Payers' perspectives on wound care coverage policy determination: what we know and ways to move forward.

Abstract

Many coverage challenges in wound care stem from a lack of shared clarity among researchers, manufacturers, payers, and regulators about the clinical evidence payers need to make positive coverage determinations. The Alliance of Wound Care Stakeholders, a multidisciplinary trade association, convened its Wound Care Evidence Summit in May 2022 to explore this issue and identify shared challenges and solutions with a diverse range of policymakers, payers, and researchers. This article focuses on payers' clinical evidence requirements and the processes used when making coverage determinations, as discussed at the Summit. The authors explore the role of alternative sources of evidence beyond randomized clinical trials that were raised in the discussions: clinical practice guidelines, health technology assessments, and clinical consensus. The article reviews discussions around the use of these in coverage decisions and explores potential solutions to achieve evidence-based practice and coverage policies that meet the needs of all patients with chronic wounds.