Three surgeons in masks (Adobe Stock Photos)
Photo Source: Adobe Stock Photos

Seeking to cut spending on Viagra, a medication used to treat erectile dysfunction, a politician once argued that sex is not medically necessary. Seeking to exert political pressure, another politician proposed a bill to make it hard to get Viagra. Not to be outdone, Medicare has cut spending for vacuum devices used to restore erections. Politicians and the government can be unkind to men with lousy erections. On the face of it, this makes no sense given that nearly everyone has had an erection, liked an erection, and wanted to see one again. However, the government is part of our society, in which nearly everyone is unkind to men with erectile dysfunction.


The problem with erectile dysfunction

Our broad society at once venerates and shuns erections. On the one hand, gentlemen’s clubs are everywhere. On the other, corporate America suppresses erections: a corporate employee told me that his company server sent back an email to a colleague because it included jagoff. Our society’s extreme bipolarity is largely unwelcoming to an authentic conversation about the needs of common men, who are neither studs nor eunuchs.

There is another problem: commerce biases any remaining authentic conversation. Our airwaves are saturated with pharmaceutical advertisements, including for oral medication to restore erections. To be sure, medications have a role in restoring some erections, but they are imperfect. More to the point, they are not the only treatment, which is almost always omitted. Men with lousy erections are thus generally poorly aware of effective injections, suppositories, vacuum devices, and penile prostheses.

Exacerbating all this is the modern physician’s exhaustion from electronic records, complex billing coding languages, and the need to churn patients. One common result is the trivialization of the clinical significance of lousy erections, which is unfair to the patient and doctor. For one thing, just as breasts are about more than feeding babies, erections are about more than sex. Poor erections, like many other physical dysfunctions, ripple durably, profoundly, and adversely through a man’s emotional and social functions. For another, erectile dysfunction can be a sentinel of diabetes, hypertension, and heart disease. To dismiss it is to potentially compromise the clinical evaluation.

There’s more. Treatments for lousy erections are poorly covered by insurance. This means that many men who are paying out of pocket for such treatments as penile implant surgery are lonely healthcare consumers facing a delivery system that is almost uniformly opaque and inconvenient.

The cumulative effects of a cool society, incomplete commercial communications, exhausted doctors, and healthcare delivery opacity and inconvenience conspire in one way or another to under-serve tens of millions of Americans who are living with erectile dysfunction. Erectile dysfunction thus represents a test case by which to gauge our resolve to treating the disabled with substance and compassion. In this perspective, penile implant surgery represents one relatively costly dimension. Here, we examine the development and delivery of a new kind of penile implant surgery packages with clear cost. We observe how surgeons and patients behave in this new environment and draw lessons that may help us to shape how we think about the delivery of other kinds of surgery.


Delivering penile implant surgery: surgeon quality

Men seeking penile implant surgery need what every surgical patient needs: a qualified surgeon. Finding the right surgeon for an individual case can be hard. This is true for the general public, hospital administrators, and also most doctors. If you are not sure that this is true, ask a gynecologist to name a qualified hip arthroscopist.

There is one clear exception: surgeons in the same specialty. This is because surgeons in the same specialty have direct exposure to each other. They train, teach, cover, review, examine, and rate each other. Surgeons in the same specialty are inter-connected and can often quickly identify others in their specialty, including across great distances; if you want a qualified hip arthroscopist in Chicago, ask a hip arthroscopist in Tel Aviv.

Surgeons know each other and surgeon peer ratings are empirically validated informants of surgeon quality. This was the fundamental conclusion of a study of bariatric surgeons who were asked to rate each other on the basis of anonymous video recordings of surgery. Peer ratings of surgical technical quality correlated with a number of clinical outcomes.

The observations that surgeons know and can rate the quality of other surgeons in their specialty form the basis of Surgeo, a new kind of peer credentialed surgeon network. Specifically, they are the basis of a growing multi-specialty network in which surgeon qualification requires peer credentialing. Every surgeon who joins Surgeo not only passes the usual criteria of licensing and minimal malpractice losses, but also the input of other surgeons who have operated with him or her.

As applied to penile implant surgery, peer credentialing and associated criteria have led to the identification and inclusion of 18 surgeons who have on average implanted 1,300 penile prostheses, a cumulative experience of over 22,000 cases that are associated with a single $2,500 malpractice payment. The network also represents hundreds of research papers published, presentations made, surgeons taught, and devices invented.


Delivering penile implant surgery: convenience and choice

Nobody wants the minutiae, hassle, and opacity of fee-for-service medical billing. Cars come simply packaged with windshield wipers and brakes at a flat cost. Surgeons should come simply packaged with recovery room and anesthesia at a flat cost. Accordingly, Surgeo penile implant surgery packages deliver clinical elements, including the surgeon, anesthesia, facility, and penile prosthesis at a flat cost.

Nobody likes financial surprises. When you buy a hamburger, you expect as much ketchup as you want at no additional cost. When you buy a penile implant surgery package, you get ancillary procedures, such as circumcision, at no additional cost.

Patients also want non-clinical service and support. The penile implant surgery packages thus also include call center support, navigation to healthcare lenders, and financial protection in the event of complications, much as car rental often includes collision insurance.

People want choice. You can buy the same car model in different locations and in different colors and you should be able to buy the same surgery package in different locations and with different surgeons. Accordingly, the surgeons in the peer credentialed penile implant surgery package network are distributed from New York City to Phoenix to Seoul. One surgeon operates in Salt Lake City and South Jordan. Another operates near Atlantic City and near Philadelphia. Surgeo enables men seeking penile implant surgery to choose from 20 packages by surgeon, location, and cost.

Surgery and shopping is a new combination, but people shop for everything and they shop online. For added convenience, the uniformly defined, transparently priced, flat-fee choices of penile implant surgery packages can be shopped on the Surgeo interactive online portal.


How surgeons and patients interact in a self-organizing penile implant surgery market

Surgeo does not impose fee allowances, so surgeons and associated facilities freely set their own fees. Their guidelines are theirs: how much they want to work, how much they want to make. In other words, it asks them to think about why a customer would come to them: quality, location, cost, and so on.

penile implant
Price Variation of Penile Implant vs. Knee Replacement

The financial self-organization of penile implant surgeons and associated facilities in a transparent geographically distributed market has brought relatively little cost disparity. Specifically, the cost of the most expensive penile implant surgery package is a relatively modest 50% more in New York, the most costly location, than in Austin, the least costly location (graph, green bars). By comparison, a report by Blue Cross shows that the cost of the most expensive knee replacement service is nearly 300% more in New York, the most costly location, than in Montgomery, the least costly location (red bars).

Cost and cost disparity matter greatly to third-party payers. They also matter to individual healthcare consumers, but to them, they are relatively less important. For example, one patient from Knoxville turned down a package in Austin for $19,400 in favor of a package in Nashville for $24,900. He chose the more costly package because he wanted to stay close to home. This illustrates the, perhaps, obvious point that people’s choices are personal and that they pay to get them. This is why choice matters to the delivery of care.

There is surely a limit to how much a consumer would pay to stay close to home. Had the Nashville package retailed for 300% more than in Austin ($77,600), it is a good bet that the Knoxville patient would have chosen the Austin surgery package. For this to happen, he would have needed to know the cost in Austin. This is why transparency matters to the delivery of care.


How to simplify access to quality surgical care

No one reform will fully optimize healthcare delivery. What seems clear is that doctors can suggest and implement some of the useful reforms. This is the premise of the doctor driven direct primary care movement. This is also the premise of the surgeon driven surgery package market. The latter has shown the ability to help individual patients overcome barriers to care. It has also shown an ability to help third-party payers optimize their surgical networks. This has implications for delivery of covered procedures, such as knee replacement.

Ultimately, we will have to decide as a society what the purpose of healthcare is. If it is to help men, women, and children live longer, happier, more functional lives, then money has to take a back seat to quality.

Erectile dysfunction is badly deserving of a voice that will express its needs. Among those needs is the one for simple access to quality penile implant surgery. The lesson of the penile implant surgery package market referenced above is that self-organizing, highly qualified surgeons can bring quality, convenience, and choice. This can be and is being expanded to knee replacement, hysterectomy, bariatric surgery, and many lines of service. It seems a reasonable bet that surgeon driven surgical delivery solutions will be qualitatively better, less costly, and more accessible than many others.



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