2026 Skin Substitute Policy Changes: A Vascular Surgeon’s Perspective on Access, Reimbursement, and Long-Term Wound Care Sustainability

As CMS begins implementation of major changes to skin substitute reimbursement in 2026, questions remain about how these policies will affect real-world wound care, especially for complex vascular patients and underserved populations. In this interview, Leo Fong, MD, a vascular surgeon with decades of academic and community-based experience, shares an on-the-ground perspective on why these changes were inevitable, how they may temporarily strain access, and why they could ultimately preserve skin substitutes as a viable tool in chronic wound management. 

1. Policy restraint may preserve—not eliminate—skin substitute access. 
   While tighter reimbursement and spending caps may limit short-term utilization, Dr. Fong emphasizes that these guardrails are necessary to curb inappropriate use and ensure skin substitutes remain a sustainable, reimbursable option long term rather than being phased out entirely. 

2. Early intervention and integrated care models matter more than ever.
   For vascular and underserved populations, success hinges on intercepting wounds early and treating the underlying disease—not just the wound itself. Vertically integrated care models can better absorb policy shifts without compromising outcomes. 

3. Medicare and Medicaid patients won’t be excluded—but efficiency is critical.
   CMS-aligned Medicaid programs, such as Medi-Cal, continue to cover skin substitutes with increased scrutiny. Practices that understand appropriate product selection, documentation, and utilization can continue to serve high-risk populations effectively under the new rules. 

I think the general movement is good. The previous way was unsustainable. (In our experience) products coming on with extraordinarily high ASPs weren't any different than legacy products. And so, I think it's good. I think it will also wipe out the wound care providers treating patients with these products who probably weren't benefiting.  

I'm a vascular surgeon. I was with University of California San Francisco for about 25 years and recently departed to focus on wound care and amputation prevention. We really service more of the underserved communities. So, instead of a traditional model where we wait for referrals, our goal is to find patients with wounds and intercept that clinical process early on, when there is minimal tissue loss. When you have massive tissue loss, then you may need much more robust blood flow to heal, and much more intensive wound care and hyperbarics. And with this model, we've been very fortunate and successful. This is especially relevant when you look at the downstream impact of some of these skin substitute changes. 

When it comes to reimbursement for these products, the price is the price. In an age of $2,000 ASPs, putting a ceiling on the spend is good, because, to me, it means that the dollar spend can be applied to more patients. We have payers that don’t cover surface topical treatments because of the cost. We find that the payers’ philosophy is that treatment should go to the HOPD wound centers, but there are more wounds than they can take care of.  

So, from a broader standpoint, these policy changes may limit access to care in one sector, but they may allow that treatment option to continue. For instance, look at what happened with hyperbarics. It exploded with chambers everywhere. Over time, Medicare narrowed the covered diagnoses and the covered settings. That put a lid on rampant inappropriate use.   

And then the commercials fell in line, so that it closed off an area of potential growth in that treatment because of unreasonable exuberance in the usage. That's human nature, right? People push until they get to that limit, and then someone must slam the door closed, and that's what's happened. They've slammed the door closed. 

I don’t think the reimbursable dollar amount will change much anytime soon. It may get a little more sophisticated, and possibly segment out into scaffolding products, biologically active products, or products with different levels of data. 

In the short term, I do think it's going to limit access for some patients. In the long term, I think it will allow this type of treatment to carry on and become an ongoing part of the  treatment of chronic wounds, versus just being eliminated as something that insurance will pay for. 

We saw this coming, they signaled it months ago, and we've been able to find vendors and find products that will fit our needs. 

Here's the in-the-trenches take on this. I'm in California. Our Medicaid provider is Medi-Cal and their local contractors follow CMS guidelines. And so, Medi-Cal will actually pay for this. Now, you have to be efficient, you have to know what you're doing and use it appropriately. There's more scrutiny, but as long as you're doing it the right way, it's not an issue. For us, we treat a heavily Medi-Cal population, 70 to 80% across 7 centers. 

Medicare and Medicaid also encompasses the majority of patients who have chronic wounds, and they have inherent access-to-care issues independent of these policy changes. For those well taken care of from a health care maintenance standpoint, they’re probably less likely to get a large VLU because intervention would have happened sooner. So that’s what we are working to do. There are multiple avenues. You can’t just look at the wound. You have to treat all of the pathology, venous insufficiency, etc. The wound is not the disease. The wound is a signal. And so, our philosophy is figuring out why that wound is present and treating the disease. Our model is a vertical integration of everything necessary to get that wound healed, so policy changes like this don’t change our philosophy. 

Dr. Fong is board certified in vascular surgery and is the Founder and Medical Director of Central Valley Vein and Wound Centers in California.