Check out the entire series here.

In 2015, CMS moved to “package pricing” for CTPs/skin subs in the hospital-based outpatient clinic. When that happened, the cost of the product was incorporated into the charge for the visit, and that caused a sudden and dramatic increase in patient copays. In 2018, out of curiosity, I did a quick data analysis of the data in the US Wound Registry to look at access to CTPs/skin subs after package pricing. This little data project was NOT suitable for publication because I didn’t do the proper statistical analyses and I didn’t control for all the possible variables. I just asked the question of whether, when package pricing was implemented in the HOPD and copays increased, it decreased the use of CTPs/Skin subs in patients of color. To simplify analysis, we limited the dataset to information obtained after the national ICD-10 conversion. From October 2015-July 2018, there were 761,214 wounds and ulcers (all types) in 236,352 patients seen in Hospital Based Outpatient Departments (HOPDs) in 34 states. A total of 14, 634 wounds were treated with CTPs (1.9% of all wounds). The racial distribution of patients with wounds was 72% White and 11% Black or African American. However, the racial distribution of CTP application after package pricing was 76% White and 8% Black. Remember, we need to look at this in a more controlled fashion, but after package pricing in the HOPD was implemented, there was a 28% decrease in the use of CTPs/skin subs in patients of color. The racial disparity seemed to go away after a couple of years.

What persists to this day is a disparity in who gets CTPs based on insurance. CTPs are almost exclusively offered to patients with Medicare Fee for Service (FFS) and a secondary insurance to cover the cost of the copay. I wondered about that and in about 2010, I glanced at the data to understand the likelihood of a patient in the HOPD getting a CTP/skin sub if they do not have Medicare plus a Medicare secondary. At the time, 98% of patients who got a CTP/skin sub in the HOPD had Medicare plus a secondary to cover the 20%. Meaning that, insurance type determined who got offered a CTP/skin sub over a decade ago, even before the prices went out of control. Since then, Medicare Advantage plans have taken over and that has further changed who gets CTPs/skin subs since the MA plans will only cover one or two products and doctors often give up rather than trying to get them approved through the draconian prior authorization process.

I was initially worried that if package pricing was implemented in the doctor’s office, it would increase patient copays and increase inequities in access. Here’s the irony of what I’ve learned since I started “saying the quiet part out loud” about CTPs. In the doctor’s office setting, patients are already paying a copay on the incredibly high cost of these products -– product costs that are far higher than they are in the hospital-based setting. If package pricing were implemented in the doctor’s office, the runaway product costs would be controlled, and it would almost certainly DECREASE patient copays and perhaps DECRASE inequities in access. But no one is talking about THAT aspect of the issue.

I don’t know what is going on in the doctor’s office setting because I don’t have access to that data, but:

  • If CTPs/skin subs are being over-utilized in the doctor’s office and patients are paying a 20% copay on an expensive therapy they don’t need, then this is a travesty.
  • If patients who need CTPs can’t get them because they don’t have the money for the copay — on a product the price of which was wildly inflated by the manufacturer simply because they could, then that’s a travesty.
  • If patients are selected for CTPs/skin subs solely on the basis of their insurance, then Medicare Advantage (MA) patients are getting a different level of care than Medicare Fee for Service (FFS) because we all know that the MA plans are NOT following Medicare’s rules on coverage for them.
  • If doctors are using the profits from discounts and rebates to “cover” the cost of the copay (the “Robin Hood” approach to medical care), it may seem like a nice thing to do but it’s considered an inducement to treat under Medicare rules, and it still doesn’t justify what is happening.

Everywhere I turn, there seems to be an issue that is ethically worrisome about CTPs.


Check out the entire series here.

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