In many ways, policymakers, insurance companies, and certain health care providers seem to have a total disregard for men’s health, writes Henry Rosevear, MD.
While it may surprise some, my time as a junior officer on the submarine USS Pittsburgh (SSN 720) has served me well in my current profession as a urologist. And I’m not talking about the bad joke I use when patients ask about the transition (“It was an easy transition from working on one tube of seamen to another”); rather, I’m talking about the life lessons. The lesson that seems most appropriate now is the phrase “overcome by events.” Overcome by events is an expression designed to explain how the hours that we spent making intricate plans suddenly changed when presented with the facts on the ground.
When it comes to men’s health, the upcoming changes to the health care system, whatever they may be, may make my complaints about the forgotten topic of men’s health overcome by events. Regardless, let me give you a few examples of how current policymakers, insurance companies, and certain health care providers seem to have a total disregard for men’s health.
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Let’s start with the policymakers. One of the provisions buried in the Affordable Care Act was a requirement that birth control be a covered benefit. For women, that is. Do you realize that vasectomies are not required to be covered? The argument that somehow women should be able to have their birth control covered but vasectomies are not strikes me as short-sighted at best and sexist at worst. I'm not the only one. Numerous organizations are pressing both the federal government and their respective states to broaden this coverage.
The issue is even making the national press. This is probably a moot point at least on the federal level. While I am still unclear on exactly what President Trump is going to do with health care, I somehow doubt that expanding the federal government's role is high on the list of possibilities. But if we needed an example of federal disregard for men’s health, we need to go no further than this.
How about the insurance companies? It’s no secret that their purpose is to make money. Further, while the limitations of PSA testing are well known, the prevalence and seriousness of the disease is also well documented. As such, when talking to patients with elevated PSAs who are curious about what to do next, many options exist. One such option is a multiparametric MRI of the prostate. I will concede that it would be inappropriate for me to claim that it is standard of care for all patients with an elevated PSA before proceeding to biopsy, but the data behind such a treatment algorithm is becoming stronger (here is one recent important journal article on concept).
Next: "Not every patient can afford a $1,000 MRI out of pocket."
In my practice, one situation where I prefer to get an MRI is in men who are at higher risk of developing a complication from biopsy. I recently had a patient who has had multiple non-provoked DVTs and, as such, is on warfarin (Coumadin) for life. He's in his early 50s and otherwise perfectly healthy. His PSA has been rising over the last two years and is now over 10 with a free percentage under 10. Seems like a pretty straightforward biopsy candidate.
I called his hematologist and he basically told me that stopping this patient’s warfarin would cause a DVT, not might, but would. I then recommended he obtain an MRI. His insurance company declined it. I called the company and had a long conversation with some doc in a box and, despite pressing my case, was told that prostate cancer is low risk and not worth investigating. Case declined.
The patient paid out of pocket, had a PI-RADS 5 lesion and we did stop the warfarin on an enoxaparin (Lovenox) window, biopsied it, found high risk disease and he is now treating it. Not every patient can afford a $1,000 MRI out of pocket. Another example of society disregarding men's health.
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Want another example? Let’s look at testosterone replacement. For some reason, urology has done such a poor job addressing this need that numerous for-profit centers have popped up to serve the community. A few months ago, I started asking my patients who went to the local testosterone replacement center about the cost and it appears that the average cost is between $4,000 and $5,000 a year. Five grand!
The business model of these centers is to cheaply or even freely offer testing for low T, but if you want replacement, it's a weekly injection at the center where they provide the drug. And $100 a week for drug and injection adds up. Any urologist worth his cystoscope should be able to diagnose a man and teach him to inject himself at a fraction of that cost.
This is where we need more help from our governing bodies. The last time I checked, there is no AUA guideline (though there is an AUA position statement) available on the diagnosis and management of low testosterone. However, I was in Dallas recently at an AUA conference and heard a rumor that this may be changing, so stand by!
While I realize that urologists treat men, women, and children, we end up treating a lot of men. As I have become more aware of the problems with men's health, I have become more of an advocate for men's health and I hope that all of us at least acknowledge the gaps in coverage and work to improve it.
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