever it is!) has been sidelined because nearly all the investment money had gone into the CTP/skin sub market. Now the door is open to the development of new treatments.
- Improved Practice Standards and More Committed Practitioners: Practitioners who care about their patients and who are committed to the field of wound care are going to stay in the field and thrive. They will no longer be distracted by (frankly illegal) marketing schemes and sales representatives who know nothing about wound care. The practitioners who should be caring for patients will keep caring for patients. Hopefully their risk of Medicare audits will decrease as the bad actors leave the field, and those committed practitioners can focus on providing good clinical care. The rest of us can focus on ways to support those caring practitioners to help them thrive, rather than bemoaning the fraud and abuse in the skin sub market.
Will there be some downsides to the change in skin sub payment policy? Perhaps. It may be harder for rural and home bound patients to access care now that profits from skin subs are down– but not all the medical care those patients got was of good quality. Some clinicians were paid a lot of money to provide poor care to patients in the home. Hoping that practitioners would practice Robin Hood wound care was always a bad model.
Will there be more amputations? No. I don’t think so. In more than three decades, I have never seen a patient get an amputation due to lack of a CTP/skin substitute. Patients lose limbs due to undiagnosed vascular disease, out of control comorbid diseases, poor nutrition and infection. Correcting these problems is not associated with lucrative procedural revenue. The sad fact is that the most important reforms in wound care payment policy have not happened yet. But this is a start. Let me know your thoughts about the good and the bad.
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