Skin Substitutes' Influence on Wound Practice Sustainability: Historic and Research-Based Context

In part 1 of this interview series, Zwelithini Tunyiswa, BS, and Ryan Dirks, PA-C, of Open Wound Research examine how mobile wound care has been reshaped by the rapid rise of cellular and acellular matrix products (CAMPs)/skin substitutes. Drawing on national data and firsthand market analysis, they discuss how reimbursement-driven practice models disrupted traditional care delivery—and why evidence-based patient selection and sustainable clinical frameworks are now more critical than ever. 

• Reimbursement-driven models distorted mobile wound care economics. While traditional mobile wound care practices historically relied on evaluation and management (E/M), debridement, and bedside modalities, newer CAMPs-heavy models became disproportionately dependent on them—often accounting for the vast majority of encounters and revenue—leaving them highly vulnerable to reimbursement shifts and regulatory enforcement. 
• Regulatory changes exposed unsustainable practices and accelerated consolidation. Open Wound Research data show that a relatively small subset of mobile providers drove a majority of CAMPs spending, and when proposed changes and CMS clawbacks emerged, many of these groups collapsed financially, fueling bankruptcies and rapid roll-ups into larger entities. 
• The future depends on evidence-based use—not blanket acceptance or rejection—of CAMPs. Tunisiwa and Dirks emphasize that CAMPs are neither universally appropriate nor inherently problematic; their value is conditional. Sustainable wound care requires clearer standards, stronger clinical guidance, and disciplined patient selection rooted in outcomes data rather than reimbursement opportunity. 

Please note: This content is a direct transcript, capturing the authentic conversation without edits. Some language may reflect the flow of live discussion rather than polished text. 

I think maybe it would be good to review some numbers that we've talked about. I think depending on how you count, of course, there's about 4,200 to 5,000 mobile wound care providers or specialists, whatever you want to call them. The rise of CAMPs, of skin subs, brought some participants to market, especially home-based, but also in nursing, whose models were very different, right? A normal, I hate to use that word, but a normal mobile practice is predominantly about E/M codes, debridement, and other modalities like Unna Boot removal or other advanced bedside wound care modalities.   

That's the bread and butter, and then with the rise of these new smaller groups that were more skin sub/CAMPs driven, you saw numbers of 80% of encounters being skin subs, etc., and their revenue flows were maybe 90% skin sub and CAMPs-driven. And we of course know about the ASP and the pricing, etc. And so those models, to your earlier point, was simply not sustainable, especially on a smaller scale if those ASP prices or reimbursement changed or, conversely, if there were massive clawbacks.  

And in the research we did, we saw that when the LCDs and all these things started happening and the CMS started these clawbacks, a lot of groups actually filed for bankruptcy and precipitated the roll-up that we see of these smaller groups into larger entities, oftentimes for pennies on the dollar. And so it was very interesting for me. I said, wait, what do you mean you don't bill E/Ms? And they said, oh, we don't need to bill them. And coming from, sort of the old school, what does that even mean? It took me a while to compute what that meant. And I pulled the guy aside. I said, you know, you really care about your patients. You're trying to do the right thing. But your model is going to blow up if you don't do the usual type of wound care because you're over-dependent on something that is going to change. It's always guaranteed to change. And in ways that are unpredictable and probably the wrong direction. So that's when it really kind of sunk into me that there were people around the country who had built these models, de novo. 

In addition, there were some of the first and second wave people who had modified their models substantially to benefit relative to skin subs and CAMPs. And again, I always try to stay away from this declaration that many people have that, oh, all of it was fraud, waste, abuse. Well, in some cases, in many cases, I would say, in most cases, there was appropriate usage. But as our data review showed, when we went through the data at Open Wound Research, that top 100 skin sub users were also mobile providers and really dominated cost.  And remember, we're talking of a wider population of 4,200 to 5 ,000 accounting for 70% of CAMPs spending. 

And so I think that those distortions in the market really changed the conversation around mobile wound care from what we've been talking about to something that did not represent our charge, and that's our commitment and that's our license and scope of practice. We have to practice medicine. Now, there are people that have achieved a level of certification and a level of training where they now are specialists and even subspecialists, and I don't fault people for that. I mean, if we go back to the orthopedic analogy, I have friends that are towards the second half of their career or the later half of their career. And all they do is knee replacements because they're really good at it and they love it and they can sustain their practice just doing knee replacements. And it's not that they're abusing knee replacements because that's all they do and all they bill for. It's because that's where people from all across the state or sometimes all across the country drive to them because they're really, really, good clinicians and artists at doing this particular procedure.  

If we step back and we look at wound care, well, first of all, we haven't done a very good job building a society around what good specialists do and what those clinical practice guidelines or what those standards of care are. We have lots of room for improvement in that. It's not that people haven't tried and the outcome is closure of the skin, if that's what we're looking at. So, there's a lot of problems that I think have kind of led to where we are. But I don't fault people for just saying, hey, I only want to take care of pressure ulcers on the sacrum. I'm really, really good at it. I would just say, I don't know if you can do that sustainably. Maybe you can. Maybe you have enough patients with, you know, pressure ulcers on the sacrum. You probably are if you're a plastic surgeon. If all you're doing is knee replacements, you’ve still got to have enough patients that have bad enough knee arthritis to need those procedures and to get good outcomes from them - not every patient's a good candidate for a knee replacement, so not every patient's a good candidate for a CAMP.  

But again, how do we go back to the research and the body of evidence and the society to stand up as physicians and say, these are the right patients we should be putting (them) on, and these are the scenarios where it should happen. And all that, I think, kind of led to where we are today. So, I'll get off of my bandwagon on that. 

No, it's a decent bandwagon. I mean, what we're really talking about is how wound care changed, right? So, the movement from primarily E/M and debridement to CAMPs/skin subs. Again, I think, and we've talked about this a fair amount, and I've done on the Open Wound Research side, I'm always asked by people, does it work, does it not work? And, as a quantitative person, I go, well, under which conditions? 

It's a very odd question to have, does something work or not? Well, it's conditional, right? So I think it is appropriate if a clinician believes and has exhausted other avenues, and that patient is going to remain in a nonhealed state for an extended period of time, for them to accentuate treatment, to look for modalities that they can better attack the disease state.  

You know, in healthcare, it depends. So, I do think there's a place. There's been newspaper stories, et cetera, that do present it as black and white. And that, to me, speaks to a lackof knowledge about what actual wound care looks like.  

Zweli Tunyiswa is Chief Executive Officer and Co-Founder of Open Wound Research. 

Ryan Dirks is the Chief Clinical Officer and Co-Founder of Open Wound Research.