Visualizing the Complex Patient – and the Implications for Cellular Products

This is a retired healthcare professional with insulin dependent diabetes. The ankle lesion she has this time doesn’t look too bad (see above), and she has a normal arterial supply, based on skin perfusion pressure assessment. However, I’ve taken care of her intermittently for more nearly a decade for these recurrent ulcers. She has muscular dystrophy (so she can’t walk) and a hypercoagulable state, status post multiple DVTs for which she must stay on anticoagulation. She spends all of her time in her tilt chair and in the past year has begun sleeping in her chair due to worsening sleep apnea. Her excruciatingly painful ankle lesions are due to atrophie blanche and are incredibly hard to close. A year ago she healed a terrible ulcer in the same area with a cellular product (see slides below).

I had to use donated cellular products last year because the lesion was larger than any product I could afford under package pricing. And, when I first applied it, there was nothing favorable about the wound bed. However, I knew her arterial supply was normal, her venous disease had been treated to the extent possible, and she was on antibiotics. Her pain was dramatically reduced after the first application and she closed the ulcer after 4 applications.  There’s another reason I had to use a donated cellular and/or tissue based product (CTP). CTPs are not covered for patients with multiple co-morbid conditions like hers under the Local Coverage Determination of my Medicare Administrative Carrier (MAC), even if I could have afforded one large enough. Thanks to the donated CTP, she stayed healed for a 14 months, and for her, that is a long time.

I will use another donated product this time for a different reason. Now she has a Medicare Advantage plan that only approves Apligraf and Dermagraft, both of which are priced (for my hospital, anyway) higher than I can afford under package pricing.

And if you think her case is unique, it’s not.

The current situation under package pricing has had many unintended consequences. The use of CTPs is about to get more complicated, based on the Hospital Based Outpatient Payment System proposed rule.

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