Too often in healthcare, innovations are reserved only for the affluent and those who can afford to pay out of pocket. However, in one area, we’ve recently seen an improvement that will hopefully begin to bridge the gap to expand access to new therapies.
What is this promising development? Medicare recently decided to improve reimbursement for hospitals performing non-invasive high-intensity focused ultrasound (HIFU) to treat prostate disease. By covering the cost of the procedure, hospitals are now more likely to offer HIFU, and the mix of patients who will be able to access this non-invasive therapy is much more expansive and consequentially much more diverse.
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And that’s particularly good news because when it comes to prostate cancer, a disease in which data shows that historically disadvantaged populations are at greater risk. Black men are 1.8 times more likely to be diagnosed with— and 2.2 times more likely to die from—prostate cancer than white men and Hispanic men are more likely to present with Stage IV prostate cancer and experience delayed treatment compared to non-Hispanic white men.
But as of this past January, men aged 65-and-over can use their Medicare coverage to access HIFU, which uses ultrasound energy to heat and destroy cancerous tissue in the prostate and has significantly less risk than surgery or radiation and fewer side effects, such as erectile dysfunction (ED) and urinary incontinence.
While this is good news for those who are covered by Medicare, many with private insurance must still pay out of pocket. Ironically, for this innovative prostate cancer treatment, the government offers men more comprehensive treatment options than private insurance, though commercial insurance is often perceived as superior. As a urologist, I’ve seen the impact that this has on my patients’ decision-making. For example, one of my patients delayed treatment for six months until his Medicare coverage kicked in.
Even though data supports including HIFU in urological society and National Comprehensive Cancer Network (NCCN) clinical guidelines, until these guidelines are updated, many private payers will not cover this innovative procedure, leaving it out of reach for most men younger than 65.
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Improved Medicare facility reimbursement will spark more conversations about HIFU between doctors and their patients. As more men learn about HIFU as an alternative to the more aggressive radical prostatectomy and radiation, I expect physicians who might have been hesitant to recommend HIFU will get more comfortable with presenting it as an option. That, in turn, will increase access.
Additionally, Medicare access will impact research. Today, researchers are looking at how biomarkers and tissue genomics may impact HIFU outcomes and whether a focal intervention can be the first step to treat cancer while preserving sexual function and reducing side effects and potentially avoiding a more invasive procedure for 5-10 years.
As more men access HIFU because of the improved Medicare reimbursement, it will have a flywheel effect providing a larger pool of patients to study the procedure’s effectiveness. This could lead to discoveries about the potential benefits of HIFU and could even lead to the development of new applications for this technology.
Appropriate Medicare reimbursement of HIFU for prostate disease is a significant development for the treatment for men 65 years and older today. As it drives private insurance coverage, the decision will serve catalyst to expand access and help researchers answer questions about a disease that impacts 1 in 3 men.
Photo: bayhayalet, Getty Images
Derek J. Lomas, M.D., is an assistant professor of Urology at Mayo Clinic, Rochester, Minn. His clinical interests include prostate cancer diagnostics and imaging as well as focal therapies for prostate cancer including irreversible electroporation and high-intensity focused ultrasound. Dr. Lomas completed his residency training at Mayo Clinic, Rochester. He completed additional training as a Mayo Clinic Scholar at Imperial College London and University College London in the fields of prostate cancer imaging, targeted transperineal biopsy and focal therapy.
