Medicare Part B paid $9.86 billion for skin substitutes in 2024 — more than it paid for ambulances. Here are the 600 highest-billing clinicians in the country, every one of them plotted by the square centimeter.
A skin substitute is a sheet of processed tissue — often amniotic membrane — laid on a chronic wound. Medicare pays for it by the square centimeter, and until this year it paid whatever the manufacturer said the thing was worth.
In 2013 the entire national Part B bill for these products was $23.9 million across 16 billing codes. In 2024 it was $9.86 billion across 94. CMS puts the same trajectory at $252 million in 2019 to over $10 billion in 2024 and attributes most of it to one thing: launch prices.
Nobody had to sell more bandage. They only had to name a bigger number.
Each dot is one clinician. Vertical position is what Medicare allowed them per square centimeter of product. The red line near the floor is $127.28 — the single flat rate CMS finalized for nearly every skin substitute starting January 1, 2026.
1. Press “2026 flat rate.” Every dot drops to the line. The same 2.9 million square centimeters, the same patients, the same wounds — and the bill for this group of 600 falls from $4.39 billion to $369 million. Nothing clinical changed. CMS re-classified the products as incident-to supplies and stopped paying by brand.
2. Set the specialty filter to nurse practitioners only. 372 NPs appear in the full provider file, billing $1.64 billion — the largest single specialty block in the dataset, ahead of podiatry, dermatology and general surgery combined. This is not a claim about nurse practitioners. It is a claim about which billing seat the product companies found easiest to sit next to.
3. Push the minimum-square-centimeter slider up and watch the correlation readout below the chart. All 600 clinicians give r = −0.19. At 5,000 sq cm (n = 157) it is +0.04. At 15,000 (n = 35), +0.20. At 30,000 you are fitting seven points and it reads −0.69. Same data, same question, four different answers. Six hundred dots is a sample. Seven is a mood, and it is exactly the size of sample that gets quoted in a slide deck about “outlier prescribers.”
| Item | Value |
|---|---|
| National Part B skin-substitute allowed, 2024 | $9.86B |
| Visible at the individual-clinician level | $4.62B (47%) |
| Clinicians with any unsuppressed row | 1,153 |
| Plotted here (top by allowed) | 600 |
| Rows CMS suppresses | ≤10 beneficiaries |
| “Patients” column | summed across products |
Apligraf has been on the market since 1998. It is a PMA-approved living bilayer product, it is paid under the ASP methodology, and Medicare's allowed amount has sat between $29 and $39 per square centimeter for twelve straight years.
Amchoplast entered the code set recently. In 2024 Medicare allowed $4,160 per square centimeter for it — 138 times Apligraf — across 36 clinicians and 138 beneficiaries.
The reform is real and it is already law: CMS-1832-F, finalized October 31, 2025, effective January 1, 2026. CMS projects it cuts skin-substitute spending by roughly 90%. Wolf's reporting is about the years of political effort that went into stopping the other lever — a national coverage determination — and what happened to the executives who tried.
The build: if you run a wound program, the useful exercise this quarter is not reading the rule. It is pulling your own 2024 Q4-code utilization out of your billing system, dividing dollars by square centimeters, and seeing where your own dot would land on this chart. Every practice that lands above the line has a 2026 revenue problem, and the ones that land far above it have a documentation problem arriving right behind it.