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Ruchika Talwar: Hi everyone, and welcome back to UroToday's Health Policy Center of Excellence. My name is Ruchika Talwar, and today I'm joined by Dr. Kevin Wymer, Assistant Professor of Urology at the Mayo Clinic. He will be discussing with us some recent work published in the Gold Journal outlining the out-of-pocket costs for patients as they relate to the surgical management of BPH. Thanks, Dr. Wymer, for being here.

Kevin Wymer: Yeah, thanks for having me. So, first off, thanks for inviting me to be part of this. I am excited to have the chance to talk about our work. As you mentioned, it's looking at costs associated with BPH, and specifically for this project, looking at private payer and patient out-of-pocket costs associated with the surgical management of BPH.

We're all quite aware that BPH is incredibly common, right? It's essentially ubiquitous in older men and it's one of the more common, if not the most common thing that a lot of us see in our clinic. We also all know that particularly when it comes to surgical intervention, there is a multitude of ever-expanding treatment options for patients and providers to choose from, which obviously has a lot of benefits, but also necessitates the need for thoughtful and accurate comparisons between these interventions. I think appropriately, most of the work thus far in this area looking at comparing these interventions has focused on clinical aspects, but in a system with escalating and sometimes crippling costs, it's important to also think about the cost impact and cost comparisons for these types of procedures.

It was along those lines that we performed this study. This was a retrospective cohort study looking at private payer claims data from the OptumLabs data warehouse. For those that aren't familiar, OptumLabs is essentially the academic partner of UnitedHealthcare. This is UnitedHealthcare data and it's a nationwide data set that includes privately insured patients, both those that only have private insurance and then also Medicare patients with Medicare Advantage through UnitedHealthcare. We looked at all patients with a BPH diagnosis initially from 2015 to 2021, and of those 1.5 million patients, narrowed it down to those that underwent a surgical intervention of interest. Here we include TURP, PVP, HoLEP, Rezūm, UroLift, and Simple Prostate. Among those 55,000 patients, we excluded patients further based on their follow-up time, other diagnoses of exclusion. Then we matched our final cohort of about 25,000 surgical BPH patients to a non-BPH control group. This group was meant to serve as a baseline cost comparative group, and they were matched on both clinical as well as demographic factors.

Our primary outcome for this was total healthcare costs, which we defined as the health plan paid, so what UnitedHealthcare paid as well as the patient out-of-pocket costs. We looked at that for both the index procedure, so the first BPH surgical intervention, what were the costs associated with that discrete episode, and then follow-up costs up to five years.

You can see the majority of our results here. Starting with the top two graphs, you have the cost of the index procedure on the left. Again, this is their first BPH surgical intervention. Patients, as we know, may have multiple BPH surgeries, they may be of different types, but during this period, and for this patient, what was their initial surgical intervention? If they started with a Rezūm and later got a TURP, they'd be categorized in that BPH Rezūm cohort, and those costs would be associated with that BPH Rezūm index procedure group. For the index procedure itself, you can see the cost breakdown there on the left.

The main takeaway here is that there really was a lot of significant variation between all of these groups based on index surgical intervention, ranging from the non-BPH control group, expectedly having the lowest, to Rezūm at about twenty-five hundred for the index procedure being the lowest intervention group, all the way up to simple prostatectomy at around 15,000. You can compare this with the follow-up costs. These are total healthcare follow-up costs for years one through five combined. They had their index procedure, we followed them for five years, combined all those costs together, and you can see that among these groups, non-BPH was still the lowest, but both simple prostatectomy and HoLEP groups had significantly lower follow-up costs compared to UroLift, TURP, and PVP. That bottom table is just combining aggregate costs. This is index plus follow-up costs for those groups. You can see this ranged for the intervention arms from around $32,000 for HoLEP at the lowest, up to $36,500 for UroLift.

I think this study highlights a few important findings. First, not surprisingly, it shows that there are significant costs associated with BPH relative to a non-BPH control group. Second, it highlights that there are significant differences in costs, both in the short- and long-term, between different BPH procedures. Now obviously, this is a large retrospective study. We can't conclude any causal associations. There are a lot of limitations here, one of which is a lack of granular data to connect these data points. I think from a 50,000-foot perspective, it opens a door for some critical next steps. Ultimately, it shows that we need to be asking the question of what are we paying for and why? I think that we, as clinicians, should be heavily involved in that question and that answer.

Moving forward, I think there are two main impacts that I see for this area of work on two different levels. First, these data are going to be needed to help make educated, evidence-based, informed decisions on what to prioritize as far as reimbursements, as well as policy decisions, and guideline decisions moving forward. Second, on a more individual level, we know that costs are becoming a critical factor, or already are a critical factor, for patients. The percentage or proportion of healthcare costs being shifted to patients has been increasing over recent years. This really impacts health outcomes and sometimes at least as much, if not more so, than a lot of the clinical factors. Knowing on a patient level what patients are paying, how that impacts their decision, what they're willing to pay for, all of these are pretty much unanswered, particularly in the BPH disease space, and I think important for patient decision-making. Both on a broader scale and on a smaller individual level, I think this type of work will be more and more important. Thanks.

Ruchika Talwar: Thanks, Dr. Wymer, really great study. I think it's really challenging often to accurately capture out-of-pocket costs for patients, particularly in a group like in your dataset. What I mean by that is both private payer but also Medicare Advantage plans. Those can vary significantly. I think another lens by which we have to view this data is remembering that every patient's specific insurance plan has different deductibles or structures regarding co-insurance. With that said, I still think that this information can significantly impact how we counsel patients, particularly in BPH when they do have a variety of different options on how to go about treating their disease.

One thing that really stood out to me, particularly in the simple prostatectomy cohort, was that although they had greater upfront costs associated with the index procedure, the follow-up costs were certainly less. That may be something when you're counseling a patient and they say, "Hey, listen, my insurance is going to end at the end of this year. I've already met my deductible and I'm planning on retiring or leaving my job," or whatnot. That information could be of particular use in that specific situation. Similarly, for patients who have not met their deductible, it also is important to know that there are certain procedures that may have significantly lower index costs. I think this data is really going to be impactful when it comes to answering that age-old question of a patient saying, "Hey doc, what is this going to cost me?" Curious to hear your thoughts about how you've applied this in a clinical setting.

Kevin Wymer: Yeah, no, I completely agree with everything you said. It's interesting, the idea of price transparency that you're touching on here, has become more of an issue. As you may know, CMS passed the final rule on price transparency, I think it was back in 2021, yet we still haven't really seen the implications. In theory, a lot of these hospitals should be or are starting to post what they charge for different interventions. The application of that, the uptake of that, has not at all been uniform and is still incredibly difficult for patients to navigate. A lot of us as providers have no idea how to approach this topic when a patient says, "How much will this cost?"

I do think, though, again, it's very relevant. Financial impact and medical debt is a huge problem, with 20 to 40% of US households facing that. Whether or not we want to confront it, we have to; our patients are. Again, as you pointed out, I think this serves as a starting point for when this patient comes to you and BPH is a perfect area for this. They have 10 different options, and yes, there is a lot of clinical variability, but also a lot of cost variation for that index procedure. Those out-of-pocket costs represent average out-of-pocket costs for all these patients combined but range from $200 to $1,000. There's a lot of significant variation that can impact whether or not they reach their max out-of-pocket and when, and impacts other procedures.

To your second point, how does that relate to the next five years in potential costs? Again, it's hard to know causal relationships. We did see an overall trend here with SP and HoLEP as well, being associated with slightly higher index costs and then lower follow-up costs, which may be reflective of more durable treatment, and did translate to lower patient out-of-pocket costs as well. Certainly, I think that will be important for patient counseling.

Ultimately, I don't know if these data are quite specific enough to confidently tell patients accurate numbers, and health plans will vary. On an individual level, we'll need to get a little bit more nuanced data and interactive data and communicate with their health plan and their insurance providers and all that. On a surface level, to be able to say, "Yes, there's going to be a lot of variation, here's the general structure for the index procedure and here's how it may impact you in the longer term financially," is going to be important.

Ruchika Talwar: Yeah, you're so right about price transparency. CMS did put out the final rule, but hospitals have not integrated price transparency tools in a way that would be meaningful for patients, particularly because of the issues that I brought up. It's very variable based on what type of insurance a patient has. Furthermore, when you see price transparency data that is out there, often it's on an Excel sheet with a random code. It's really not clear if anesthesia and operating room charges have been integrated into that estimate. We do have a long way to go, and I'm optimistic, looking at how people are now using things like pharmacy real-time benefit tools, that we will eventually get to a point where it'll be a lot easier for physicians to counsel patients accurately when they're at this juncture of deciding what treatment they'd like to pursue. What would you say your biggest takeaway for the urology community is regarding this study?

Kevin Wymer: Yeah, so as far as the main takeaways from this, I think first and foremost for the day-to-day urologists, again, our tendency when it comes to cost is to sort of put our hands up and say, "I have no idea, I focus on the clinical side of things." For better or worse, that's not going to be sustainable. Number one takeaway is that we need to be involved and at the table when we're talking about these costs, because these costs will impact reimbursement justification, they'll impact compensation, and more importantly, they'll impact the uptake of different technologies. I would propose that we want to advocate for interventions that are associated with better clinical outcomes. Just being involved with that as the most knowledgeable people when it comes to clinical outcomes is first and foremost.

For BPH providers specifically, starting to think about incorporating cost into patient counseling. Again, I think we're kind of at the very beginning of this, but we know cost impacts patient decision-making. We know at least a quarter of patients, based on one abstract in the BPH disease space, suffer from financial toxicity. Hopefully, we'll start to learn how that cost is taken into consideration when they make their decision. Just again, the first step, being aware of that and being involved with it moving forward. Then as we get more data, I hope that we'll be able to better implement it into aids and things to help patients with these decisions, both in BPH and elsewhere, but obviously for me, BPH being a main clinical interest.

Ruchika Talwar: So many great points. Dr. Wymer, thank you so much for joining us today. This is a really, really important topic, and we appreciate your expertise.

Kevin Wymer: Yeah, absolutely. Happy to be here. Thanks.

Ruchika Talwar: To our UroToday audience, thanks for joining us. We'll see you next time.