The United States is facing a well-known health care cost crisis—with health care costs representing a disproportionate amount of government expenditure and Americans increasingly citing health care costs as their top financial concern.^1,2 Indeed, estimated yearly individual costs for benign prostatic hyperplasia (BPH) management exceed $1,500 and national costs to the private sector approach $4 billion.³ We also know that for patients in which surgical management is indicated a multitude of options are available.⁴ Each of these options is associated with varying complication rates, durability, and convalescence. Among the various factors that patients and providers consider when selecting a surgical intervention for BPH, the impact and influence of cost is significant yet understudied.

It is against this backdrop that we sought to evaluate private payer and patient out-of-pocket (OOP) costs associated with BPH—a study that was recently presented as a poster at the AUA2023 conference. We utilized the OptumLabs Data Warehouse, which includes longitudinal data for commercially insured and Medicare Advantage enrollees to identify patients with a BPH diagnosis who had a medical claim for a procedure of interest—holmium laser enucleation of the prostate (HoLEP), transurethral resection of the prostate (TURP), photovaporization of the prostate (PVP), water vapor thermal therapy (WVTT), prostatic urethral lift (PUL), or simple prostatectomy (SP)—between October 1, 2015, and June 30, 2021.⁵ Patients in the treated BPH cohort were matched to a non-BPH control cohort, which consisted of patients with no documented diagnosis of BPH. These patients were matched based on patient characteristics which may have impacted total health care costs including age, race, geographic region, insurance type, year of index procedure, and medical comorbidities. Our primary outcome was total health care costs (THC) which included both patient OOP and health plan paid costs for the index procedure and combined follow-up years 1-5.

Our analysis ultimately included 25,407 patients with BPH of whom 10,117 (40%) underwent TURP, 6,353 (25%) underwent PUL, 5,411 (21%) underwent PVP, 1,319 (5%) underwent SP, 1,243 (5%) underwent WVTT, and 964 (4%) underwent HoLEP. We found significant variation in index procedure costs between all groups. As expected, the non-BPH control group had the lowest average cost. Among BPH procedures, WVTT had the lowest index cost and SP had the highest—separated by approximately $12,000 (Figure 1). For combined 5-year follow-up, THC, HoLEP, and SP were found to have significantly lower costs than the other procedures included, and no difference was found between TURP, PUL, and PVP (Figure 2). Lastly, when combining index and follow-up costs, HoLEP had the lowest aggregate cost, but this did not differ significantly relative to TURP, PVP, and SP. Interestingly, PUL had significantly higher aggregate costs relative to all other procedures. Similar trends were identified when evaluating aggregate patient OOP costs (Tables 1 and 2).

Figure 1. Total health care (THC) and out-of-pocket (OOP) cost of index procedure. *In pair-wise comparisons, means that share the same letter within each column were not significantly different from each other at the P < .01 level. BPH indicates benign prostatic hyperplasia; HoLEP, holmium laser enucleation of the prostate; HPP, health plan paid; PUL, prostatic urethral lift; PVP, photovaporization of the prostate; SP, simple prostatectomy; TURP, transurethral resection of the prostate; WVTT, water vapor thermal therapy.

Figure 2. Total health care (THC) and out-of-pocket (OOP) cost post procedure, follow-up years 1-5 combined. *In pair-wise comparisons, means that share the same letter within each column were not significantly different from each other at the P < .01 level. BPH indicates benign prostatic hyperplasia; HoLEP, holmium laser enucleation of the prostate; HPP, health plan paid; PUL, prostatic urethral lift; PVP, photovaporization of the prostate; SP, simple prostatectomy; TURP, transurethral resection of the prostate

Overall, these data highlight the significant costs associated with the surgical management of BPH. For aggregate index procedure and 5-year follow-up costs, patients who underwent BPH surgery had an average additional cost of $20,318, of which $1,636 were OOP costs, relative to the non-BPH control group. More specifically, there were significant variations in cost based on the index BPH procedure type. Although aggregate costs were similar between HoLEP, TURP, PVP, and SP, differences emerged when separating index procedure and follow-up costs. Most notably, SP had the highest index procedure THC ($14,423) and the lowest 5-year follow-up THC ($19,962). Similarly, HoLEP had relatively low follow-up THC ($22,772) and was associated with the third highest index THC ($7,412). For both HoLEP and SP, one potential explanation for the relatively high index procedure costs is that each of these procedures is more likely to be used in the treatment of very large glands (>80 g).⁶ Certainly, it would be expected that these patients may have more complex initial management and higher costs.^7-9 Regarding the low follow-up costs of these 2 interventions, this may correspond to high durability and low retreatment rates, which have been shown to help drive down costs.^10-12

In contrast, PUL had significantly higher aggregate THC and patient OOP costs relative to all other procedures evaluated. This resulted from a combination of high index procedure THC ($8,170) as well as high follow-up THC ($26,103). Such findings call into question the costs associated with PUL from a payer and patient perspective, and make it hard to financially justify the high index procedure costs.

We believe that the findings of our study are a critical step towards the comprehensive assessment of surgical treatment options for BPH. Private insurers are estimated to represent an impressive 40% of total health care expenditures vs 25% for Medicare, highlighting the need for a better understanding of these costs.¹³ Similarly, it is becoming apparent that patient OOP costs likely impact patient outcomes; however, little is known about financial toxicity in the BPH disease space. A recently published abstract found that 28% of BPH patients reported at least moderate financial toxicity associated with their disease.¹⁴ Despite this, we also know that costs are rarely addressed by providers, commonly due to a lack of knowledge.¹⁵ Ultimately, a better understanding of patient costs will go hand-in-hand with research regarding financial toxicity to allow for more comprehensive treatment of BPH patients. Coupled with clinical outcomes, patient quality of life data, and individual patient preferences, these cost data can better inform patients and providers, and help guide policy decisions in the future. Ultimately, given the high prevalence of BPH, these decisions will necessarily have significant ramifications.