Navigating obstacles impacting the sustainability of Medicare-funded wound care pricing

Abstract

As the US population continues to age, costs for hard-to-heal wounds are expected to rise and negatively contribute to the long-term financial stability of Medicare, which is currently labelled a ‘high-risk’ program by the US Government Accountability Office. Within wound care, some skin substitutes, also known as cellular tissue products (CTPs), and now referred to as CAMPS (cellular, acellular, and matrix-like products), have demonstrated improved healing times and cost-effective usage. However, a dramatic increase in the number of CAMPs has led to controversy on reimbursement rates. For instance, in the third quarter of 2022, 30 of 68 CAMPs represented a disproportionate $256 million USD in costs, due to failures to report their average sales pricing. In its calendar year (CY) 2024 Proposed Rules, the Centers for Medicare and Medicaid Services (CMS) did not implement the proposal to package (‘bundle’) CAMPs products within the private office. Moreover, three Medicare Administrative Contractors (MACs) withdrew Local Coverage Determinations (LCDs) that sought to curb use of CAMPs with limitations on covered products and number of applications, all of which illustrates a continued lack of consensus in coverage and reimbursement of CAMPs. To stabilise Medicare wound care expenditures, the CMS should use tools already at its disposal, to enforce reporting of average sales prices (ASP) for Q-coded CTPs or CAMPs, and to suitably audit ASPs for all potential abuses. MACs should consider adopting more rigorous strategies that drive all manufacturers of CAMPs to adopt an ASP reporting model. Conclusion: With more effective oversight, Medicare costs can be reduced, while stabilising a portion of its trust fund, disincentivising non-compliance and improving outcomes for the growing population of US beneficiaries with hard-to-heal wounds.