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Experts discuss erectile dysfunction’s effects on work productivity


“There really is a significant lack in sexual medicine research of cost information, care information, [and] outcomes information,” says Martin S. Gross, MD.

In part 3 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 health plan coverage for erectile dysfunction treatments as well as loss of work productivity associated with 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.


Burnett: [Let's discuss] health plan coverage. And I know we talked about how there is such an impact here on employers: work productivity, absenteeism, and work impairment. Surprisingly enough, the coverage is not there—employer health insurance plans, particularly, do not provide coverage. I was able to do a recent report where we were able to show that only about a third of men in these situations are receiving coverage. And, again, it's just really disheartening to know that when we look at the real facts, there's a reason to help these men and we're not; we're actually contributing to the problem. Other concerns have to do with the federal mandates for breast reconstruction, and the absence of that for prostate cancer survivors, and prosthetics and things of that sort. So I'm interested to get all of your thoughts surrounding some of these topic areas.

Gross: Having been to the AUA [American Urological Association] Advocacy Summit too, we are the stepchild of the entire AUA's outlook on what we should be asking Congress for, and our priorities as sexual medicine providers are really limited. So I think if we can't get this kind of information out through the legislative branch of government, I certainly think that it might be time to explore the judicial branch. Perhaps, if by law, it's enshrined that we have coverage for treatments after breast cancer or other types of cancer that are specifically for women, there's no reason why a few well-timed and well-aimed lawsuits really wouldn't be able to pierce the veil of this process and really get erectile dysfunction after prostatectomy treatment to be covered as well. If you have to cover the one, by law, you should have to cover the other. It's discriminatory not to do so. So I think if we can't continue to do in the fashion we have been doing, it would make sense for somebody to step up and start throwing lawsuits left and right and see what happens.

Yafi: I completely agree with the arguments that are made, and I'll also add that there's a lot of discrepancy also amongst insurances, which also makes things a little bit more difficult for patients. Depending on the insurance coverages, and in different states, you're going to have differences in approval from state to state, but also from insurance provider to insurance provider. And if you look at the 4 or 5 major private insurers, there's really no consensus about what is covered and what is not covered. The other thing is, it adds bias and unfairness to patients that sometimes the employers may decide on the health plan that they will exclude anything related to sexual dysfunction, which is something that we see commonly here in California. And then as Medicare reimbursement goes down, I wonder whether in the future, there will also be an issue with Medicare coverage for penile implants, which obviously would be disastrous to prosthetic surgeons, but also to patients. And finally, in California, for example, if you look at Medicaid or CalOptima, it covers implants, but only malleable devices and doesn't cover inflatable devices. We did a study that we published last year looking at all 50 states and trying to see coverages and you'll see that the majority of states on Medicaid will cover only a malleable device, but not an inflatable device, and some will cover either. So again, there is no homogeneity. I think it's pretty unfair that some patients will have on their insurance coverage the ability to get an implant while others wouldn't. But that's the same as the issue with fertility. State to state, there are differences with fertility coverages; you go to New Jersey, everything is covered pretty much by law for fertility, whereas in other states like California, most patients don't have any fertility coverage. These things tend to be a little bit parallel in terms of the issue of inconsistent coverage across insurances and across different plans.

Mulcahy: One thing that could be done is counsel employers that because of the loss of productivity that ED causes, they would be better off covering this so that employees would be much more productive on the job and tend to be more innovative and all the other things go along with being alert and having a positive outlook on life. This has not been brought out. I was the president of the Sexual Medicine Society of North America 23 years ago, and one of the things I wanted to do as president was to solidify this fact that this is not recreational, this is medically necessary, because of these reasons we're [discussing]. I talked to Ray Rosen, and he said, "John, there's not a lot of stuff out there that confirms that this is medically necessary, [there's] not a lot of studies that show if you don't have it, you're going to be this way, if you have it the other way, you're going to work better." Another dissuading feature, too, is the number of people who don't go for penile implant. There was a good study with over 1000 patients who had radical prostatectomy and ED after their radical that did not respond to medication. They surveyed what percentage of these men went for penile implants; I think it was about 1% to 2% range for penile implant. Well, if a vendor or somebody who's trying to not pay for something sees this, they're going to say, "Well, wait a minute, 98% of guys out there don't want a penile implant. Why should we cover this?" One of the reasons is because they can't get coverage, but there are other reasons, as well, why men don't follow up and get a penile implant when this other medical treatment doesn't work. We have to consider when we're approaching people about this, [that] is a statistic that's certainly not in favor of coverage. But there are reasons behind this. This all has to be brought into consideration.

Burnett: There are a number of factors that certainly go into how treatments for ED are administered, and health care access is one, not to mention other patient and provider factors as well. I did a study on the cost of lost productivity associated with ED and we published this about a year ago. I'm going to read to you some of our findings. This comes from doing an analysis that involved administrative claims data, the US Bureau of Labor Statistics, and published literature. "We have found that men with ED had an additional about 280 hours per year of work impairment. This resulted in an annual incremental cost of about $72,070." We estimated among all US employers, they're standing to lose as much as $9.3 billion per year of work due to work impairment associated with ED. These are not trivial amounts of money; this is $9.3 billion associated with work impairment associated with ED. We talked about strategies to address this: legislation, maybe guidelines. What additional projects and studies can we do? Do we need to do more cost effectiveness studies? What else can be done to try and address this?

Gross: I think a 2-pronged strategy would be appropriate. Number 1, a lot of sexual medicine research tends to focus on a few specific areas of care delivery and what we're doing and how we're doing it well, or how we're doing it poorly. But there really is a significant lack in sexual medicine research of cost information, care information, outcomes information in that regard, that certainly, if any hot young researcher out there is looking to make a name for themselves, they can really look into this field and find a whole wealth of data that are available through Medicare and through other databases. They can track stuff down and really get a lot of cost and disparity and utility information for erectile dysfunction that just hasn't been covered. So we need to broaden the research bandwidth here.

And then the second thing is, in addition to having the help of the companies whose products are beneficial for this area, we need to have grassroots [efforts]. There needs to be foundations of men who are getting together who are saying, "Look, we need to have the same quality of care and quality of life for these things. They need to be covered equally, they need to be covered substantially. They need to be covered clearly." Because trying to get insurance to cover this and jumping through these hoops is a significant challenge for all of us. I think we need broad grassroots advocacy, as well as improved research to supplement that and provide adequate data to make sure this is all clear for a reason.

This transcript has been edited for clarity.

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