Check out the entire series here.
Here’s another message that I agreed to post anonymously that asks many questions we are asking:
- Why are two products made in the same tissue lab and identical as far as any of us can tell, priced completely differently, with one of them 3 times more expensive than the other?
- Why do private payers cover one product and then classify another as experimental when they are the same material from the same lab and just have different Q codes?
- How can we stop the madness in the way that the Average Sales Price (ASP) is calculated?
- Is there any way to standardize or control discounts to physicians and the madness in pricing?
- What do we do about the limited access to CTPs/skin subs for patients with private insurance (many doctors have stopped offering CTPs/skin subs to patients with private insurance due to the burden of prior authorization)?
- Where to patients go when office-based doctors give up on CTPs/skin subs due to prior authorization issues and the patients can’t get treated in the HOPD (due to the severe limitations under package pricing)?
SKIN SUBSTITUTES, CMS, FAILED PROPOSALS AND THE BROKEN SYSTEM
There is plenty of blame to go around. The ASP reporting model, CMS and the FDA contribute to the current graft/skin substitute problem. Manufacturers are constantly launching new higher priced grafts to deal with reductions in pricing. There should be a reasonable way to establish a stable and sensible ASP that is not changed every quarter. CMS requires ASP reporting to battle discounts to doctors and lowers the reimbursement of the graft. Manufacturers fight this with newly launched products with higher ASP’s. A hamster wheel.
Now with the current market we have Private Equity Firms investing money into bulk buying grafts. My doctors run into wound care reps that were selling used cars a week ago and know nothing about wound care except for margins. Standardize or at least control discounts and pricing. I have spoken with doctors who are offered ridiculous discounts. I have spoken with doctors who want no discount. If the doctor has to pay thousands of dollars for a graft for his patient he/she should be able to expect a reasonable expectation for the risk they take.
Why is one dual amniotic membrane $1,500 per sq cm and another $500 per sq cm when they are actually the exact same graft made in the same Tissue Lab. Why do insurance companies cover one but not the other citing it as experimental! It is the same darn graft made by the same tissue lab. The only difference is the Q code. Is that science?
Some doctors are interested in increased margins and profits, but a majority would like to at least get their expenses, time and risks covered.
Reimbursement across all insurances should be more standardized. Some doctors are hesitant to bill any insurance except for straight Medicare because no Medicare replacement pays the way they are legally supposed to if it all. The doctor gets stuck with bill and future patients may or may not get treatment. Then we can go on and on regarding commercial insurance plans which may have only one to two graft choices and require 30 minutes or more of a doctor’s staff time to authorize the treatment for the patient. No wonder why quite a few of my doctors have discontinued grafting in their office.
Then where do the patients go? HOPD wound care centers where they are severely limited regarding what they can do, especially for larger wounds due to the “Bundled Reimbursement”.
Just my humble thoughts…