(Including How to Make it More Equitable for Practitioners & Patients)
I got this thoughtful email from Dr. Timothy Johnson with a list of practical suggestions to help fix the broken system around CTPs/skin subs. He has given me permission to post his comments. If you have additional thoughts, feel free to dovetail on his comments which I have numbered to make them easier to reference. We’ve spent a lot of time talking about what is broken, now is the time to collaborate in a positive way about how to make it better.
I don’t expect we will find the perfect solution to any system as dysfunctional as the CTP market. However, CMS can make it even worse with badly considered policies. Surely we can come up with a few ways to make at least some aspects better.
There are a lot of things broken or wrong in the current graft market. I read many posts pointing this out every day. There is plenty of blame to go around, including CMS and private insurers.
We have time now over the next year or so to focus on the positive and figure out sensible and acceptable solutions. We need solutions that make sense both in the HOPD and clinic setting. We need solutions for the patients who need the care. We need solutions for doctors who have to navigate the confusing and time consuming task of determining coverage and if they will receive adequate reimbursement for their Medicare replacement and commercial patients.
- Create a set fee schedule for Q codes and A codes $3-500.00 per sq cms and let manufacturers line up at or under that price. This alone can save CMS millions of dollars without compromising patient care.
- Standardize MAC reimbursement for grafts with a National Fee Schedule. Maybe create an innovative product designation for new unique promising products that allows slightly higher reimbursement and incentives to defray costs of new product development. This could be limited to a certain time frame.
- Set up a standard algorithm for graft patients that are not responding appropriately after a set number of graft applications ie: 4-5. Require certain steps to follow such as (vascular analysis, A1C re-evaluation, evaluation of comorbidities, nutritional assessment, etc.). [That sounds like quality measures to me – so he’s got my attention! CF]
- Set up some sort of graft tracking based upon reporting of product utilized, wound type, comorbidities and patient complications and wound response that is required to submit to manufacturer and CMS for retrospective analysis. This sounds cumbersome; however, doctors are required to file tissue tracking for amniotic and xenografts. There could be a simple form with additional information that could be submitted. This could be developed and required for any discount to be issued to a doctor. This should not be labor intensive to the physician, and it could possibly provide valuable information for retrospective analysis.
- Allow a reasonable discount incentive for doctors who take the risk and purchase grafts for their patients, so they are not underwater for the graft.
- Allow pass through billing for grafts in the HOPD space with pricing similar to clinic grafts.
- Require Medicare replacement plans to reimburse grafts per Medicare guidelines. They are legally obligated to do this. Penalize those who do not follow Medicare guidelines.
- Require Commercial plans to expand their reimbursed products. Typically, they only reimburse products that have been around for many years. Sometimes this may only be one or two products (Aetna). This does not mean the patient is getting the best graft available. Realistically, only a very few grafts have level one studies. All dual amniotic, amnion chorion grafts are pretty much the same. Why favor one over the other.
- Simplify and standardize the graft authorization process for commercial insurers. This often takes 30 minutes or more for a doctor’s staff member to perform over the phone. It may take weeks for an answer.
- Propose that some percentage of wound care investment comes from insurers and hospital systems to fund free clinics for underprivileged diabetic patients. Geisinger Health System did this a few years ago, investing thousands of dollars monthly to provide access to free preventative care for diabetics. Outpatient centers who taught diabetics how to cook healthier meals, if they could not afford healthy meals, they provided them at no cost. They also had exercise classes and diabetic education. They realized that this upfront investment lowered their future healthcare costs for these patients far outweighing their preventative investment costs.
- Require that manufacturer’s “in-house reps” and all distributors and their reps be “Industry Wound Care Certified” with periodic CME like updates every two years. These programs already exist and could be accredited to ensure proper training. We currently have numerous reps who are involved in wound care sales simply because of the money, sell on the margin. They know nothing about wound care. Your wound care rep is there to represent the product, explain the product indications and application to the doctor and assist with any product/wound specific questions.
Let me know your thoughts!
Timothy Johnson, MD