The benefit manager the chronic wound has been missing

A spigot opened, and no one is at the valve

Medicare Part B spending on skin substitutes went from $256 million in 2019 to more than $10 billion in 2024 — about 40-fold — while the number of patients treated only roughly doubled.¹

That gap between dollars and patients is not biology. It is the signature of a payment incentive with no clinical guardrail behind it. The graft got applied more often, in larger sizes, on wounds that did not need it, because the rate rewarded volume and the payment itself never asked whether the wound was closing.

CMS saw it. Effective January 1, 2026, it replaced ASP+6% with a single flat rate of $127.14 per square centimeter, paid as an incident-to supply at the same rate in office and hospital outpatient settings. That is roughly a 90% cut, about $19.6 billion saved in CY2026 alone.²³ A clean fix to the price.

But CMS fixed the price, not the coverage. The seven MAC skin-substitute coverage policies that would have restricted which products and which wounds qualified were withdrawn on December 24, 2025.⁴

So which product, which indication, how many applications, how large a graft — all of it is still unguarded. A flat per-square-centimeter rate even rewards a larger graft. CMS capped dollars per unit and left medical necessity open. No regulator has stepped in to fix that side. That is the benefit manager's job, and the chronic wound is a major spend category with no dedicated one.

This is a clinical failure before it is a financial one

It would be easy to read the 40x chart as a fraud story and stop there. The harder truth is what happens to the patient when the wound is managed for the graft instead of for the limb.

Five-year mortality after a major diabetic-foot-ulcer amputation is roughly 56.6%, worse than breast, prostate, and colorectal cancer, and worse than the pooled all-cancer average.⁶ The burden falls unevenly: Black patients are amputated at two to four times the rate of white patients, with lower rates of limb-saving revascularization before the amputation.⁷

An amputation is rarely a single decision. It is the end of a chain of missed steps: an infection caught late, a vascular problem never worked up, an ulcer left under pressure. The graft is the loudest line on the invoice, but the limb is lost in the visits that didn't happen.

Manage the episode, not the product. Be the brain and the scoreboard; rent the hands.

KEEP is a benefit manager for the chronic wound, the PBM-equivalent for a category that has no dedicated one. It is built to manage the whole wound episode through a credentialed home-care network it contracts and measures, with an evidence-based formulary and a closure-rate registry sitting inside it.

The episode, not a slide off a graft list

The skin substitute is the trigger, not the prize. It books the meeting, but it is a slice of the dollar. The bulk of the burden lives in hospitalizations, ED visits, surgery, and amputations, not the graft. A manager that touches only the formulary handles the loud 10% and leaves the real money, and the real outcomes, untouched. So KEEP manages the episode end to end:

• Home nurse monitoring — the Tuesday visit that catches the infection early. This is the actual mechanism of keeping a limb.
• Medications — the right antibiotic before it reaches bone; pain control; glycemic control, because a diabetic foot ulcer does not heal on a high A1c.
• Labs and the vascular gate — wound cultures and vascular studies. No graft goes on a limb with no blood supply; the vascular workup is a hard gate before advanced product is approved.
• Offloading and DME — total-contact casts and therapeutic footwear, because an ulcer under pressure does not close.
• Acuity management — escalate to vascular, surgery, HBOT, or admission when the limb is threatened; step down to home maintenance as it closes. Levels of care are the lever; limbs kept is the result.
• Nutrition, behavioral health, navigation, transportation — the supports a chronic-wound patient, often elderly, immobile, and diabetic, needs to actually heal.

A hybrid, aimed at capitation

KEEP owns the high-value control points and rents the hands. It owns the closure registry, the tele-wound MD and NP supervision, the formulary, and the steerage engine. Credentialed home-wound-care providers deliver the hands-on visits; KEEP does not employ a field workforce. A paperwork-only manager can't move outcomes, so it is stuck at thin fees. An own-and-operate provider is labor-bound and lowest-margin. The hybrid is the structure that reaches a capitated carve-out without being labor-bound. And you can only take a capitated rate if you can move the outcome, which means you must control measurement and supervision.

KEEP climbs a risk ladder: an admin or PMPM management fee first (formulary, prior authorization aligned to evidence, network access, the diagnostic); then performance guarantees that put fees at risk against closure and limb-preservation targets; then a capitated wound carve-out, taking a per-member rate and keeping the spread it saves. The precedent that payers will capitate a young vendor for a carve-out is recent and real: Synapse Health and UnitedHealth, DME, 2026.

Claims data cannot see whether a wound closed

This is the gap every incumbent shares. A claim records that a graft was applied and paid for. It says nothing about whether the wound closed, whether the limb was kept, or whether a different product would have worked at a third of the cost.

KEEP makes photographic, measurement-based wound documentation a network-contracting requirement, producing a closure-rate dataset segmented by product, by provider, and by wound type — the record claims data can't supply. A utilization-management rule copies in a quarter. A longitudinal closure registry takes years to build. That registry is also the risk-enabler — it is what makes capitation possible — and the steerage engine, because it lets KEEP point volume to the providers and products with the best real closure rates.

Today the pieces sit apart. The US Wound Registry owns risk-stratified closure benchmarks. Net Health owns product utilization. Swift Medical owns objective imaging. None of them fuses closure-rate-by-product-and-provider into payer purchasing and steerage. That fusion is KEEP.

Where the exposed dollars actually are

The honest read on the market matters here, because it is also the strategy. Medicare Advantage already self-manages this category: MA accounted for only about 7% of fee-for-service skin-substitute spend despite holding more than half of the lives, because plans use prior authorization.⁹ MA is not a large unmanaged pool to rescue. It is a buyer for the home spine, the registry, and managed services.

The genuinely exposed dollars are commercial and Medicaid — the fee-for-service segments and weak-medical-policy states — plus the coverage gap everywhere, now that the LCDs are withdrawn. Same clinical wound burden, no CMS rate to cap it, and no public dataset even sizing it. That data vacuum is both the opportunity and the moat: the plan that can see its own exposure first has the advantage, and producing that view is exactly what KEEP's diagnostic does.

The economics follow from the model. Adding the right care — more nursing, the vascular gate, offloading, correct medications — while removing the wasteful care, mostly over-grafting, is what makes "savings follow the outcome" true rather than a slogan. A plan does not save money by denying grafts. It saves money by closing wounds and keeping limbs, because a kept limb is the avoided hospitalization, the avoided surgery, and the avoided amputation that drive the real spend.

Lead with limb preservation. The savings are downstream of the outcome, and they are larger when the outcome is real.

Built by someone who has run the delivery and the payer side

Joe Nalley · Operator

Care delivery, billing integrity, and payer growth — in that order

Joe built a 13-location integrated health system from the ground up — behavioral health, SUD and MAT, primary care, urgent care, lab, imaging, a surgical center, and a community hospital — and ran it as CEO through acquisition. He founded and sold ClearBill, a billing-integrity platform that returned $9.2M to payers in its first six months of full deployment.

Today he is Staff Vice President of Carelon Growth (Elevance Health's specialty health-services arm), where he owns six high-acuity clinical risk books — MSK, oncology, CHF, maternity, autoimmune, and dementia — across more than $50B in specialty medical spend. Across the lifetime of the companies he has led, more than 200,000 patients have been served.

KEEP is the benefit manager that work has been pointing toward: the home spine from delivery, the integrity discipline from ClearBill, and the carve-out mechanics from inside payer growth, aimed at one number — limbs kept.