OBJECTIVES: Medicare and many commercial insurers have published medical policies detailing the medical necessity of penile prosthesis (PP) for erectile dysfunction (ED). Despite the widely acknowledged medical necessity, many employers have a specific benefit exclusion for PP, which creates a barrier among men enrolled in employer-sponsored health (ESH) plans. This study explored key stakeholder perceptions of the benefit exclusion for PP in ESH plans.
METHODS: Semi-structured telephone interviews were conducted. Pre-read information on burden and treatment options of ED was provided to 37 invited participants from 3 stakeholder segments: 13 medical directors (MDs) at commercial insurers, 22 employee benefit managers (EBMs) from self-funded employers, and 2 consulting representatives from health benefit consulting firms. Respondents were asked scripted questions regarding their awareness of employee benefits offered for PP and the processes used to consider changes to the benefits.
RESULTS: Eleven participants elected to engage in an individual one-hour interview (3 MDs, 6 EBMs, 2 consulting representatives). All respondents recognized the health burden of ED and the value of PP. MDs agreed on the medical necessity of PP but recognized that benefit exclusion overrides medical policies. Four of 6 EBMs (66%) indicated their plan had a benefit exclusion for PP and they were unaware of such exclusion prior to this study. EBMs were likely to revisit their employee benefits only after an employee contacted human resources complaining about an exclusion. All respondents acknowledged that it appears gender discriminatory to have federally mandated access to breast reconstruction following a mastectomy, but no mandated access to PP for ED following a prostatectomy.
CONCLUSIONS: Non-clinical factors determine patient access to PP among men with ESH plans even when key stakeholders agree on the value and medical necessity of PP. Self-funded employers are best positioned to address this benefit exclusion and allow access to this medically necessary treatment.
