The Senior Scene

By Shelly Gordon

Like the estimated 160,000 men diagnosed with prostate cancer every year in the U.S., each man must make decisions about what kind of treatment to pursue—and every single one of them wants to avoid the dreadful side-effects of incontinence, erectile dysfunction, and penile shrinkage that can and often do accompany standard prostate cancer treatments, including radical surgery and radiation. Most importantly, they want to maintain their quality of life and continue pursuing activities that bring them joy.

In evaluating their treatment options, men with localized prostate cancer are eligible for active surveillance, or “watchful waiting,” which is commonly offered to lower-risk prostate cancer patients. But many men aren’t a fan of that approach because of the uncertainty of living with a diagnosis of cancer.

Men with localized cancer who are fortunate to live in areas of the U.S. with hospitals that offer robotic focal HIFU find they are good candidates for this non-invasive outpatient procedure. HIFU (high-intensity focused ultrasound) uses concentrated sound waves to destroy the diseased tissue in the prostate. Urologists use ultrasound imagery to guide a probe during the procedure to spare healthy tissue. In addition, if the cancer, it can be retreated with HIFU or other traditional options like surgery or radiation.

Some men have shared their experience with robotic focal HIFU. William Whitlow is one of them.  

“I’m 58, African American, and born and raised in Brooklyn, N.Y. I’m trained as a social worker and for 20-plus years, I worked for the Office of Child and Family Services.

“Had I not been getting my PSA checked since I was 40, I wouldn’t have caught my prostate cancer early enough and my quality of life could have suffered, or worse. Unfortunately, my dad didn’t go to the doctor until his prostate cancer spread to his lymph nodes. He died of the disease in 2001 at age 56.  My uncle also died of prostate cancer. I heeded the advice of my doctor to get tested early and often. That’s why I was able to catch my prostate cancer at stage 1. Because the cancer was detected early, it was easily treatable.

“Before I got the diagnosis, my doctor said my PSA levels were high and he sent me for an MRI, which showed a suspicious shadow. My doctor referred me to a surgeon who does robotic surgery at Maimonides Medical Center.  But I decided it was too invasive, and I was warned of the side-effects of urinary incontinence and erectile dysfunction. I went to see Dr. David Silver, chief of urology at Maimonides, and that’s where I learned about robotic focal HIFU. He said HIFU is ideal for patients whose prostate cancer is still confined to a small part of the prostate like mine was.  He explained that there’s no incision with HIFU and he only destroys the diseased portion of the prostate, sparing surrounding nerves, which means incontinence and impotence are less likely to occur. HIFU is done quickly, in approximately two to three hours, and in a single session at an outpatient surgery center. I chose that option and was able to go home the same day.

“So not only were urinary incontinence and sexual impotence low-risk, I also liked that HIFU was an outpatient procedure. It was the best choice for me. After I returned home, the drugs wore off, and while there was a bit of discomfort, as I had to wear a catheter for a few days, I was able to heal quickly and returned to work after five days. Now I’m back to normal.”

Thousands of men diagnosed with prostate cancer have two things in common: They are determined to beat the cancer and hold on to their quality of life in the process. Most importantly, men have to ask their urologists if they qualify for robotic focal HIFU. It’s a good chance they do, as between 2015 and 2019, 71 percent of prostate cancer cases were diagnosed at a localized stage, meaning the cancer hadn’t spread outside the prostate.

The coverage for a hospital performing a robotic focal HIFU procedure on a Medicare patient is increasing. More than 90 percent cover the current reimbursement level effective Jan. 1, 2023. Both are very positive for prostate cancer patients who can benefit from this therapy,

Shelly Gordon is the founder of G2 Communications. She has worked with medical specialists and medical device manufacturers on articles about medical conditions and treatments.

By Monte Butler

Bob (not his real name) was diagnosed with trigeminal neuralgia, an excruciatingly painful condition caused by damage to the 5th cranial nerve. After all non-surgical treatments failed to relieve his agony, Bob located a neurosurgeon who specialized in the treatment of trigeminal neuralgia. Bob’s surgery was a success, but then he received a surprise bill for $74,973.

The problem was that Bob’s surgeon was an “opt-out provider.”  According to Medicare rules, his surgeon was allowed to set up a private payment contract with Bob. In the contract Bob agreed that, “if your insurance company does not cover all billed charges for services such as consult and/or surgery, you will be balance billed.”  The contract also included a hand-written note that Bob’s “Out-of-pocket & Deductible Payment” was be “$2,315.” Was Bob only obligated to pay the $2,315 or did he have to pay the additional $74,973?

We are talking about Medicare rules here, so you won’t be surprised when I tell you that the answer is a little bit complicated.  Bob’s surgeon was an opt-out provider in Medicare. Opt-out providers are different from participating and non-participating providers in three very important ways.  First, opt-out providers are required to have special signed private-pay contracts with patients before providing any services.  Second, the patient is responsible for 100% of the bill from an opt-out provider.  Medicare pays nothing (0%) – unless the care was provided in an emergency situation.  Third, there is no limit on what the opt-out provider can charge.  You are likely used to Medicare placing limits on what providers can charge you (“limiting charge”), but there are no such limits for opt-out providers (see “Types…” box for more detail).  So, what did this mean for Bob?  Did he have to pay the additional $79,973 or only $2,315?

Well, in Bob’s case, the answer was that he only had to pay $2,315 to his surgeon.  Why?  The contract used by the surgeon did not follow Medicare rules designed to help Bob understand the financial obligation he was taking on. Under Medicare rules, this nullified the contract.  Also, the surgeon broke several other opt-out provider rules.  After these rule violations were pointed out, the surgeon gave Bob a clean financial bill of health – “$0.00” due.

So, what does this mean for you?  First, if you decide you want the services of an opt-out provider, remember that you are responsible for the entire bill – 100 percent.  No help from Medicare.  No help from your Medigap policy.  Second, Medicare does not limit what the opt-out provider can charge you.  You need to make sure that the cost of the service is within your budget and you should ask that the cost of the service be included on your signed contract.  Third, if you get a surprise, contact your State Health Insurance Assistance Program (www.shiphelp.org; 877-839-2675) or the Senior Medicare Patrol Program (www.smpresource.org; 877-808-2468) for help.

Monte Butler is a professor of social work and social ecology at Loma Linda University in San Bernardino, Calif. This article is adapted from an original piece he wrote for the Journal of Gerontological Social Work.