Erectile dysfunction and the emergence of direct-to-consumer companies


“Patients are paying humongous amounts of money to get pills that are essentially very, very, very cheap,” says Faysal A. Yafi, MD, FRCSC.

In part 2 of this Expert Forum series on the hidden burdens of erectile dysfunction, moderator Arthur L. Burnett II, MD, MBA, and panelists Martin S. Gross, MD, John J. Mulcahy, MD, PhD, and Faysal Yafi, MD, FRCSC, discuss the primary care physician’s role in managing erectile dysfunction, as well as the effect of direct-to-consumer companies offering treatments for the condition. Burnett is the Patrick C. Walsh Distinguished professor of urology and oncology at the Johns Hopkins University School of Medicine and the James Buchanan Brady Urological Institute in Baltimore, Maryland; Gross is an assistant professor of surgery at Dartmouth Geisel School of Medicine in Hanover, New Hampshire, Mulcahy is president of Mulcahy Consulting Inc, and Yafi is an associate professor of urology, chief of the Division Men’s Health and Reconstructive Urology, director of Men’s Health and Newport Urology and co-Director of the Eric S. Wisenbaugh GURS Fellowship in Male Reconstructive and Prosthetic Urology at the University of California, Irvine.


Mulcahy: One thing that I've found in my experience is that primary care doctors really don't focus on erectile dysfunction. I was involved, years ago, when Viagra first came out. We really had educate these family docs about what an erection was and what was causing it. Studies at that time showed that 85% of them were not interested in treating anything below the belt. And when it came to ED, they were many times embarrassed to discuss it with patients. [They saw it as] prying into their private lives. So we found out that the direct-to-consumer and the PDE-5 inhibitor vendors were the way to go. I think we're in a different ballgame, though, then we were 25 years ago. The public is well aware that ED is a treatable situation. The problem is that they go to their primary care docs and the docs kind of turn them off if Viagra doesn't work. And I think better referral to urologists, especially urologists who are interested in treating sexual dysfunction, is very important. And I see from the Sexual Medicine Society of North America and the International Society of Sexual Medicine that they're becoming more aggressive in getting the primary care doctors involved and getting other sex health professionals involved in this as well. Now, nurse practitioners are getting into the area of sexual function. So I think we're seeing that even though there many who don't feel comfortable treating it, we certainly have many who are comfortable treating it today and should basically be seeing these patients.

Gross: Dr. Mulcahy, I agree with you that there certainly is a reticence for primary care doctors to proceed with treating ED. I don't think that has changed all that much. Unfortunately, what has changed in the past 25 years is they don't have the time to do it. So they have to see more patients nowadays, they have shorter visits. Let's say you have a 20-minute visit with a patient that you've been treating for many years, and you basically have 12 or 14 minutes to actually have a decent conversation with them. You really want to focus on the issues that are going to potentially kill them in the next 5 or 10 years; you don't really have the time to sit down and say, "Tell me about your sex life. How are your things with your partner? How are things going?" And so there's a hesitation, and there also is a compromise of the amount of quality they can deliver because they're getting squeezed at both ends.

Burnett: These are good points. Dr. Mulcahy raises an interesting thought here. With the way the field has evolved, perhaps there is easier access to certain erectile dysfunction treatments and certainly, companies now that can offer this by direct-to-consumer marketing have recognized that people do want to be treated. The one question I have is, has that helped or perhaps hindered how we are effectively managing ED for the broad population?

Yafi: I think that's a great point. I think the fact that we have now the Hims and Romans of the world where there is direct-to-consumer ability for patients to log on to a portal, order their pills, get their pills by mail, and it all remains completely confidential has its advantages in that it allows easier access for patients who may be very busy or are very embarrassed to go to a urologist or to a primary care physician. But I think there are some hidden burdens with this. We published on this recently, comparing the prices of PDE-5 inhibitors; if you go to a place like Hims or Roman, when you add on to it the membership fees and the number of pills, when we compare 90 pills from these websites to places like, let's say, getRx, where you can get discount coupons on pills that are not available generically for cash options for about 30 cents a pill, the patients are really overpaying. Patients are paying humongous amounts of money to get pills that are essentially very, very, very cheap. There are even cheaper options. On the Mark Cuban online pharmacy Costs Plus Drugs, PDE-5 inhibitors are being sold at 12 cents a pill. When you think about how much patients are spending, because they're seeing this direct-to-consumer advertising, they think that this is how much they should be spending on these pills, then they come to see you in the office and you tell them, "Well, you can actually get 90 pills for $30 or $40," they're a little bit surprised at how much money they've spent. But that also I think, goes a little bit further when you get to the field of restorative therapies, which also have a lot of direct-to-consumer advertising, when you talk about shock wave, stem cells, PRP. Because now that patients are more savvy on the internet, they'll see PDE-5 inhibitors on Hims and Roman. They'll try these; these don't work. Then they try shock wave treatment; there's 0 evidence that that kind of therapy works. Then someone convinces them to go get PRP somewhere; they're spending money now on PRP, they spend money on stem cells. [By the time the patient] comes to see you, that patient is already about $10,000 in the deep, with money spent on things that are not absolutely necessary. But beyond the financial perspective of it, where the patient has lost a lot of money along the way, also, that patient has lost an opportunity for being screened for other medical conditions with their ED. You get the guy who comes in to see you for ED; I have a routine...we do a Doppler, there's an arterial finding, we'll send those guys to be seen by a cardiologist, [and] we'll do some additional testing. Those guys are not getting a physical exam, they're not getting screened for other medical conditions. There are advantages for direct-to-consumer online, but the disadvantages are costs and inability to screen for other conditions.

Burnett: Excellent. Martin, you had a point to make.

Gross: I think, to Dr. Yafi's point, those cost issues and concerns really get exacerbated when you get to the level of local injection clinics, which have really cropped up in the past 20 years or so in abundance, particularly my area, and on the East Coast in general. You have these places where people are going in to get intracavernosal injection therapies, and they're being charged 10 times the rate of what they should be, and you have to buy into these structures where they take your credit card information, and they bill you $1000 or $4000 a year for injections. They're really getting bilked by the stuff. The advantages of these direct-to-consumer things are clear - patients can make their own decisions and have their own ability to seek out treatment. The disadvantage is they don't get access to the expertise from people like us who will guide them through this process in a very step-by-step fashion and really try to get them to the best solution for them as quickly as possible. And they do sink a lot of money into this, and sometimes in fashions that can be rather seedy, I would say. A lot of guys come to see me who have already tried things online or have already been to shot clinics and they just bounce right off and they come to see me and they're repulsed by the treatment they've received so far.

Mulcahy: The big thing is getting them to the right professional in the first place. It's steering the people to this type of an environment where they're going to get the best treatment options. And that's going to encourage him to continue. Because if they get these humongous bills of 1000s of dollars each year, they're going to be turned off pretty soon.

Yafi: And I'll add to this that the issues that are big here in the United States are much more compounded in other places in the world that are underserved. [There was a stud]y from India [that] does a really good job of summarizing this where [they] showsthat the costs of for, example Trimix or an implant in India is so prohibitive, that you really have to pursue other, cheaper options where they get creative by using for example, chlorpromazine instead of some of the ingredients that we used in our injectables, just to decrease the cost. So I think it should be also the responsibility of us as urologists to maybe find options that tend to be a little bit cheaper for our patients to turn off less of the patients who are not financially strong from treatments for ED, especially if they don't have insurance coverage.

Burnett: I couldn't agree more that there is potential within this field the consideration that there could be health system inequities. I've had patients who, even after radical prostatectomy, young guys, African American men, who say, "Well, what are my options?" Some men may get above age 65 where Medicare may cover penile prosthetics, and they feel that they can't afford anything else and say, let's just move that forward, even though it's not clear that they necessarily have to opt for that. I think in this field, perhaps as much as any other field of medicine, that there are some significant inequities. And I'm also thinking that this direct-to-consumer marketing does almost exacerbate some of that.

This transcription was edited for clarity.

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