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Employer exclusion drives lack of insurance coverage for implantable penile prostheses for ED

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Article

"Our study raises concerns that some insurance plan policies are denying an effective, research-proven therapy, for a very common condition for which treatment is considered medically necessary," says Mohit Khera, MD, MBA, MPH.

Findings from a recent study show that approximately 80% of patients with erectile dysfunction (ED) who have health insurance in the United States have coverage for implantable penile prostheses (IPP), with employer exclusion being the most common reason for denied coverage.1,2

The investigators assessed health plan benefit verification records of patients in an all-payers database and an employer-sponsored health plan database.

The investigators assessed health plan benefit verification records of patients in an all-payers database and an employer-sponsored health plan database.

The findings were published in Urology Practice.

"Our study raises concerns that some insurance plan policies are denying an effective, research-proven therapy, for a very common condition for which treatment is considered medically necessary," said lead author Mohit Khera, MD, MBA, MPH, in a news release on the findings.2 Khera is a professor of urology and F. Brantley Scott Chair in Urology at Baylor College of Medicine in Houston, Texas.

For the study, the investigators assessed health plan benefit verification records of patients in an all-payers database (including commercial payer insurance, private payer insurance, and government or public payer insurance) and an employer-sponsored health plan (ESHP) database. All patients included in the study had a diagnosis of ED and were seeking IPPs.

In total, records from the all-payer database were available for 3167 patients in 2019, 3016 in 2020, and 2837 in 2021. Insurance plans for patients from the all-payer database in 2021 mostly consisted of preferred provider organization (27.5%), Medicare Advantage (26.9%), Medicare (15.9%), or point-of-service (10.5%) coverage. The employer-sponsored database included records from 3083 patients.

The investigators found that approximately 80% of all-payer patients included in the study had insurance coverage for IPPs, with 79.4% covered in 2019, 79.6% covered in 2020, and 78.4% covered in 2021. The most extensive coverage was offered by government plans, with 100% coverage for Tricare, 98.7% for Medicare, 97.1% for Medicare Advantage, and 80% for Veterans affairs in 2021. Commercial insurance plans offered coverage for 75% of patients. However, for certain types of commercial plans, the percentage of patients with favorable coverage fell below 50%.

The primary reason for a lack of IPP coverage was employer exclusions. Among patients in the all-payer database, the proportion of patients with no coverage for IPPs due to employer exclusion continued to rise during the years analyzed, with a lack in coverage seen among 13.5% of patients in 2019, 15.6% in 2020, and 17.5% in 2021. This represents an increase of 29.3% in exclusions from 2019 to 2021.

Further, 34.2% of patients in the ESHP database lacked IPP coverage due to employer exclusion.

The authors write,1 “IPP coverage exclusions usurp clinicians’ determination of medical necessity under the health plan’s medical policy and make it difficult for providers to appropriately implement ED treatment guidelines.”

Khera also added in the news release,2 "The employer exclusion could also have a negative impact on the quality of life of patients recovering from prostate cancer and experiencing ED as [an adverse] effect of prostate cancer treatment.”

References

1. Khera M, Langston JP, Pollard ME, et al. Implantable penile prosthesis for erectile dysfunction: Insurance coverage in the United States. Urol Pract. Published online August 18, 2023. Accessed August 22, 2023. doi:10.1097/UPJ.0000000000000416

2. For men with erectile dysfunction, penile implants are usually covered by insurance – but not always. News release. Wolters Kluwer Health: Lippincott. August 21, 2023. Accessed August 22, 2023. https://www.newswise.com/articles/for-men-with-erectile-dysfunction-penile-implants-are-usually-covered-by-insurance-but-not-always

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