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If I Were Queen I Would Fix These Six Stupid Things in Wound Care

by | May 21, 2025 | Fight the Good Fight, If I Were Queen | 0 comments

If I Were Queen I Would Fix These Six Stupid Things in Wound Care

In the 30+ years I’ve been taking care of patients with chronic wounds, I’ve given a lot of thought to the things that are covered by Medicare and other payers (some of which, frankly, don’t work very well) vs. the things that are NOT covered,  but work incredibly well. I suspect that most practitioners have their own secret list of things that should be covered, but here is mine. This is the list of 6 things I would make sure patients (or practitioners) had, if I were Queen.  (Links at the end show why these things make the “Queen’s list.”)

  1. L-arginine supplements: L-arginine supplements are nothing short of magic for wound healing. They revolutionized my practice, and my only regret is that I didn’t figure it out 30 years earlier. I’m talking about Juven or Arginaid (there may be others that work, but these two I know make a difference). I must beg patients to buy these supplements, and they are not cheap. Abbott and Nestle have been very generous in helping those of my patients who could not possibly afford to buy them and would commit to taking them, but there has to be a better way to do this than having the personal cell phone number of one of these kind sales reps. I’ve posted many pictures of the difference L-arginine made in wound healing, including one patient in hospice who was dying of a horrible neurological disease and whose sacral pressure ulcer entirely closed on L-arginine, despite taking only a few hundred calories a day. If every chronic ulcer patient could be on an L-arginine supplement for at least three months, we could cut the time to heal in half and we could heal many wounds that otherwise would fail. (If I could have anything I wanted, I’d provide every one of the needed supplements for all patients with chronic wounds.
  2. Off-loading devices like Darko shoes: There are some fantastic devices for patients with plantar foot ulcers who are not candidates for total contact casting (TCC). The (often insurmountable) problem for offloading an active diabetic foot ulcer (DFU) is that many excellent options are not covered by insurance because they are not classified as therapeutic shoes or custom orthotics. This is yet another thing that I must beg patients to buy whenever they are not a candidate for a total contact cast. There are many off-loading devices that work, depending on the location of the ulcer (e.g., Darko shoes, wedge or half shoes, etc.) that could dramatically decrease the time it takes to heal a DFU. The reason that DFU-offloading is done so infrequently is that often the patients have to pay for the devices (while Medicare spends billions on “skin substitutes”).
  3. Vitamin D-25 levels for patients with open wounds: To be clear, pharmacological doses of Vitamin D3 are covered by most insurance plans. That’s not the problem. The problem is that the lab test to check for a Vitamin D deficiency and to guide supplementation is NOT covered by insurance for the diagnosis of a non-healing wound/ulcer. The lab test is relatively expensive. To get it covered by insurance I have to say that the patient has a history of falls, which usually is not much of a fib, but it is simply stupid that a non-healing wound is not a justification for this blood test. We should get it on every patient with a non-healing wound. With all we now know about the benefits of vitamin D and the national epidemic of vitamin D deficiency, it’s time to fix the barriers to obtaining this test so that we can correct a major reason for the inability to make collagen. This problem is high on my list of “totally stupid stuff we should not have to fight about.”
  4. A good high-density foam mattress or a memory foam overlay to help prevent pressure ulcers at home: Patients at risk for pressure injuries/ulcers but who do not have an active ulcer do not meet the criteria for a specialty mattress. To get a specialty mattress, they must have one or more relatively severe pressure ulcers. However, if we could get patients on a slightly better support surface at home (or in nursing homes) as preventive therapy, we might not have to wait until serious pressure ulcers develop (after which, we spend months trying to get a specialty bed through a DME).
  5. Velcro compression “garments”: Yes, they may be covered by insurance if there’s an open venous leg ulcer, but patients need them to manage edema to prevent tissue breakdown. We can’t get them via insurance unless the patient has an open ulcer (and then only for the affected leg), and they can’t be replaced when they wear out until the patient develops another ulcer. This is so stupid! These Velcro devices are so easy to put on that a three-year-old can do it and they work just as well as compression bandages if applied appropriately. They are far better tolerated than compression stockings. Every patient with chronic edema should be wearing them, especially the patients with heart failure whose legs act as a reservoir for excess fluid when they are behind on their diuretics.
  6. An affordable, portable device to measure skin perfusion pressure (SPP) and pulse volume recording (PVR) so that clinicians can evaluate patients for poor perfusion in any care setting: Vascular assessment needs to be so affordable that we don’t have to charge for doing it. (I know there are a lot of novel technologies out there, but most of them as far as I know, cannot provide an objective number that clearly means “this patient needs revascularization”.) SPP/PVR have never failed me in detecting a patient who needed an interventionalist. When my old Vasamed machine wore out, I bought used one off eBay because my hospital administration would not replace my old one. The hospital refused to buy it because  I could not charge for the test (and thus the hospital could not recuperate the cost of the device). In the hospital-based outpatient setting, SPP/PVR can only be performed by a certified vascular technologist, which is why I could not charge for it. However, I could keep the interventionalists busy in the cath lab with patients whose arterial disease had been missed by arterial Doppler and Ankle Brachial Index (ABI). In the office-based setting, a physician can charge for performing SPP/PVR, but the machines are so darn expensive that a typical private practice doctor can’t afford to buy one. And they are so big, they can’t be transported to the home setting. We need a lightweight, portable device that is inexpensive enough to be affordable by every-day doctors so that we can stop missing arterial insufficiency. 

I will add that I never used a CTP/skin substitute in the absence of the above technologies – but patients often had to spend hundreds of dollars of their own money to buy the basic things that were needed to heal them. The only downside to this list is that a lot fewer patients would need CTPs/skin substitutes if we could get these basic things for every patient. If I ruled the world, I would start by correcting these 6 stupid problems- and if I was making a huge profit off from the skin substitutes that I was using, I would provide them to patients myself. (Providing things to patients for free that Medicare does NOT cover is totally legal).

Now I would like to know what’s on your list of “stupid things” that need to be fixed. Message me and I will post them.

(And next time, I am going to talk about how I would change clinical trials if I were Queen.

Resources:

L-arginine/Nutrition:

Vitamin D3:

SPP/PVR:

Compression:

 

Off-loading and why it’s hard to do the right thing in wound care:

Pressure ulcers (there are a lot of posts here!):

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.

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