November 25, 2025 

RE: Protecting ACOs and Physicians from Skyrocketing Skin Substitute Spending

Dear Deputy Administrators Sutton and Klomp:

The undersigned organizations thank you for your attention to the challenges posed by increased billing for skin substitutes. We strongly urge the Centers for Medicare & Medicaid Services (CMS) and the CMS Innovation Center to use their existing authority to ensure that accountable care organizations (ACOs) and Merit-based Incentive Payment System (MIPS) eligible clinicians are held harmless from this increased spending, which often constitutes egregious examples of waste, fraud, or abuse.

As you know, Medicare spending on skin substitutes has experienced unprecedented growth, increasing from $256 million in 2019 to more than $10 billion in 2024, with CMS leadership projecting expenditures could exceed $20 billion by 2026.1 Although some of this spending stems from appropriate wound care, the evidence suggests that much of it represents wasteful or even fraudulent activity.

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