How New CTP Regulations Will Change Wound Care in VA and Rural Settings: One Provider's Perspective

The new CTP-based protocols will restrict available products, require four weeks of documented standard-of-care wound therapy, and shift many applications from the clinic to the OR, significantly affecting workflow for VA and rural wound-care providers. While these changes may delay advanced care for some patients, this speaker notes they are expected to improve cost transparency, expand access through better coverage, and reduce prior reimbursement abuses—though providers must adapt to stricter documentation and evolving definitions of standard of care.

•  
• US VA and rural critical-access hospitals—new CTP regulations: Forthcoming CTP-based protocols limit products to “a select few companies,” standardize costs, and require ≥4 weeks of documented standard-of-care wound therapy before CTP use, delaying immediate grafting previously common in VA settings.
• Care-setting and access changes: In-office CTP application may no longer be billable, pushing cases to the OR, increasing scheduling burden; potential downside includes delayed access for chronic wounds, while standardized pricing may expand insurance coverage and patient access.
• Documentation and compliance: Providers must meet detailed documentation requirements; unclear definitions of “standard of care” may evolve; inadequate documentation may delay CTP approval and reimbursement.

So the new CTP-based protocols that are coming out soon are going to impact VA providers and critical access hospital providers, especially in rural communities, in a number of ways. Probably the biggest aspect of it that providers will see is that now there's going to be a select few companies that provide these products as opposed to being inundated with hundreds, maybe even thousands, of various versions of the same thing, all of which have little tweaks in them to make them marketable, but they're relatively the same type product. 
 
And the cost of which will be a little bit more streamlined and consistent across the board, as opposed to some where some products are a little cheaper and some are astronomically expensive. And there's not really a clear indication as to why that is sometimes as a provider. So, I think that will definitely change the landscape a bit. 
 
Probably the biggest thing, though, for especially VA providers, is that now, as part of the regulations, we're going to need to show documentation of at least four weeks of standard of care wound therapy before we're even able to entertain the idea of putting on the CTPs on patients. You know, coming from the VA, I've been there for about three years, a little bit more as a student. And so while I was there, we did a lot of these types of wound care products. And it was wonderful because we'd have a veteran come in with a wound. It may be the first time that we're seeing him. And we're able to go right into it, debride, clean, and then graft over that wound. And we achieved excellent results that way. 
 
So I think it will change the pace of the VA because that was never a restriction for us. And now we're going to have to go with standard of care for four weeks, hope and pray that that wound doesn't deviate in the wrong direction during that time, and then potentially go move forward with more advanced wound care products. So that's kind of one big aspect of it. 
 
The other thing that I think we'll see in this also impacts community care and rural providers, is that the use of these products in office is going to be limited, especially for billing purposes. And so I know in my situation, I'm at a rural community hospital. I can't put on these products without taking (patients) to the OR first. And that's just really for the billing aspects of it. Whereas in the past, especially at the VA, we did this all in office. And it was just, you know, off the shelf kind of stuff. 
 
So I think it’s just going to change the way, I think it’s going to make us a little more cognizant of what grafts and products we use and making sure we’re thoroughly documenting and making sure that we’re using them for the right patients at the right times.
 
I do think this will impact the patient’s ability to access these CTPs and other advanced wound care products, potentially good and bad. On the bad aspect of it, you know, a lot of times these wounds that we come in, they may have been there for months or years, and the patient hasn't had care from a provider during that time. And so, you know, when we see these grossly wounds that just aren't looking well, a lot of times I would think it's in the best, the patient's best interest to go with the most optimized treatment and get them the best wound care possible to achieve the best outcome down the road. And so having to wait four weeks or more potentially delays that. And whether that means that the wound goes south during that time, or that you've just taken an additional four weeks of that patient's dignity, independence, and life that they could have had if we healed them up sooner. I think that's potentially a negative aspect of that requirement. 
 
On the flip side, though, I think by standardizing the costs across the board and narrowing it down to a select number of companies, that should drive the costs of these products down and also hopefully encourage insurance companies to cover them more. So at lot of these grafts were out of reach for patients that didn’t have the greatest insurance or financial needs. I think this is going to give better access to those products and potentially help them. 
 
So on the one hand I think there will be situations where it may be as a hindrance and a frustration, but I think as a whole, largely, it's going to allow these products to be used for more patients. 
 
The biggest challenges that providers are going to experience in light of these updates that have come out is the detail that's going to be required in their documentation. You know, I think we all, as providers, have developed our own style and routine of doing things. And sometimes our notes are very detailed and sometimes they're a little lacking. And the documentation requirements of these changes are going to require us to be standardized and to include all of the pertinent information. And if we are found to be lacking when we're applying for those wounds to be, or those grafts to be used on our patients, that could end up delaying the use of those products and be an issue. So I think that's probably the biggest thing that I see as provider, that I'm going to have to really pay attention to the guidelines and what they're expecting, probably build out some templates and things, and just make sure that my staff and I know as we go through and see these wounds, that these are the absolute essentials that have to be documented. 
 
I think also, in terms of what is standard of care, right? You know, the requirement is that these wounds have to be given the standard of care for at least four weeks. So what does that mean? My standard of care, I think, might be different than another wound care provider’s. And so I think that has yet to be seen. I don't, in reading through the guidelines and what's out there, I don't know that that's explicitly stated what that qualifies as. And so I think over the next year or so we're going to really see some developments there and potentially more specific guidelines as far as what they consider to be standard of care. 
 
And then, you know, as far as, again, with providers, I think that we're going to see more and more rural community hospitals, more and more VAs opt to not allow these grafts to be applied in office for fear of them not being reimbursed. So kind of a financial decision. And so I think more and more these CTPs are going to be, have to be applied in the OR setting, which in terms of the patient care is superior, that's more sterile and that's great. In terms of patient volume, though, for podiatric surgeons who have busy OR days, it's going to cluster things up. I already know for myself, you know, I'm doing three to four of these cases a week, and I have to fit those in between my normal surgical cases, and so that can add up and it takes up time that otherwise I can use for actual surgeries. 
 
So hopefully, there will be more guidelines that way that come out and maybe they'll make some adjustments for like sub-sterile procedure rooms and things, which is what we used at the VA that I trained at. But that really has yet to be seen and it wasn't immediately clear in the guidelines that that was going to be a factor. 
 
So I think that I think that overall it's a really positive change for our field. I think there's been both in the private sector and on the government side, there's been abuses of these products and the reimbursements and I think this is going to help make it more equitable for patients and help avoid some of those problems. And I know a lot of horror stories out there from docs with clawbacks and other things that have happened so you know, all the way around when it's not regulated and there's not clear rules, patients and providers suffer. And so I think by having these clear guidelines, we're all going to benefit overall. And we’re all going to have some growing pains as we all learn to adjust.

Dr. Evensen is a podiatrist in the Department of Veteran Affairs at the Southern Arizona Veteran Affairs Healthcare System in Tucson, AZ.