Keep
We keep limbs. We keep people whole.
At home.
A wound is not a billing line. For too many patients it is the start of a countdown, and nobody is managing it.
A diabetic foot ulcer becomes an infection, the infection becomes an amputation, and the amputation starts the clock. Five years after a major amputation, more than half of patients are gone. That is a mortality worse than breast, prostate, and colorectal cancer and the all-cancer average6. And the limbs are not lost at random: Black patients are amputated at two to four times the rate of white patients7. KEEP exists to bend that countdown the other way.
Every other runaway category got a manager. The chronic wound still has no dedicated one.
Why did no manager form here? Because the wound is not a billing lane. It scatters across Part B drugs, DME, home health, outpatient, and surgery. A benefit nobody can see whole is a benefit nobody manages.
The PBM
Manages the drug benefit.
TurningPoint
Manages the surgical benefit.
Synapse
Manages durable equipment.
No one
No dedicated benefit manager.
A category that crosses every billing lane was nobody’s whole job. It is KEEP’s whole job.
Skin-substitute spend ran away by 40x, and a billion-dollar fraud rode in behind it.
About 40x in five years
Medicare Part B skin-substitute spend went from $256M in 2019 to over $10B in 2024 while the patient count only roughly doubled1. Dollars outran people by 20 to 1.
Adjudicated, not alleged
An Arizona wound-graft scheme drew guilty pleas and 15.5- and 14-year sentences, plus $309M in civil recovery5. The money was real. So was the harm.
The graft, not the patient
The patient count barely moved. The spend wasn't tracking need. It was tracking an unguarded product line. And the graft itself is a slice of a $28B+ Medicare wound burden8.
Dollars outran patients, 2019–2024
Medicare Part B skin-substitute spend, plotted against the patient count it was meant to track.1
The wound-spend diagnostic is built to redraw this chart from a plan's own book.
CMS slammed the price: a flat rate, and a ~90% cut.
Effective January 1, 2026, CMS replaced ASP+6% with a single flat rate, paid as an incident-to supply at the same rate in office and hospital outpatient.
One flat rate, volume-weighted across all 361 products, effective Jan 1, 20262.
The single biggest swing in this category's history landed in one ruling.
The flat rate solves the price per unit. It cannot touch product choice, application count, graft size, or medical necessity. A manager does not fight the ruling. A manager governs what it left open.
CMS-1832-F · Fed. Reg. correction Nov 28, 2025 · was $127.28 pre-correction
CMS fixed the price. It did not fix the coverage.
The new rate caps dollars per square centimeter. It says nothing about which product, which wound, how many applications, or how large a graft. And on December 24, 2025, the seven MAC coverage rules that would have answered those questions were withdrawn4.
What is now capped
- Dollars per square centimeter, flat at $127.142
- Same rate in office and hospital outpatient
- Paid as an incident-to supply, not a marked-up product
What is still unguarded
- Which product, of 361 on the list
- Which wound, which indication, medical necessity
- How many applications, how large a graft. A flat per-cm² rate even rewards larger grafts
CMS capped the dollars-per-unit and walked away from medical necessity. No regulator has stepped in to fix the other side. That is the benefit manager's job.
Every payer carries the wound. We start where the dollars are most exposed.
The CMS rate only touches Medicare FFS. Commercial and Medicaid carry the same clinical wound burden with no rate to cap them and no public dataset even sizing them. That vacuum is the opportunity and the moat.
Commercial
Same wound burden, no CMS rate to cap it, weak medical policy in many plans. The most exposed dollars, and the clearest first meeting.
Medicaid MCOs
FFS segments and weak-policy states carry the same risk with no public number sizing it. A regional MCO without internal wound capability is the wedge buyer.
Medicare Advantage
Already self-manages this through prior auth, only ~7% of FFS skin-sub spend despite over half the lives9. A managed-services play: the home spine and the registry, not a rescue.
Medicare FFS
Got the price fix but still carries coverage-side risk: larger grafts, more applications. A managed pathway still has a job through the coverage gap.
KEEP manages the wound episode end-to-end, not a product.
The skin substitute is the trigger, not the prize. A manager that touches only the formulary handles the loud 10% and leaves the real money and the real outcomes untouched. KEEP owns one disease vertically, all the way down, with the formulary and closure registry inside a managed care pathway.
The wound episode, governed end-to-end
The services the wound touches, orchestrated to one number, with acuity managed up when the limb is threatened and stepped down as it closes.
KEEP adds the right care — more nursing, the vascular gate, offloading, the correct meds — while removing the wasteful care. Right care up, wasteful grafts down. That is what makes "lead with limb preservation, savings follow" true, not a slogan.
Claims can't see whether a wound closed. KEEP owns the record that can.
KEEP makes photographic, measurement-based wound documentation a network-contracting requirement. That produces the only closure-rate dataset segmented by product, provider, and wound type, owned by KEEP and reported to the payer. It is the record claims data can't supply. A UM rule copies in a quarter. A longitudinal closure registry, plus the owned home-delivery spine, takes years to build.
Today the pieces sit apart. No product on the market fuses closure-rate-by-product-and-provider into payer purchasing and steerage. That fusion is KEEP. Esperta delivers wound care as a single vendor; KEEP manages and measures a network of them.
Own the brain and the scoreboard. Rent the hands. Then climb.
KEEP owns the registry, supervision, formulary, and steerage: the control points that let it bear risk. It partners for the hands-on home visits. That hybrid is the structure built to reach a capitated carve-out — the wound category only, condition cost of care, never total cost — and it climbs there one rung at a time. Rungs one and two build the registry; the registry prices rung three.
Admin / PMPM management fee
Formulary, evidence-aligned prior auth, network access, and the wound-spend diagnostic.
Performance guarantees
Closure-rate and limb-preservation targets put fees at risk against real outcomes.
Capitated wound carve-out (CCOC)
A per-member rate for the wound category only, not total cost of care, keeping the spread it saves, priced from KEEP’s own closure registry. Precedent that payers will capitate a young vendor: Synapse Health / UnitedHealth, DME, 2026.
What KEEP reports back is limbs kept.
Not dollars saved. A limb preserved. A wound closed. A person kept whole, at home.
The metric is limb-preservation rate, supported by closure rate, and only then by cost. When a wound benefit is managed, the outcomes move first. The savings are the quiet consequence. They come last, on purpose.
A wound population, unmanaged vs. managed
One condition. One buyer. One artifact that books the meeting.
KEEP doesn't open with the whole platform. It opens with the narrowest true thing, and an artifact a plan can see its own exposure in, before any network exists.
The DFU
The diabetic foot ulcer: the wound where the limb is most at stake and the pathway is clearest.
A regional plan
A regional commercial or Medicaid MCO without internal wound capability. Exposed, and able to move.
Your own 40x chart
The wound-spend diagnostic, built from public and plan-shareable data, so a specific plan sees its own exposure. It needs no network to produce.
THE OPERATOR
Joe Nalley
Founder, KEEP
Built by someone who has carried patients and built the businesses around them.
Joe Nalley built KEEP from inside the machinery of payer growth. Today he is Staff Vice President of Carelon Growth (Elevance Health), operating at national scale.
He founded and sold ClearBill, which returned $9.2M to payers in its first six months. He built and exited GetWell, a 13-location behavioral-health and substance-use provider that served more than 30,000 patients.
Across a career in care delivery and payer growth, he has been responsible for more than 200,000 lifetime patients served. KEEP is the benefit manager that work has been pointing toward.
Book the wound-spend diagnostic.
Bring one book of wound spend. We build your own 40x chart from public and plan-shareable data, and walk it together. No network required to produce it.
We open with limb preservation. We close with limbs kept. The savings are real, and they come last.
What the first meeting produces
- Your plan's own wound-spend exposure, charted
- Where the coverage gap is costing limbs and dollars
- A staged path: admin fee → guarantees → carve-out
Joe Nalley · joe.nalley@showyourwork.health
keepwhole.com · the benefit manager for the chronic wound
Every external figure traces to a primary source.
- HHS-OIG, OEI-BL-24-00420 (Sept 2025). Part B skin-substitute spend $256M (2019) → over $10B (2024), ~40x; patient count roughly doubled.
- CMS-1832-F; Federal Register correction Nov 28, 2025. Single flat rate of $127.14/sq cm, incident-to, office = hospital outpatient, effective Jan 1, 2026 (was $127.28 pre-correction).
- CMS press release / CY2026 PFS. About a 90% cut; ~$19.6B saved in CY2026, a single year.
- CMS LCD-withdrawal fact sheet. Seven MAC skin-substitute LCDs withdrawn Dec 24, 2025.
- U.S. Department of Justice (Apex Medical; Gehrke & King). $1.2B Arizona wound-graft scheme; guilty pleas; 15.5- and 14-year sentences; $309M civil.
- Armstrong et al., Journal of Foot and Ankle Research, 2020. Five-year mortality after major DFU amputation ~56.6%, exceeding the pooled all-cancer average (~31%) and worse than breast, prostate, and colorectal cancer.
- Durazzo et al., Journal of Vascular Surgery, 2011; tctmd. Black patients amputated 2–4x the rate of white patients; lower pre-amputation revascularization.
- Nussbaum et al., Value in Health, 2018. Chronic-wound burden $28.1B–$96.8B in Medicare; 8.2M beneficiaries (~15%).
- HHS-OIG, OEI-BL-24-00420. Medicare Advantage ≈ 7% of FFS skin-substitute spend despite over half of lives, via prior authorization.