Vi Nguyen et al., 2024: Patient out-of-pocket costs for guideline-recommended treatments for erectile dysfunction: a medicare cost modeling analysis
Vi Nguyen, Alysha M McGovern, Sirikan Rojanasarot, Darshan P Patel, Samir Bhattacharyya, Liesl M Hargens, Olubiyi Aworunse, Tung-Chin Hsieh
Department of Urology, UC San Diego Health, San Diego, CA, USA.
Boston Scientific, Marlborough, MA, USA.
Department of Urology, UC San Diego Health, San Diego, CA, USA.
Patient out-of-pocket (OOP) cost represents an access barrier to erectile dysfunction (ED) treatment. We determined OOP cost for men with ED covered by Fee-for-Service Medicare. Coverage policies were obtained from the Medicare Coverage Database for treatments recommended by the 2018 American Urological Association (AUA) guidelines. OOP cost was retrieved from the 2023 Centers for Medicare & Medicaid Services Final Rule. OOP cost for treatments without Medicare coverage were extracted from GoodRx® or literature and inflated to 2022 dollars. Annual prescription costs were calculated using the published estimate of 52.2 yearly instances of sexual intercourse. Medicare has coverage for inflatable penile prostheses (IPP; strong recommendation), non-coverage for vacuum erection devices (VED; moderate recommendation) and phosphodiesterase type-5 inhibitors (PDE5i; strong recommendation), and no policies for intracavernosal injections (ICI; moderate recommendation), intraurethral alprostadil (IA; conditional recommendation), or low-intensity extracorporeal shock wave therapy (ESWT; conditional recommendation). Annual IA prescription is most costly ($4022), followed by ICI prescription ($3947), one ESWT course ($3445), IPP ($1600), PDE5i prescription ($696), and one VED ($213). PDE5i and IPP, both strongly recommended by AUA guidelines, are associated with lower OOP cost. Better understanding of patient financial burden may inform healthcare decision-making.
Int J Impot Res. 2024 Jun 26. doi: 10.1038/s41443-024-00903-9. Online ahead of print.
PMID: 38926632 DOI: 10.1038/s41443-024-00903-9
Comments 1
Introduction
Effective treatments for ED can significantly improve physical well-being and quality of life. However, high out-of-pocket (OOP) costs may prevent patients from accessing these treatments. Physicians often lack awareness of the financial burden their patients face for ED treatments.
Study Objectives
The study aimed to estimate the out-of-pocket costs for guideline-recommended ED treatments for US Medicare patients. By understanding the financial burden, the study seeks to inform healthcare decision-making and improve accessibility to effective ED treatments.
Model Design
A cost model was developed using Microsoft Excel to evaluate the patient OOP costs for guideline-recommended ED treatments from the perspective of US men covered by Fee-for-Service Medicare. The study considered several treatments recommended by the 2018 American Urological Association (AUA) guidelines: oral phosphodiesterase type-5 inhibitors (PDE5i), intraurethral alprostadil (IA), intracavernosal injections (ICI), vacuum erection devices (VED), inflatable penile prostheses (IPP), and low-intensity extracorporeal shock wave therapy (ESWT).
Cost Inputs: Costs were sourced from the US Medicare Coverage Database, GoodRx, and other publicly available data, and then adjusted for inflation to 2022 dollar-values using the US Bureau of Labor Statistics Consumer Price Index.
Results
OOP-Costs by treatment:
o Intraurethral alprostadil (IA): $4,022 annually
o Intracavernosal injections (ICI): $3,947 annually
o Low-intensity extracorporeal shock wave therapy (ESWT): $3,445 for a course
o Inflatable penile prostheses (IPP): $1,600 for outpatient procedure
o Oral PDE5i medications: $696 annually
o Vacuum erection devices (VED): $213 annually
Medicare Coverage:
Medicare covers IPP but not VED or PDE5i, and there are no coverage policies for ICI, IA, or ESWT.
Discussion
High OOP costs can lead to financial distress and prevent patients from accessing necessary treatments. Physicians need to be aware of these costs to make informed decisions and recommend cost-effective treatment options. The study finds PDE5i and IPP to be cost-competitive and strongly recommended by the AUA. Despite their effectiveness, many patients discontinue PDE5i due to cost, lack of efficacy, or side effects.
However, the costs for a penile prosthesis ($1,600) do not reflect the situation n Europe (at least 10.000 Euro for the prosthesis). Also, it should be mentioned, that Li-ESWT may lead to fundamental changes in ED, thereby not requiring any further costs.
Obviously, disparities in access to ED treatments may exist due to varying insurance coverage and OOP costs. Advocacy for policy changes could improve access to ED treatments.
Limitations
The model is specific to US Medicare Fee-for-Service patients and may not reflect the costs for other insurance plans or uninsured patients.The model relies on data from multiple sources, which may not reflect current market conditions.
Conclusions
The study highlights the significant OOP costs associated with ED treatments and emphasizes the importance of making these treatments accessible to patients. PDE5i and IPP are identified as favorable options due to their cost-effectiveness and strong guideline recommendations.
Jens Rassweiler