Medicare’s $10 billion wake-up call: Wound care is more than numbers — why primary care physicians must step up in 2026

For the millions of Americans living with chronic wounds, every misstep in treatment delivers far more than a financial blow. It means daily pain, sleep lost, isolation, missed work, abandoned hobbies, and the slow, relentless erosion of independence and dignity. The downstream costs of poorly managed wounds, measured in amputations and premature deaths, should be as urgent to us as the ballooning price tag Medicare now faces.

When government spending on skin substitutes surges from $252 million to more than $10 billion in five years, it makes headlines. Yet, the real cost is suffered by our patients through months or even years of delayed healing, recurring infections and devastating complications that might have been prevented by more decisive care. As the most sweeping Medicare wound care overhaul in history takes effect Jan. 1, 2026, primary care physicians (PCPs) find themselves at the front lines of both solution and accountability.

Why this matters to your practice — and your patients

Chronic wounds are not rare, nor are they low-impact. Each brings pain, restricts mobility and can quickly spiral into loss of limb or life, especially for our frail, diabetic or elderly patients. Yet wounds often linger at the margins of our attention, seen as “niche” or “specialist” territory. The result? Persistent wounds treated with outdated bandages; missed opportunities for early intervention; and, ultimately, a heavier burden for patients, families and payers.

As regulatory scrutiny soars, driven by the explosion in costs and troubling patterns of under- and overtreatment, primary care teams hold the keys to upstream change. With targeted attention and timely action, we can improve lives, cut preventable complications and protect our practices from mounting compliance risk.

Skin substitutes and the new Medicare era: What’s changing in 2026

Effective Jan. 1, 2026, CMS will transform how Medicare payments for skin substitutes work. These lab-grown or donated tissue products, once reimbursed up to $2,000 per square inch, will now be paid at a much lower, flat rate of about $127.28 per square centimeter — regardless of setting. The goal isn’t just fiscal discipline; it’s reducing incentives for inappropriate use and pushing the system toward safer, value-driven care.

This change means more than just budget savings. It will demand clearer documentation, more thoughtful clinical decisions and rapid escalation for those patients who truly need advanced therapies. For PCPs, the message is simple: Don’t wait for a specialist or wound clinic to flag a chronic wound. Your early and aggressive engagement is now essential.

Three calls to action for PCPs

1. Better, concise documentation

Effective wound care starts well before considering advanced therapy. The new Medicare criteria mandate the following:

• 30 days of proven, standard care (debridement, moisture control, offloading, infection management) and visible efforts to address underlying obstacles like diabetes and nutrition.
• Consistent wound measurements, clear tracking and use of photos whenever possible to highlight healing (or lack thereof).
• Evidence-driven explanations for every treatment choice (no more guessing or “let’s try this and see”).

This isn’t just about passing audits or insurance claims. It’s about ensuring that the story of each wound — its size, appearance, pain and progress — gets told accurately, so you can intervene effectively and bring in partners when the patient’s healing stalls.

2. Refer early, refer smart

Delays in proper wound escalation cost more than dollars. They cost independence and sometimes lives. New best practices suggest the following:

• Reassessment every two weeks, and specialist referral if wounds aren’t shrinking by at least 30% after four weeks.
• Don’t “wait and see” past a month for diabetic foot ulcers, venous leg ulcers or pressure injuries.
• Escalate rapidly for any signs of infection, arterial compromise, exposed bone/tendon or deep tissue involvement.

Aggressive, timely referral isn’t admitting defeat or abdicating our responsibility; it’s acting as a quarterback for your patient’s journey, saving them a longer, harder road.

3. Protect your practice and don’t wait until the audit

The year 2025 saw a sharp rise in fraud investigations and billing denials for skin substitute cases. The new reality: Even infrequent involvement in wound management or skin substitute referrals creates legal and financial exposure. Make certain your documentation supports every medical necessity claim, and use clear care pathways adapted to the latest guidelines. Don’t wait for a denied claim or Office of Inspector General letter to scrutinize your process.

A practical road map: Solutions you can implement today

• Audit your wound care notes: Compare recent cases with new Medicare local coverage determinations and guideline criteria. Are you tracking wounds closely? Are conservative measures tried and documented? If not, tighten your protocol.
• Use structured templates: A checklist for wound documentation (location, size, description, pain, cause, interventions, nutrition, progress photos, follow-up) doesn’t slow you down — it speeds future care and communication.
• Set standard pathways: Decide, as a practice, when you escalate for vascular studies, advanced therapies or specialist referral. Put this on paper, so every team member knows the plan.
• Empower your staff: Teach nurses and medical assistants to measure and describe wounds accurately and to spot high-risk changes. Their early alerts save patient suffering and optimize your time.
• Know your local resources: Build relationships with wound centers, vascular surgeons, home health and referral networks. These partners are your allies in delivering timely, life-preserving care.

Why it’s time for PCPs to lead

For too long, chronic wounds have remained in “emergency mode” rather than a coordinated, proactive system of care. That is due partly to training gaps and partly to siloed systems — but it’s fixable. PCPs are the natural leaders here: We see our patients first, know their comorbidities, and forge the relationships that drive follow-up and accountability.

As Medicare clamps down on both cost and compliance — and as fraud enforcement reaches new levels — the time for half-measures is past. Get ahead of the curve, and you’ll not only avoid headaches down the road, you’ll transform patient outcomes in a way that only strong primary care can.

Looking ahead: Be proactive, be aggressive, be patient-focused

The overhaul coming in January 2026 is a wake-up call, not just a policy note. It’s about ensuring that every patient gets the opportunity to heal, rather than languish. Step up with smarter documentation, earlier action and true teamwork — and you’ll be part of the solution to one of medicine’s quietest, most devastating public health challenges.

Our patients deserve no less. And neither does our profession.

Zaid Fadul, M.D., chief medical officer of WoundCare 360, is a primary care physician specializing in practice optimization, wound care systems and health care policy analysis. He leads clinical strategy for WoundCare 360’s nationwide mobile wound care program focused on rapid bedside response, advanced healing and improved care coordination for complex patients.