Last week I gave a talk at the Amputation Prevention Symposium entitled, “Elevate the CLI Patient’s Voice: Why it is so Important to do the Right Thing?” I have to confess that when the meeting organizers first asked me to explain why it’s important to do the right thing, I assumed the lecture title was the result of a typo. Since 2010, I’ve been discussing the fact that wound care practitioners often fail chronic wound patients by not providing the most basic care (e.g., arterial testing, diabetic foot ulcer off-loading, etc.) However, I took it for granted that we all wanted to do the right thing. Fifteen years later, not only do we need to educate doctors on what the right thing is, we need to explain why they should do the right thing.
To prepare for the AMP meeting, I spent a lot of time thinking about why we need to do the right thing through the lens of the patient. I decided the best approach was to present a series of patient stories. One of these patients was a 62-year-old man with a small diabetic foot ulcer (DFU) who had undergone 10 applications of a CTP/skin substitute in his podiatrist’s office without any improvement. Above is a photo of his DFU, and it doesn’t look too bad. In fact, it looks like he should have gotten benefit from a skin sub. However, the wound made no progress despite 10 applications. I will point out that the reason the patient had undergone 10 applications is that it is the maximum number of applications that the doctor could bill for.Sadly, the doctor didn’t try to figure out why the CTPs were not working. Frustrated with his lack of progress, the patient made his way to me in the wound center.
I think every patient with a non-healing wound should undergo arterial testing on their first visit and the test I prefer is skin perfusion pressure (SPP) with pulse volume recording (PVR) (see informative links below). The patient had no symptoms of ischemia such as claudication and the foot looked well perfused, but everyone gets screened because the right thing is to rule out ischemia as the reason for failure to heal. To my surprise, his SPP was only 28 mmHg and his PVR indicated that he did not have pulsatile flow to the plantar foot. I referred him to a colleague who performed an angioplasty on his occluded arteries below the knee. After that, he healed quickly with nothing more than basic wound care and an off-loading boot.
Why didn’t I use CTPs after he was revascularized? Well, in the hospital-based outpatient wound center (HOPD), CTPs are “package priced” so that it is not possible to separately recuperate the cost of the product – and the price that hospitals can afford to pay is capped at around $1500. If the product costs more than that, the hospital will lose money on the service. In fact, most HOPDs lose money on the use of CTPs. As a result, the use of CTPs in HOPDS is limited because there’s no financial incentive for either the doctor or the hospital. (To my surprise, doctors who do not take under the table discounts for CTPs in the office-based setting can lose money on the products as well. It turns out that when you address ischemia, nutritional/vitamin deficits, infection and pressure, most wounds will heal without a CTP. That’s why doing the right thing means addressing the basics before skin substitutes are considered.
I saw this man more 6 years ago, but CTPs/skin substitutes were already common in the office-based setting. Since then, their use has skyrocketed because practitioners can make staggering profits off rebates and discounts for high-priced products in the office-based setting. There is a lot to unpack in this man’s case (e.g., failure to do the basic work up, reapplying CTPs when they were not working, etc.). However, I’d like to focus on something that patient said as I was explaining the reason his wound had not healed and how we were going to fix the underlying problem. In an almost off-hand way, he said, “You know, I paid $17,000 for those skin substitute applications.”
He’s lucky he only paid $17,000. He could have been charged $170,000. In the years since I saw him, the price per square centimeter of these products has increased 100 fold, and with them, the potential out-of-pocket costs for patients. Their current cost is far beyond anything that can be justified when less expensive products work just as well, assuming that the patient needs one in the first place. The reason that more expensive products are being used in the office-based setting is that the more expensive the product is, the more money the doctor can make from using them. Remember that under traditional Medicare fee for service (MFFS) plans, the patient is responsible for 20% of the cost of the service and that includes the cost of the CTP. That means that as the price of the product goes up, the copay goes up.
My patient could speak off-handedly about wasting $17,000 on skin subs that he didn’t need and couldn’t benefit from because frankly, he was a wealthy man. He wasn’t exactly happy about wasting money, but it hadn’t taken food off the table. I have been wondering why there has not been more of a hue and cry from patients about huge copays for skin subs. Apparently, if the patient does not have a secondary insurance to handle the “patient responsible portion,” some clinicians have been writing off the 20%. Frankly, the doctor can afford to write off the copay if they have made a huge under the table profit off the cost of the product. Waiving copays may seem like a nice thing for the doctor to do. However, it is illegal to waive the patient copay without making a “good faith” attempt to collect it. That’s because Medicare considers this an “incentive” (a bribe) by the doctor to keep the patient coming back. Illegally waiving copays for skin subs was part of the recent judgement against a dermatologist.
If the copays are not (illegally) waived, and the patient does not have a secondary insurance, the patient and/or family could be billed thousands of dollars for CTPs. Cheaper products that work equally well are available, and if the doctor uses a cheaper product, the patient’s out of pocket costs go down. Based on the price escalations for amniotic products, patients may be paying copays that are 100 times higher than necessary. Given the meteoric increase in the use of CTPs, I wonder how many patients and/or families have been hurt by staggering copays? I want to “elevate the patient’s voice” about the out-of-pocket expenses for skin subs, so I’d love to hear from patients about this issue.
–Caroline
Related posts:
- Price & Size Limits to Cellular Tissue Product (CTP) Use in the HOPD vs the Office (This is All So Messed Up)
- Disparities in Access to Care for CTPs / Skin Subs (and How Package Pricing in the Doctor’s Office Might Actually Improve Access to Them)
- A Dirty Little Secret About Social Determinants and Access to Cellular and/or Tissue-Based Products (CTPs)
More information about Skin Perfusion Pressure (SPP) in wound care:
- Vascular Screening Basics: TcPO2 vs. SPP
- Sadly, It’s Still Hard to Do the Right Thing in Wound Care
- Why I Can’t Be a Wound Doctor Without Skin Perfusion Pressure
- Why I Can’t Be a Wound Doctor Without Skin Perfusion Pressure, Part 2
- Why I Can’t Be a Wound Doctor Without Skin Perfusion Pressure, Part 3
- Why I Can’t Be a Wound Doctor Without Skin Perfusion Pressure, Part 4
- Why I Can’t Be a Wound Doctor Without Skin Perfusion Pressure, Part 5
- Why I Can’t Be a Wound Doctor Without Skin Perfusion Pressure, Part 6
- Peripheral Arterial Disease Hall of Shame – Case #1
- Peripheral Arterial Disease Hall of Shame – Case #2
- Peripheral Arterial Disease Hall of Shame – Case #3
Dr. Fife is a world renowned wound care physician dedicated to improving patient outcomes through quality driven care. Please visit my blog at CarolineFifeMD.com and my Youtube channel at https://www.youtube.com/c/carolinefifemd/videos
The opinions, comments, and content expressed or implied in my statements are solely my own and do not necessarily reflect the position or views of Intellicure or any of the boards on which I serve.
