The Age of Wisdom and the Age of Foolishness: A Tale of Two Wounds

I got this letter from a Physical Therapist, and I am publishing it anonymously with his permission.

–Caroline

Dear Dr. Fife,

I am a physical therapist (PT) specializing in wound care. A PT acquaintance of mine has partnered with a Nurse Practitioner (PT) in a wound care practice. They created the partnership in order to use CTPs/skin substitutes because, although the NP has no wound care training, applying skin substitutes is within her scope of practice.  The PT is a certified wound care therapist who is orchestrating the patient’s care, but because applying skin substitutes is outside of his scope of practice, the NP performs the CTP application. Their financial agreement is a 50/50 split of the profits on all CTPs applied.

Wound #1

My PT acquaintance sent me this photo of this wound which had been present for 9 weeks. Because the patient had “failed conservative treatment for 4 weeks”, they applied 52 cm2 of an amniotic CTP at a total cost of $152,000 (~$2,900/cm2). The next week they applied another 40 cm2 at a cost of $90,000. They got a 45% discount on the cost of the product, so they pocketed $108,900 of the $242,000 that Medicare paid for the product itself (apart from any procedural charges). The patient had to pay 20% of the cost – which was $48,400 — either out of pocket or via their secondary insurance.

For these two CTP applications, the PT and NP each made a profit of $54,450 for about 45 minutes of work. The wound is still not healed, so I assume that they will continue CTP applications.

Wound #2

Here are pictures of a patient of mine who was told by a Physician’s Assistant (PA) that she needed a debridement in the operating room and a skin graft to manage a traumatic injury. She came to me for a second opinion. I performed outpatient debridements, wound care and compression bandaging (to manage the edema) for 12 weeks – at which time the wound was healed. My treatment cost Medicare approximately $4,500.

I am deeply troubled by what is happening in the field of wound care. Assuming Wound #1 really needed a CTP, products are available that are more than 2,000% cheaper than the CTP that was used. The patient (or their secondary insurance) also paid thousands of dollars that they did not need to pay, and the rest of the profits were paid for by our tax dollars. However, it’s possible that a CTP was not needed at all and that wound care, with compression bandaging would have closed the wound faster for a tiny fraction of the cost- saving thousands of patient- dollars and hundreds of thousands of our tax dollars.

These words were never more appropriate than they are now:

“It was the best of times, it was the worst of times, it was the age of wisdom, it was the age of foolishness, it was the epoch of belief, it was the epoch of incredulity, it was the season of Light, it was the season of Darkness, it was the spring of hope, it was the winter of despair, we had everything before us, we had nothing before us, we were all going direct to Heaven, we were all going direct the other way.”

A Tale of Two Cities, by Charles Dickens

Yours sincerely,
[Name Withheld]