Investigators compare costs for surgical treatments of BPH


"I think, importantly, when we look at comparing BPH surgical intervention options, we should not only factor in clinical outcomes and clinical differences, but also in the setting of our current health system, cost is becoming increasingly important," says Kevin M. Wymer, MD.

In this interview, Kevin M. Wymer, MD, shares the background and notable findings from the recent Urology paper “Evaluation of Private Payer and Patient Out of Pocket Costs Associated with the Surgical Management of Benign Prostatic Hyperplasia.” Wymer is an assistant professor of urology at Mayo Clinic in Rochester, Minnesota.


Please describe the background for this study.

I think as urologists, we're all pretty aware of how prevalent BPH is, and it's something that we all see commonly. We also know, from a surgical standpoint, there are a lot of options, and those options are rapidly expanding. And as part of that, it is important for us and patients to try and stay up to speed on comparisons among those treatment modalities. I think, importantly, when we look at comparing BPH surgical intervention options, we should not only factor in clinical outcomes and clinical differences, but also in the setting of our current health system, cost is becoming increasingly important. Cost, both on a systems level and a payer standpoint, with the rapid rise of health care costs and medical debt, but also on a patient sampling. We know that medical debt is becoming increasingly common; depending on where you look, 20% to 40% of American households have some level of medical debt, and financial toxicity and the impact of those costs, we're learning, are pretty significant for patients and patient outcomes. It was in that background that we got into this study where we looked at BPH costs, and in particular BPH surgical costs, and tried to compare both private payer or health plan paid costs, as well as patient out-of-pocket costs, for various BPH surgical interventions.

What were some of the notable findings? Were any of them surprising to you and your coauthors?

To start, we used what's called OptumLabs data set, which is essentially a branch of UnitedHealthcare. So it is UnitedHealthcare data, and therefore includes patients who have UnitedHealthcare either as a standalone private insurance or with Medicare Advantage. And we looked at all patients with a BPH diagnosis from 2015 to 2021. And of those approximately 1 and a half billion patients, we narrowed it down to those who underwent surgery with TURP, PVP, HoLEP, prostatic urethral lift, water vapor thermal therapy, or simple prostatectomy. We looked at total health care costs, which we defined as health plan paid, so what UnitedHealthcare paid plus patient out of pocket. We looked at it for 2 things: for the index procedure, so that initial BPH surgery, and then for 5-year follow-ups, and we compared them based on the index procedure, so they were defined by that first BPH surgical intervention. Not surprising was there a lot of differences in index procedure costs. If you have any knowledge of reimbursements, you know that these BPH surgeries vary a lot in how much they're reimbursed, whether it's by Medicare or private payer, and concordantly, patient out-of-pocket costs vary significantly for the index procedure. This ranged from anywhere from about $2500 on average for the total health care costs associated with Rezum up to almost $15,000 for the total health care costs associated with simple prostatectomy for the index procedure. What I found interesting was how that correlated or did not correlate with follow-up costs. We did combined 5-year follow-up costs. So they had their index procedure, and then if you combine all of their follow-up costs for the next 5 years after that, based on that index procedure, we saw that HoLEP and simple prostatectomies had significantly lower combined 5-year follow-up costs compared with PVP, TURP, and prostatic urethral lift. Of note, we did not include water vapor thermal therapy in the 5-year follow-up costs because we didn't have 5-year data based on when it was FDA approved. But I think that that correlation raises the question of, what are we paying for and why? In order to justify index procedure costs, what do we use to warrant higher index procedure reimbursement? As we know, our current system is flawed and reimbursement is not typically based on any sort of health care metric or health care outcome. But I think this study and these data start to raise some questions of okay, maybe it's worth paying more up front for a procedure that saves money down the road, and that actually held true for the most part with HoLEP and SP being higher index procedure costs, lower follow-up costs TURP and PVP kind of being in the middle. What was a little bit surprising, and was a little bit of an outlier was prostatic urethral lift. This was associated with the second highest index cost, second only to simple prostatectomy, but had almost the same follow-up costs as TURP and PVP. So in total, prostatic urethral lift resulted in the highest aggregate cost when you combined index and follow-up costs. It raises the question, are we overpaying for prostatic urethral lift at the index procedure? Is that cost justified by the follow-up costs? Now, the key here is there's no causal relationship here. We don't know what's driving those follow-up costs. We could hypothesize it’s durability of some of these procedures and retreatment rate for others driving up or down costs, but we don't know that. But that was the main outlier as far as index procedures cost being high and not compensated by lower follow-up costs. Prostatic urethral lift had high index and follow-up costs.

This transcription was edited for clarity.

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