Rising Out-of-Pocket Costs in Prostate Cancer Screening: A Growing Concern - Arnav Srivastava
August 30, 2024
Arnav Srivastava discusses his research on out-of-pocket costs for prostate cancer screening follow-up among privately insured men. The study reveals that by 2020, 80% of patients face out-of-pocket expenses for diagnostic testing, with costs rising significantly over time. Patients undergoing both MRI and biopsy can expect to pay over $600. Dr. Srivastava highlights the potential implications, including financial toxicity and delayed care. He emphasizes the asymmetric burden placed on those who benefit most from screening. The discussion explores reasons for cost increases, including healthcare market consolidation and the growth of high-deductible plans. Drs. Srivastava and Talwar consider potential policy changes, such as expanding cost coverage for diagnostic procedures beyond PSA testing, drawing parallels with recent changes in colorectal cancer screening coverage. They stress the importance of advocacy to improve prostate cancer screening recommendations and subsequent insurance coverage.
Biographies:
Arnav Srivastava, MD, MPH, Urologic Oncology Fellow, University of Michigan, Ann Arbor, MI
Ruchika Talwar, MD, Assistant Professor of Urology, Urologic Oncologist, and Associate Medical Director in Population Health, Vanderbilt University Medical Center, Nashville, TN
Biographies:
Arnav Srivastava, MD, MPH, Urologic Oncology Fellow, University of Michigan, Ann Arbor, MI
Ruchika Talwar, MD, Assistant Professor of Urology, Urologic Oncologist, and Associate Medical Director in Population Health, Vanderbilt University Medical Center, Nashville, TN
Read the Full Video Transcript
Ruchika Talwar: Hi everyone. Welcome back to UroToday's Health Policy Center of Excellence. As always, my name is Ruchika Talwar, and I'm a urologic oncologist at Vanderbilt in Nashville, Tennessee. Today, I'm really excited to be joined by Dr. Arnav Srivastava, who is a urologic oncology fellow at the University of Michigan. He's here discussing some recent work that he published, exploring out-of-pocket costs for prostate cancer patients. Thanks so much for being here with us today.
Arnav Srivastava: Thanks for having me, guys. Appreciate it. So really what we're going to be talking about is the out-of-pocket costs that follow abnormal prostate cancer screening. And this is really among those men who are privately insured. So prostate cancer screening has this long history of controversy regarding how impactful it really is. I think despite that, 300,000 people are diagnosed with prostate cancer every year, and most of those folks are diagnosed using PSA-based screening. So this is going to be an issue that touches a lot of patients. Now, PSA testing, when it's done in an age-appropriate fashion and by guidelines, does save lives and it does reduce deaths from prostate cancer.
So the patient we're talking about, this is a man who fits under the guideline-recommended ages. He has private insurance. And he gets his PSA test. That PSA test is typically either totally covered or very affordable. But after he has an MRI or a biopsy or both testing modalities, that's where costs start to accrue, and coverage becomes much more unreliable. So the way we study this is using MarketScan, which contains private insurance claims. And we looked at men ages 55 to 69 over the last decade, and we captured the out-of-pocket costs 12 months from the initial screening event. So the screening pathway that we captured, the patient comes in, they're age-appropriate, they have private insurance, they get their first PSA test. By guidelines, because that PSA was elevated, their provider repeats that test. Now they have two PSA tests and an elevated PSA diagnosis. We sorted those folks into three buckets.
Number one, you get a biopsy. Number two, you get only an MRI. And number three, you get an MRI and a biopsy. And really the first question is, well, of these privately insured folks, how much are they paying out of their pocket, and how often are they paying something out of their pocket? So what we find is that both of these numbers have ticked up over time. So by 2020, 80% of patients roughly, regardless of what bucket they were sorted into, can expect to pay something out of their own pocket, no matter what testing modality they get—MRI, biopsy, or both. And the kicker to this is that these costs are rising really substantially. So by 2020, as you can see, if you get an MRI and a biopsy, which is increasingly the standard of care, you can expect to pay over $600. And that number's probably even higher today, four years after this initial data was collected.
And there's some natural implications here. There's obviously financial toxicity, which has been well described in the cancer literature, not just in prostate cancer. Delays in care. We know from the RAND Health Insurance Experiment that even small amounts of cost sharing can lead to foregone necessary healthcare utilization. And this is not exactly trivial when we're talking about $600, $700. So kind of the punchline to what we found in our recent paper was that the out-of-pocket costs for diagnostic testing, particularly MRI and biopsy, are common, they're substantial, and they're only rising year after year. And I think what's really important is that the people who bear a lot of this cost are the folks that have an abnormal PSA and need that additional testing. But those are also the patients who benefit from prostate cancer screening. So we've kind of asymmetrically placed the burden of prostate cancer screening on the people who benefit the most from prostate cancer screening.
And that kind of undermines the whole point of cancer screening. And I think ultimately, the way we have to start thinking about these things is we can't think about cancer screening as just this one test with a binary result, yes or no. It's really a continuum and a pathway where at the end of your diagnostic testing in that workup, you have either a diagnosis in hand or a reasonable percentage to exclude that diagnosis. And only then are you done. And really, our insurers should be covering that entire process. I want to thank the team that helped put this together, Dr. Kim, Dr. Dalton, Dr. Fendrick, and Anca Tilea. And then I just want to thank my whole team at Michigan who's been spectacular. So thank you.
Ruchika Talwar: Thank you. Really, really interesting data that you present here. First, I just want to ask, what do you think is driving the substantial cost increase? Because clearly, going from above $200 to above $600, that's more than just inflation. And so why is an MRI, for example, in 2017, $400 cheaper than an MRI in 2020?
Arnav Srivastava: Yeah, so there are a couple of reasons. I think the first thing is just the general costs, not just the ones that patients face, which is partly due to inflation, is partly just due to how healthcare prices have risen with increased consolidation in radiology, urology, and hospital markets. I think probably the bigger driver is the growth of high deductible healthcare plans. So in an effort to keep premiums low, insurers offer all these kind of consumer-directed plans, which are great in theory until you need to actually start using your insurance, and now you're on the hook for the first $1,000, $1,500. And that's going to squarely face these patients who, again, are going to be the people who benefit most likely from prostate cancer screening, because ideally, they have less immediate health risks. They might actually benefit from the prostatectomy as a result of their prostate cancer screening.
Ruchika Talwar: Yeah, that's a great point. I think a lot of people also who sign up for high deductible health plans don't fully grasp what they mean, because a lot of patients are just choosing the lowest cost plan. So there has been a lot of discussion on work being done to make sure patients are educated and fully understand as they enroll in their benefits. But the other thing that I wanted to point out is there has been quite a bit of shift on the legislative effort to reduce cost sharing for PSA screening. And the data that you present suggests perhaps we should be focusing policy efforts on minimizing cost sharing for other cancer screening modalities. And I was just curious about your thoughts on if you felt perhaps maybe in addition to PSA screening, biopsy, MRI, things like that, should potentially be included.
Arnav Srivastava: Yeah. No, I think you're spot on. So your PSA test ultimately is one blood test, and it's awesome to have that totally covered. But ultimately, the cost of that one blood test typically is not going to be that much, especially when it's widely offered. And I think where you're going to have a lot more bang for your buck is covering these more resource-intensive modalities—MRI, biopsy, especially in the fusion biopsy era. Colon cancer provides an amazing roadmap for this. So in colorectal cancer, they used to have the screening gap where if you had a positive stool test, you were on the hook for your colonoscopy to ultimately rule in or rule out your colon cancer. And in 2022, under the Affordable Care Act, they closed that screening gap. And that made a huge difference for those patients, especially considering they expanded who gets screened for colon cancer. So that is a concrete way that legislation under an existing bill can really change the way people interact with screening and the testing that follows screening.
Ruchika Talwar: Yeah, and that example that you give underscores the importance of our advocacy as a urologic community to make sure that we are educating our partners in primary care to understand prostate cancer screening because the reason colon cancer screening is included is because the USPSTF has a better recommendation than they do for prostate cancer. So this is just one example of work that we need to continue pushing on. Prostate cancer used to have a grade D screening from USPSTF. It's now grade C. We're hoping to bump it up to a recommended test so that a lot of the protections under the Affordable Care Act would be implemented for prostate cancer.
Arnav Srivastava: Yeah. No, that letter grade makes such a difference. And it's stunning because on the urology side, you don't see it as much because the guidelines you reference are not the USPSTF guidelines. So AUA guidelines, NCCN guidelines, those are just what we use because our patients are molded sort of that way to be more applicable that way. But if you're a primary care physician and you have a thousand things to do for your patients, the easiest way to sort it is, well, what's clearly recommended, what's pretty much recommended, and what's kind of eh. And that stuff is always going to be pushed to the bottom. And that has real consequences. There have been tons of studies that sort of have looked at what happened after 2012, and there are real implications for patients with prostate cancer.
Ruchika Talwar: Yeah, absolutely. Well, the good news is that our focus is renewed on this important issue, thanks in part to work like yours. So we really appreciate you spending a bit of time chatting with us today.
Arnav Srivastava: Great. Thanks so much, guys. Appreciate it. Thank you.
Ruchika Talwar: And to our audience, thanks so much for joining us. We'll see you next time.
Ruchika Talwar: Hi everyone. Welcome back to UroToday's Health Policy Center of Excellence. As always, my name is Ruchika Talwar, and I'm a urologic oncologist at Vanderbilt in Nashville, Tennessee. Today, I'm really excited to be joined by Dr. Arnav Srivastava, who is a urologic oncology fellow at the University of Michigan. He's here discussing some recent work that he published, exploring out-of-pocket costs for prostate cancer patients. Thanks so much for being here with us today.
Arnav Srivastava: Thanks for having me, guys. Appreciate it. So really what we're going to be talking about is the out-of-pocket costs that follow abnormal prostate cancer screening. And this is really among those men who are privately insured. So prostate cancer screening has this long history of controversy regarding how impactful it really is. I think despite that, 300,000 people are diagnosed with prostate cancer every year, and most of those folks are diagnosed using PSA-based screening. So this is going to be an issue that touches a lot of patients. Now, PSA testing, when it's done in an age-appropriate fashion and by guidelines, does save lives and it does reduce deaths from prostate cancer.
So the patient we're talking about, this is a man who fits under the guideline-recommended ages. He has private insurance. And he gets his PSA test. That PSA test is typically either totally covered or very affordable. But after he has an MRI or a biopsy or both testing modalities, that's where costs start to accrue, and coverage becomes much more unreliable. So the way we study this is using MarketScan, which contains private insurance claims. And we looked at men ages 55 to 69 over the last decade, and we captured the out-of-pocket costs 12 months from the initial screening event. So the screening pathway that we captured, the patient comes in, they're age-appropriate, they have private insurance, they get their first PSA test. By guidelines, because that PSA was elevated, their provider repeats that test. Now they have two PSA tests and an elevated PSA diagnosis. We sorted those folks into three buckets.
Number one, you get a biopsy. Number two, you get only an MRI. And number three, you get an MRI and a biopsy. And really the first question is, well, of these privately insured folks, how much are they paying out of their pocket, and how often are they paying something out of their pocket? So what we find is that both of these numbers have ticked up over time. So by 2020, 80% of patients roughly, regardless of what bucket they were sorted into, can expect to pay something out of their own pocket, no matter what testing modality they get—MRI, biopsy, or both. And the kicker to this is that these costs are rising really substantially. So by 2020, as you can see, if you get an MRI and a biopsy, which is increasingly the standard of care, you can expect to pay over $600. And that number's probably even higher today, four years after this initial data was collected.
And there's some natural implications here. There's obviously financial toxicity, which has been well described in the cancer literature, not just in prostate cancer. Delays in care. We know from the RAND Health Insurance Experiment that even small amounts of cost sharing can lead to foregone necessary healthcare utilization. And this is not exactly trivial when we're talking about $600, $700. So kind of the punchline to what we found in our recent paper was that the out-of-pocket costs for diagnostic testing, particularly MRI and biopsy, are common, they're substantial, and they're only rising year after year. And I think what's really important is that the people who bear a lot of this cost are the folks that have an abnormal PSA and need that additional testing. But those are also the patients who benefit from prostate cancer screening. So we've kind of asymmetrically placed the burden of prostate cancer screening on the people who benefit the most from prostate cancer screening.
And that kind of undermines the whole point of cancer screening. And I think ultimately, the way we have to start thinking about these things is we can't think about cancer screening as just this one test with a binary result, yes or no. It's really a continuum and a pathway where at the end of your diagnostic testing in that workup, you have either a diagnosis in hand or a reasonable percentage to exclude that diagnosis. And only then are you done. And really, our insurers should be covering that entire process. I want to thank the team that helped put this together, Dr. Kim, Dr. Dalton, Dr. Fendrick, and Anca Tilea. And then I just want to thank my whole team at Michigan who's been spectacular. So thank you.
Ruchika Talwar: Thank you. Really, really interesting data that you present here. First, I just want to ask, what do you think is driving the substantial cost increase? Because clearly, going from above $200 to above $600, that's more than just inflation. And so why is an MRI, for example, in 2017, $400 cheaper than an MRI in 2020?
Arnav Srivastava: Yeah, so there are a couple of reasons. I think the first thing is just the general costs, not just the ones that patients face, which is partly due to inflation, is partly just due to how healthcare prices have risen with increased consolidation in radiology, urology, and hospital markets. I think probably the bigger driver is the growth of high deductible healthcare plans. So in an effort to keep premiums low, insurers offer all these kind of consumer-directed plans, which are great in theory until you need to actually start using your insurance, and now you're on the hook for the first $1,000, $1,500. And that's going to squarely face these patients who, again, are going to be the people who benefit most likely from prostate cancer screening, because ideally, they have less immediate health risks. They might actually benefit from the prostatectomy as a result of their prostate cancer screening.
Ruchika Talwar: Yeah, that's a great point. I think a lot of people also who sign up for high deductible health plans don't fully grasp what they mean, because a lot of patients are just choosing the lowest cost plan. So there has been a lot of discussion on work being done to make sure patients are educated and fully understand as they enroll in their benefits. But the other thing that I wanted to point out is there has been quite a bit of shift on the legislative effort to reduce cost sharing for PSA screening. And the data that you present suggests perhaps we should be focusing policy efforts on minimizing cost sharing for other cancer screening modalities. And I was just curious about your thoughts on if you felt perhaps maybe in addition to PSA screening, biopsy, MRI, things like that, should potentially be included.
Arnav Srivastava: Yeah. No, I think you're spot on. So your PSA test ultimately is one blood test, and it's awesome to have that totally covered. But ultimately, the cost of that one blood test typically is not going to be that much, especially when it's widely offered. And I think where you're going to have a lot more bang for your buck is covering these more resource-intensive modalities—MRI, biopsy, especially in the fusion biopsy era. Colon cancer provides an amazing roadmap for this. So in colorectal cancer, they used to have the screening gap where if you had a positive stool test, you were on the hook for your colonoscopy to ultimately rule in or rule out your colon cancer. And in 2022, under the Affordable Care Act, they closed that screening gap. And that made a huge difference for those patients, especially considering they expanded who gets screened for colon cancer. So that is a concrete way that legislation under an existing bill can really change the way people interact with screening and the testing that follows screening.
Ruchika Talwar: Yeah, and that example that you give underscores the importance of our advocacy as a urologic community to make sure that we are educating our partners in primary care to understand prostate cancer screening because the reason colon cancer screening is included is because the USPSTF has a better recommendation than they do for prostate cancer. So this is just one example of work that we need to continue pushing on. Prostate cancer used to have a grade D screening from USPSTF. It's now grade C. We're hoping to bump it up to a recommended test so that a lot of the protections under the Affordable Care Act would be implemented for prostate cancer.
Arnav Srivastava: Yeah. No, that letter grade makes such a difference. And it's stunning because on the urology side, you don't see it as much because the guidelines you reference are not the USPSTF guidelines. So AUA guidelines, NCCN guidelines, those are just what we use because our patients are molded sort of that way to be more applicable that way. But if you're a primary care physician and you have a thousand things to do for your patients, the easiest way to sort it is, well, what's clearly recommended, what's pretty much recommended, and what's kind of eh. And that stuff is always going to be pushed to the bottom. And that has real consequences. There have been tons of studies that sort of have looked at what happened after 2012, and there are real implications for patients with prostate cancer.
Ruchika Talwar: Yeah, absolutely. Well, the good news is that our focus is renewed on this important issue, thanks in part to work like yours. So we really appreciate you spending a bit of time chatting with us today.
Arnav Srivastava: Great. Thanks so much, guys. Appreciate it. Thank you.
Ruchika Talwar: And to our audience, thanks so much for joining us. We'll see you next time.