In response to the meteoric rise in spending, the Centers for Medicare and Medicaid Services (CMS) enacted payment reforms, establishing a standardized reimbursement rate of ~$127/sq cm for skin substitutes across physician offices, mobile and hospital outpatient departments (HOPD). SmartTRAK believes that these reimbursement reforms could trigger an access-to-care crisis for some patients in the wound care sector. This could result in care being shifted to the high-cost, inpatient operating room (OR) for the most critical patients or lead to an increased number of amputations. The system may realize short-term savings on grafts, but the systemic result could be a spike in the total cost of care for some patients and, for others, no advanced care at all.
Since 2021, the US Advanced Wound Care Market has undergone a transformation defined by a "site-of-service" migration away from the hospital outpatient department (HOPD). As CMS implemented restrictive bundled-payment models in HOPDs in 2014 that capped reimbursement in “high” and “low” buckets, care began to shift toward... (read more)
The Physician Office (PFS) - In the physician office (PO), the $127/sq cm rate could result in a "reverse triage" effect, where minor or complex wounds become ...(read more)
Mobile and Home Care (PFS) - Mobile providers whose model was focused on the application of skin substitutes will need to pivot to ... (read more)
The HOPD (OPPS) - The HOPD may see its volume swell from referrals from the physician office or mobile, and the OPPS payment system is not subject to ... (read more)
Inpatient Operating Room/Surgery (DRG) - Inpatient surgery operates under the Diagnosis-Related Group (DRG) system, which often means ... (read more)
While most would not deny that the spending on skin substitutes reached unprecedented, unsustainable levels, the regulatory correction has likely swung the pendulum too far, prioritizing short-term savings over patient well-being. The real tragedy of the reimbursement changes will not be .... (read more)
Click the button below to download and read the complete "Will the New Skin Substitute Reimbursement Policies Create an Access to Care Crisis?" Market Outlook article by Elizabeth Anderson, SmartTRAK Senior Analyst, Wound Biologics.
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