New York State health insurers now required to cover PSA blood test

A new law quietly went into effect last month that requires health insurers to cover the cost of routine screening for prostate cancer, a measure aimed at encouraging more men to consider the benefits of being tested.

New York is the only state in the country to pass a law that supports full insurance coverage of the PSA (prostate-specific antigen) blood test, which helps determine prostate cancer risk. 

The new law is the brainchild of a coalition of New York urologists and patient advocacy organizations that not only saw a need for the legislation, but over a two-year period made a case for the measure among legislators in Albany.

“As far as physician practices go, we were in the lead,” said Dr. Deepak Kapoor, president of Advanced Urology Centers, which has offices throughout Long Island and in New York City. “This is something that was done for the public good.

“We had lawmakers on both sides of the aisle who really linked arms together to make this happen,” said Kapoor, a longtime advocate of PSA screening. “This is what happens with bipartisanship. It was also a great example of the private sector and nonprofit organizations working closely with legislators to make this happen.”

Hewlett-based 1 in 9 Long Island Breast Cancer Coalition was one of the leading advocacy groups to support the law, Kapoor said.

As far as insurance coverage, New York now puts men’s prostate screening on par with routine mammography, which under the Affordable Care Act became fully covered nationwide with the act’s passage in 2010. Framers of the ACA didn’t extend the same consideration to the PSA, despite the prevalence of prostate cancer in the United States and roughly similar costs for the two forms of cancer screening.

A PSA exam averages between $60 and $80, while a mammogram can cost anywhere from $75 to as much as $250, but generally runs about $100, according to several local and national patient advocacy organizations.

“This is about removing barriers,” Kapoor said of the law.

Some men may have avoided screening because their insurance company required a copay. Others, Kapoor said, may have been wary of testing because of misinformation about the PSA’s reliability.

Despite criticism of the test, the PSA in the last few decades has dramatically changed the trajectory of care by offering screening, early detection and prostate cancer management, Kapoor said.

“The PSA is part of our armamentarium,” he said of tools to help lower the risk of prostate cancer. “It’s a gateway test. It isn’t perfect, and no one would say the PSA alone is a perfect instrument. But it is a tool of a skilled provider to determine if further testing is warranted.”

Prostate cancer is the second-leading cause of cancer in men, with more than 240,000 new diagnoses and 28,000 deaths in the United States annually.

While no cancer screening is 100 percent accurate, Kapoor said the PSA has been fraught with controversy for years.

The U.S. Preventive Services Task Force discouraged screening in 2012 only to somewhat reverse itself last year. Seven years ago, the panel — an independent committee of health experts empaneled by the U.S. Department of Health and Human Services — gave the PSA a grade of D. The committee makes recommendations on clinical preventive services, particularly screenings.

In 2018, panelists issued their final recommendation, giving the PSA a grade of C for men between the ages of 55 and 69, noting those men should have a discussion with their doctors about the pros and cons of the test before undergoing screening. Committee members recommended against screening for men 70 and older, giving it a letter grade of D.

For older men, they concluded that benefits of the test do not outweigh the “harms,” which were defined as the anxiety produced by additional testing required in the event of a positive result. Older men are more likely to have slow-growing tumors that will not lead to their deaths.

Men at average risk should consider screening, starting at age 50, Kapoor said, while African-American men and anyone with a family history of the disease should consider screening starting at age 40. Men of all ages should discuss the test with their doctors.

Kapoor — and other doctors — say it’s better to know one’s status than to be left in the dark.

“I am totally in his camp on that,” said Dr. Aaron Katz, chairman of urology at NYU Winthrop Hospital in Mineola.

“I was trained as urologist at a time when there wasn’t a way to screen for prostate cancer. I remember men coming in with extreme bony pain,” Katz said of pain caused by prostate cancer that had spread to patients’ bones by the time the cancer was recognized.

“We have to be smart about this,” he said of screening. “We should not be putting our heads in the sand.”

Katz emphasized that just because a patient has an elevated PSA result does not mean he has cancer. And even if cancer is found, he said, the malignancy may be slow-growing and require what doctors refer to as active surveillance, a strategy in which the tumor is monitored over time.

Some of Katz’s patients have been under active surveillance for as long as 15 years.         

Kapoor also supports active surveillance, a strategy in which the PSA also plays a role.

“The utility of the PSA is in how you use it over time, Kapoor said. “There’s a variety of ways to use it. If you have an abnormal PSA, that’s an invitation for further testing. We have the patient undergo additional evaluation and only when warranted do we proceed with a biopsy.”