Pocket Urology

[Octavis Uberstine]

The scope of the problem is that prescription medications cost $348.4 billion annually. Only 20% of physicians can accurately estimate patient out-of-pocket costs, yet 9 in 10 patients over the age of 65 want their physician to do so. The main barrier is that it is a convoluted and complicated system, and often, no two patients pay the same out-of-pocket costs. Most patients purchase prescription drugs via an insurance benefit or purely pay cash for medications. Moreover, cost sharing varies significantly based on (i) deductibles/high deductible health plans, (ii) co-insurance charging and fixed percentages, (iii) out-of-pocket caps, and (iv) many other models.

Dr. Talwar then highlighted several avenues for providers to assist their patients with affordable prescription drugs. The first she discussed is the Medicare Part D Plan Finder. Prior to 2006, Medicare did not cover any drug costs, so the Part D program was created as a voluntary prescription drug benefit, but run by insurance companies. By 2022, 49 million of 65 million Medicare patients were enrolled in Part D plans. Within Medicare Part D, over 25 different plans are available with consistent premiums ($328/month in 2023), but deductible and co-insurance varies leading to variation in out-of-pocket prescription costs. For example, for abiraterone, there was up to $10,000 variation between two different 2022 plans, and for mirabegron, one year of treatment varies between $1,330 to $3,090 in 2024. Going to -compare patients can find the following prompts/displays:

Dr. Talwar concludes that the Medicare Part D Plan Finder is a resource for Medicare patients that allows them to review insurance benefits before renewing plans. Also, it provides transparency regarding prescription costs and annual estimates allowing for proactive financial planning.

Secondly, Dr. Talwar discussed the Mark Cuban Cost Plus Drug Company (www.costplusdrugs.com), which is a direct-to-consumer, online, mail delivery pharmacy that does not accept insurance. The price for drugs is equal to the manufacturing cost + 15% markup + 3% pharmacy cost + a $5 shipping fee. This program is different in that it is transparent, has consistent pricing by removing insurance, has pharmacy benefit managers, and also has rebates. This is a good solution for patients with high cost-sharing plans on oral prescription drugs, offering 30-, 60-, and 90-day prescriptions. Providers can send prescriptions directly to the Mark Cuban Cost Plus Drug Company via electronic medical records, with delivery taking 5-7 business days. Of note, this is not a good option for acute issues, such as a urinary tract infection, but can provide low-cost access to quality of life improving medications such as for lower urinary tract symptoms, erectile dysfunction, or chronic conditions.

Schloegel and colleagues recently assessed the potential urologic prescription drug savings with the Mark Cuban Cost Plus Drug Company.3 They found that a 90 day treatment via the Mark Cuban Cost Plus Drug Company led to savings for 9 of 12 drugs, purchases outside of health insurance:

Additionally, the Mark Cuban Cost Plus Drug Company conferred a cost savings for 5 of 12 drugs even compared to those utilizing an insurance benefit. There were significant variations noted, thus underscoring the benefit of pharmacy shopping.

Next, Dr. Talwar discussed patients using the Amazon pharmacy (www.amazon.pharmacy.com). This was launched in November 2020 and requires an Amazon Prime membership for discounted offers (and 2 day Prime delivery versus standard 4-5 day shipping). There is no acceptance of insurance and it does have a cash-pay comparison tool. Additionally, the RxPass is $5/month, and refills common generic medications at no additional cost, with no proof of insurance or prescription needed. Amazon pharmacy has partnered with PillPack for organizational packaging of prescriptions by date and time and offers faster shipping than the Mark Cuban Cost Plus Drug Company. Dr. Talwar highlighted that the PillPack + RxPass is helpful for patients with multiple chronic conditions requiring daily medications.

Lalani and colleagues recently performed a cross-sectional analysis of five direct-to-consumer pharmacies assessing availability and cost of expensive and common generic prescription drugs.4 The expensive drugs were defined as the 100 generic drugs with the highest cost-per-patient and the common drugs were defined as the 50 generic drugs with the highest number of patients. Among expensive drugs, 80% were available at one or more direct-to-consumer pharmacy, which was 98% for common drugs. For expensive drugs, 47% had the lowest cost at Amazon, 26% at Mark Cuban Cost Plus Drug Company, 14% at Health Warehouse, and 13% at Costco. For common drugs, 31% had the lowest cost at Costco, 27% at Amazon, 20% at Walmart, 12% at Health Warehouse, and 10% at Mark Cuban Cost Plus Drug Company

The following figure highlights the frequency of the lowest cost generic drugs available by pharmacy:

Finally, Dr. Talwar discussed the option of GoodRx for prescription medications (www.goodrx.com). GoodRx was founded in 2011 by former Facebook engineers. It is free to use and compares the generic/brand prescription drug prices at local pharmacies and cash-pay versus co-pay. Additionally, GoodRx provides patients with coupons to present for discounts, which are only valid at specific locations, over specific time periods. The interface for GoodRx is as follows:

GoodRx allows patients to receive discounts on in-person prescription pick-ups and is good for immediate and acute treatment needs (ie. urinary tract infection, pain, etc). In Provider Mode, it allows prescribers to compare local pharmacy out-of-pocket costs for medications and can be used as a decision tool:

For additional resources, Dr. Talwar discussed the integrated electronic medical record real time benefit tools at point-of-prescribing. Importantly, in 2021, CMS mandated that all MPD Plan sponsors incorporate real time benefit checks into the electronic medical record software, but implementation has to date been limited.

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Purpose: The high costs of fertility care may deter couples from seeking care. Urologists often are asked about the costs of these treatments. To our knowledge previous studies have not addressed the direct out-of-pocket costs to couples. We characterized these expenses in patients seeking fertility care.

Materials and methods: Couples were prospectively recruited from 8 community and academic reproductive endocrinology clinics. Each participating couple completed face-to-face or telephone interviews and cost diaries at study enrollment, and 4, 10 and 18 months of care. We determined overall out-of-pocket costs, in addition to relationships between out-of-pocket costs and treatment type, clinical outcomes and socioeconomic characteristics on multivariate linear regression analysis.

Treatment for urinary incontinence depends on the type of incontinence, its severity and the underlying cause. A combination of treatments may be needed. If an underlying condition is causing your symptoms, your doctor will first treat that condition.

Your doctor may recommend that you do these exercises frequently to strengthen the muscles that help control urination. Also known as Kegel exercises, these techniques are especially effective for stress incontinence but may also help urge incontinence.

Electrodes are temporarily inserted into your rectum or vagina to stimulate and strengthen pelvic floor muscles. Gentle electrical stimulation can be effective for stress incontinence and urge incontinence, but you may need multiple treatments over several months.

Pessaries come in many shapes and sizes. The device fits into the vagina and provides support to vaginal tissues displaced by pelvic organ prolapse. A health care provider can fit a pessary and help provide information about which type would work best.

During sacral nerve stimulation, a surgically implanted device delivers electrical impulses to the nerves that regulate bladder activity. These are called the sacral nerves. The unit is placed under the skin in the lower back, about where the back pocket is on a pair of pants. In this image, the device is shown out of place to allow a better view of the unit.

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There are no alternative medicine therapies that have been proved to cure urinary incontinence. Early studies have shown that acupuncture can provide some benefit. Yoga also may provide some benefit for urinary incontinence, but more study is needed.

If you have urinary incontinence, you're likely to start by seeing your primary care doctor. You may be referred to a doctor who specializes in urinary tract disorders (urologist) or a gynecologist with special training in female bladder problems and urinary function (urogynecologist).

A bladder diverticulum is a pouch, pocket or sac that protrudes out of the bladder wall. There are two types of bladder diverticulum: congenital and acquired. Congenital means that the individual was born with this pouch; acquired means that the pouch formed from a health condition that has affected the bladder. Patients diagnosed with this condition, may have more than one pouch that has formed.

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