Bethesda, MD – September 26, 2018 –The Alliance of Wound Care Stakeholders has questioned a new exclusionary United Healthcare (UHC) policy on cellular and/or tissue-based products for skin wounds (CTPs) slated to go into effect on Oct. 1st. In a comment letter to UHC medical directors addressing "Commercial Medical Policy 2018T0592A, Skin and Soft Tissue Substitutes" the Alliance alerted the insurance provider of concerns that the policy would be detrimental to patient care. The Alliance requested a meeting to address concerns and encouraged UHC to delay policy implementation.
Addressing patient care concerns, the Alliance counseled: "This policy, if enacted, will cause significant disruption in the care of your members in outpatient, hospital, rehabilitation, skilled nursing and other settings who are currently receiving skin and soft tissue substitutes (CTPs) for the management of their chronic wounds. By restricting coverage to only a few CTP options the Alliance believes that the proposed policy may result in unintended consequences of increased product wastage and higher costs, including higher member patient co-pays. As such, we believe this proposed policy will have substantial negative impacts on patient outcomes, quality of life, and cost of care…Our practicing clinical members' concern is that by not providing coverage of CTP options that are indicated for the treatment of these more severe wounds, member patients may experience higher amputation and associated death rates."
Addressing the clinical evidence for CTPs, the Alliance recommended: "As RCTs limit co-morbid factors, which cannot be removed in the actual treatment of wound care patients, we suggest that UHC consider alternative clinical study forms in addition to its reliance on RCTs for developing wound care coverage decisions. RCTs only tell a part of the clinical outcomes story, as claims data shows that real world patients are often sicker than patients enrolled in RCTs. We believe that the utilization of well designed EHR data and registry data studies, with well-matched cohorts for comparative outcomes analysis, would provide real world clinical outcomes data for making UHC coverage policies determinations. Because practicing clinicians are treating sicker patients with multiple co- morbidities that would fall outside of the patient types typically included in RCTs, clinicians often have to rely on this real world data of retrospective studies based on EHR data or registry data to make treatment decisions."
While this policy is currently targeted to UHC's commercial (employer and individual) plans, the insurance giant also administers Medicare and state Medicaid plans. While Medicare/Medicaid coverage is established under a separate process, the policy triggers alarm bells for clinicians – as CMS policy makers often look to see how large private insurers handle coverage.
About the Alliance of Wound Care Stakeholders
The Alliance of Wound Care Stakeholders: The Alliance is a nonprofit multidisciplinary trade association of health care professional and patient organizations whose mission is to promote quality care and access to products and services for people with wounds through effective advocacy and educational outreach in the regulatory, legislative, and public arenas.
The views and opinions expressed in this blog are solely those of the author, and do not represent the views of WoundSource, Kestrel Health Information, Inc., its affiliates, or subsidiary companies.