More American men are living longer. An estimated 13,850,000 were
over age 65 as of July 1, 1996 . This total represents a 1.01%
increase over that in 1995, a 10.3% increase over the 1990 total
and more than a 34% increase over the number of these men in 1980
[1,2]. By the year 2020 one in every six American men, a projected
23.8 million, will be over 65 years old--72% more than in 1996
These population statistics have major social, political, and
economic ramifications for the health and welfare agencies of
this country. As the population continues to age, more people
will, no doubt, become aware of and demand technologically advanced
screening and treatment modalities to further improve longevity
and quality of life. Thus, geriatric health problems are expected
to increasingly consume larger amounts of medical care resources.
In addition, the potential for overutilization of screening tests
will no doubt increase despite incomplete documentation of therapeutic
efficacy and the possible increased identification of clinically
unimportant conditions [3-7].
Screening for prostate cancer in asymptomatic men and performing
prostatectomies are current illustrations of this point. The number
of radical prostatectomies increased more than sixfold between
1984 and 1990 and by 141% between 1990 and 1993 [3,4,8]. This
rise mirrors the trend in US prostate cancer incidence rates,
which increased by about 2% each year between 1973 and 1986 and
more than doubled between 1986 and 1992 . This latest increase
averaged 16% a year and has been attributed in large part to increased
medical surveillance and more aggressive detection efforts, specifically
to an increased use of
the prostate-specific antigen (PSA) test [4,6,10-11].
Of the prostate cancers diagnosed in 1984, only
5.8% were associated with a PSA test; by 1990, however, this proportion
had increased almost 12 times to
68.4% . Needle biopsies of the prostate are also increasing
as an important procedure for detecting prostate cancers .
Prostate Cancer Statistics
The American Cancer Society estimates that prostate cancer will
account for 41.5% of all new cancers in men in 1996, affecting
over 317,000 . It has now become the leading cancer diagnosis
in men (surpassing lung cancer in 1994) and the second leading
cause of male cancer deaths [9,12-15]. Age-adjusted incidence
rates continue to rise, increasing some 65% between 1980 and 1990,
with a dramatic 46.2% increase noted between 1989 and 1991 alone
. Rates increase with each decade over 50, with more than
80% of cases diagnosed in men over age 65. Although there is no
known etiology of this disease, it is thought to be hormone related
. There is extraordinary geographic variation in the detection
of and surgery for prostate cancer, indicating lack of consensus
about the efficacy of screening in asymptomatic men and subsequent
aggressive treatment of the disease, particularly among the older
segments of the population [6,7,17-19].
Prostate cancer is usually considered to be a slowly progressing
disease, but in approximately one-third of newly diagnosed cases,
the tumor has spread beyond the prostate gland itself [11,12].
Early forms of the disease are often discovered during the surgical
treatment for benign prostatic hyperplasia (BPH). BPH is usually
seen in men over age 50 who complain of varying degrees of bladder
outlet obstruction. Like prostate cancer, it is of unknown etiology
but may be related to changes in the hormonal balance associated
with aging . Surgery is the definitive therapy for this condition,
and the preferred operation has historically been the transurethral
resection of the prostate (TURP). BPH is even more common than
prostate cancer, with histologic evidence apparent by age 60 in
more than half the men at autopsy and in more than 90% by age
85 . Its absolute frequency and rate of occurrence have been
decreasing since 1990 at the same time prostate cancers have increased
(Fig. A). BPH was diagnosed among 375,000 men in 1993 (the latest
data available), a decrease of 137,000 cases, or 26.8%, from the
1983 total. This decrease is reflected in the declining rates
of TURPs that are performed in nonfederal short-stay hospitals
across this country . In 1983, 321,000 TURPs were performed,
whereas in 1993, 250,000 such surgeries were recorded.
Clearly TURPs and radical, or open, prostatectomies have a substantial
impact on the health-care system. First-year costs of treating
the extra cases of prostate cancer detected through mass screenings
have been estimated to range between $11.9 and $27.9 billion;
costs for TURPs, in 1990 alone, were estimated at $2.2 billion
[21,22]. Because of such costs, because these procedures continue
to be the leading surgeries performed on US men over age 65, and
because the PSA test and other newer, less invasive screening
tests are growing in popularity, cost-effective screening strategies
and interventions need to be developed . In addition, monitoring
the frequency of and costs associated with open prostatectomies
and TURPs is warranted and gains in importance with the aging
of our population. These reasons prompted MetLife researchers
to review claims data for these two procedures during 1994 and
to investigate the average hospital charges associated with them
by state and region.
Metropolitan Life Study
In 1994 MetLife processed close to 342,000 hospital claims from
employees and dependents of companies covered under group health
policy contracts. Of these, 42% were from men, among whom 7.6%
(10,796) were 30 years old or older, hospitalized for conditions
coded as Major Diagnostic Category (MDC) 11, "Diseases/disorders
of the kidney and urinary tract," or MDC 12, "Diseases/disorders
of the male reproductive system." Over 1,000 radical prostatectomy
patients were identified from this subset, defined by CPT-4 codes*
55810-55815 and 55840-55845. Another 1,600 men had claims for
a TURP, defined by CPT-4 code 52601. The TURP patients were substantially
older than the prostatectomy group--modal ages of 70 and 64 and
median ages of 68.7 and 62.4, respectively. Ninety-eight percent
of the radical prostatectomy patients were diagnosed with cancer
of the prostate; prostatic hyperplasia was the primary diagnosis
for three-quarters of the TURP patients, followed by prostate
cancer for 12.6%. Data are presented for all with more than five
procedures but discussed and highlighted for those in which 20
or more were performed.
Geographic Variation in Charges
for a Radical Prostatectomy
For the 1,004 radical prostatectomies, the average total hospital
and physician charge to Metropolitan Life insurance Company in
1994 was just over $18,600. These charges differed by 61%, ranging
from a high of $20,790 in the Pacific states to a low of $12,910
in the East South Central geographic area (Table 1). The Pacific
charge exceeded the US average by 11.3%; the low East South Central
charge was 31% below the norm. The total charge in the Middle
Atlantic area was the second highest (10.3% above the norm); only
two other areas--the South Atlantic and the West South Central--reported
charges above the average, each just 1% higher. The Mountain area
had the second lowest area total charge ($16,220), more than $4,500
below that in the Pacific states and 13% below the norm.
· Between-State Variation--Among the 19 study states, the
variation in radical prostatectomy charges was even wider (Figure
B). The highest total charge was reported in Pennsylvania, almost
$25,000, 32% above the norm. This total was almost three times
the lowest charge reported in Tennessee, under $9,000 or 53% below
the average. Only five other study states (California, Illinois,
Florida, Louisiana, and New York) had charges 10% or more above
the norm. At the other end of the scale, three of the study states
(Washington, Michigan, and Oklahoma) reported average total charges
more than 20% below that for the country as a whole.
· Hospital Charges--The hospital charges accounted for almost
two-thirds of the total charge to insurance for a radical prostatectomy.
Ancillary fees accounted for 63% of this total, averaging $7,720
across the country. The room and board normative charges were
$4,510 and ranged from $8,010 in California (78% above the norm)
to $1,080 in Tennessee (76% below the norm). Room and board charges
similarly high to those in California were evident in Pennsylvania
and Florida, 75% and 64% above the average, respectively.
· Physician Charges--Physician charges accounted for about
one-third of the total radical prostatectomy bill in 1994, averaging
$6,450. This total differed by as much as 114% between the fees
in New York ($8,710--35% above average) and those in Tennessee
($4,080--37% below the US norm). The physicians' charge in Pennsylvania
($7,560) was the second highest of the study states and averaged
17% above the norm. Washington reported the second lowest charge,
$4,390--32% below the average; the Colorado and Michigan doctors'
fees each averaged 20% or more below the national norm.
· Length of Stay--On average, radical prostatectomy patients
remained in the hospital just under 6 days. These hospitalizations
differed by almost 3 days; New York patients' stay was 7.02 days,
whereas in Missouri, it averaged 4.42 days. These stays were 26%
above and 21% below the average, respectively.
of the Prostate (TURP) Charges
Total hospital and physician charges for the 1,597 TURPs performed
in 1994 averaged $7,600 (Table 2). The pattern of these charges
differed somewhat from that for radical prostatectomies. While
the average in the East South Central area was the lowest in the
country (as with the radical surgeries), the highest average was
recorded in the South Atlantic area followed by the Pacific (14.6%
and 13.9%, respectively, above the norm).
By state the average totals differed by 95% (Figure C). The North
Carolina total was the highest (31% above the US total) and that
in Washington, the lowest (33% below). Georgia, California, and
Illinois were the only other states with totals 20% or greater
above the average, each over $9,500. Tennessee and Ohio had equally
low charges (30% below the norm), followed closely by the average
in Alabama and Oregon (28% and 25%, respectively, below the US
· Hospital Charges--As with radical prostatectomies, over
two-thirds of the average total TURP charges were attributed to
the hospital part of the bill. These charges averaged $5,160,
with the proportion of the total costs ranging from 74% in Arizona
to 59% in Ohio. Total hospital charges varied by 132% between
those in North Carolina ($7,290) and Ohio ($3,140).
Ancillary fees made up 62% of the hospital bill, with substantial
variation evident between states. These fees accounted for just
under half of the hospital charges in California to 80% in Alabama.
Ancillary fees were the highest in Georgia, 62% above the norm,
and the lowest in Ohio (36% below the average).
Room and board charges varied even more, ranging from a high of
$3,540 in California (80% above average) to lows under $1,000
in Washington, Wisconsin, and Alabama (more than 50% below the
· Physician Charges--As with the radical prostatectomy procedures,
the physician charge was just under one-third of the total TURP
bill. The national average was $2,440 and differed by 95% between
states. Again, the New York doctors' charges were the highest
(33% above the US average), but those in Michigan were the lowest
(32% below the norm). The physician charges in the three East
Coast geographic areas were the highest of all nine, ranging from
$2,670 in the South Atlantic to $2,830 in the New England states.
· Length of Stay--The average hospital stay for a TURP in
1994 was 3.66 days. Patients in Indiana remained
in the hospital the longest (5.58 days), followed by
New York and New Jersey (4.90 and 4.24 days, respectively). In
contrast, TURP patients stayed in the hospital for an average
of 2.29 days in Oregon and 2.49 days in Colorado.
The differences in charges for and distribution of prostatectomies
and TURPs are consistent with earlier SB [Statistical Bulletin]
analyses. The causes for the noted variations continue to be perplexing
but may reflect the fairly widespread confusion and debate surrounding
the optimal approach to the early detection and management of
prostate diseases. Because prostate cancer and BPH generally affect
older men, many of whom are expected to die of unrelated diseases,
the decision to pursue aggressive medical or surgical therapy
or a regimen of watchful waiting remains controversial [23-25].
Although consensus is lacking, some argue that there may be a
"cultural component" to the choice of treatment that
promotes early and aggressive treatment . Regardless of the
reason, randomized clinical trials or the further refinement of
predictive tumor markers or host features would benefit all and
help make the treatment/screening decision easier. While the debate
continues over the efficacy of surgery for early prostate cancer
and the influence of screening tests on incidence as well as mortality,
monitoring of outcomes by various treatment regimens is also necessary.
These goals gain in importance given the increasing numbers of
older-aged men in this country and the need to control rising
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