The United States healthcare system is considered to be generally private, with third party payers(insurance companies), reimbursing the patient or medical provider directly for the cost of health services.
The employer usually contributes a certain amount of money each month and may offer one of the following types of healthcare services.
HMO – Health Maintenance Organisation
HMO health maintenance organisation offers a very NHS like experience. You are assigned a GP who acts as a gate keeper to other speciality services like endocrinology. They also manage the prescriptions and you are required to only see GPs in your strict network.
In this scenario if you are a potential TRT patient you would have to ask your GP to run some tests or explain your symptoms to them and wait for a referral to endocrinology, unless the GP was willing to treat you directly which can happen in some cases.
Usually you will get the basic service as outlined by the insurance formulary or the list of approved medicines or testosterone treatments that is permitted to be prescribed based on cost normally. You would then see a preferred in-network pharmacy to have your prescriptions of testosterone filled. You may even get your injections every 2 weeks at the doctor’s office requiring you to pay for the doctor’s co-pay each time you have your injection. Excess charges or co-pays as they are referred to in the US for doctor’s visits can be anywhere from $20-100 depending on your plan. You will also be dependent on the approval and ordering of blood tests by the HMO and will only be able to use laboratories within the HMO network.
PPO – Preferred Provider Organisation
In this scenario you are offered a network of healthcare providers to choose from. Choosing the one in the preferred network will result in a lower co-pay excess for doctor’s visits, or hospital costs if they are in the preferred network. If they are not in the preferred network then they are considered out of network then the co-pay is higher or the reimbursement is lower and you may have to pay out of pocket first then send in a form and hope to get reimbursed after. So if you find a doctor that is clued up on testosterone treatment and they or their clinic is in network then you hit the post code lottery as you can essentially get your treatment for the lowest cost. In the past decade many insurance companies have created stricter limits to what they are willing to pay for. They have made it more difficult for patients to receive treatment when their testosterone levels have fallen outside of arbitrary ranges. These ranges used to be anything under 450ng/dl and have now been lowered to closer to 300-250ng/dl in some cases. This means that even if your doctor in the PPO wants you to be on TRT you may not be able to receive medical coverage for this. Your blood tests and labs will need to be ordered by your doctor and you will get the greatest amount of coverage with the smallest co-pay if you choose a laboratory within your preferred network. There may be a sliding scale of payment as some labs may be more preferred than others.
Another way to help Americans pay for healthcare is through pre-tax savings accounts called the HSA or Health Savings Accounts. You can enroll in a tax free health savings account through your employer or through your own company if you’re self-employed. This is pre-tax money which you can have money withheld from your pay packet and this can help reduce your tax burden. You can save money each month pre-tax and use this toward any co-pay or excess charges, as well as cosmetic, or out of network healthcare expenses. You can use the money in the account as long as it is for bona-fide healthcare services.
For those who served in the military the US Governement offers some limited government provided healthcare administered by the Veteran’s administration. These government institutions are more similar to the NHS model as it’s the government assets and the doctors are employed by the US government through the Veteran’s Administration Agency.
The other model of healthcare which has quickly grown over the past 1.5 decades is the cash based practice or subscription model. In this model doctor’s or small clinics are offering services and membership fees either ala-carte or for a minimum monthly subscription of membership fee. This is also known as concierge medicine, and this type of service is not covered or restricted by the insurance based model. These doctor’s are finding certain amounts of freedom as they are no longer dictated to by the insurance companies on what they can or can’t prescribe. In this model patients pay the doctor directly and in some instances depending on how generous their insurance plan is may be able to have their insurance company pay for labs, and doctor’s consultations and examinations.
Many TRT clinics have appeared in the USA over the past 2 decades offering this model and the market is reaching a point of saturation where there are beginning to be buy out and mergers for some clinics.
Laboratories in the United States require a doctor’s prescription in order to have labs done. An innovative service called DiscountedLabs.com takes the hassle out of this by offering a one stop shop for patients looking for the freedom to order blood tests without having to see a private doctor first and incurring the cost of the co-pay or other out of pocket expense.
These labs are significantly less costly compared to what you may have to pay for when you take into account the cost of a private doctor’s consultation needed to even see if you have low testosterone levels. They have 1,900 locations for blood draws throughout the United States and can be found in most cities and states. They only charge an additional $6 per lab draw fee, and no appointment is needed. Their most inclusive panel offered on their for men who want a wide picture of their health or who are considering starting testosterone replacement therapy costs around $261 or £200.
TRT Medications available in the USA
Patients in the UK who read information from the US will often ask about getting their testosterone in a vial. One of the biggest areas of difference is the container used to distribute testosterone for injections. In the United States, and Canada it is the standard either culturally or as a result of regulation to supply testosterone in multi-dose vials. These can be 10ml, 5ml, or 1ml vials. The 1ml vials are normally considered for single use but as they contain a preservative they can be used for microdosing smaller amounts. Some men are using smaller microdoses and injecting their testosterone subcutaneously. This may be possible because the dosing sizes make it possible to have a more concentrated testosterone preparation resulting in smaller injection volume. This means only 0.1ml would be needed to inject 20mg of testosterone cypionate daily or every other day.
A draw back of multi-dose vials is the risk of contamination if the patient is not careful to practice sterile injection technique. They can also find after while of using to large of a fill needle going in and out of the rubber bung of the vials can allow small rubber particles to fall into the testosterone solution.
Besides the format another area of difference is the approved medications.
Sustanon which is a blend of testosterone esters as a commercially licenced product is not available in the United States.
The United States has a friendly regulatory environment which has helped foster innovation through private compounding pharmacies. Recent legislation has required more stringent regulation to prevent the transmission of spongiform and other potential pathogens during the compounding process. A 503A or B regulatory regime is required in order for a pharmacy to manufacture certain compounded sterile items such as testosterone injections.
These compounds cannot match licenced brands of testosterone so normally the excipient will be different to what is commercially available as well as the doses may vary from standard commercially approved testosterone prescription products.
In the UK the NHS is the government funded public healthcare system, it is free for all to use who are living in the UK. this is paid for by taxes generated across business and employment throughout the UK. There is of course private hospital services as well, however the primary healthcare system used for most people in the UK is the NHS.
NHS – National Health Service
The UK healthcare system is primarily the national health service. The first point of contact is your GP or General Practice Doctor. This would be similar to a family practice or primary care physician in the US. The GP acts as the gate keeper similar to the HMO model although they tend to be more restrictive. The GP may mean well and at time prescribe testosterone but after a few repeat prescriptions they are audited and sent to the hospital NHS for review. After you are scheduled with the endocrinologist in which you are given dates and must attend those dates or you don’t get the appointment then there is a risk the endocrinologist will have you stop your treatment the NHS GP gave you in the first place in order for them to get a fresh look at what’s going on. It’s as if they don’t trust the GP and they are more than happy to see you suffer without testosterone whilst they conduct their tests. The endocrinologist may even be surprised that your LH and FSH are supressed when you are on TRT and may cause you to be worried that you have a pituitary tumour. The endocrinologist in the UK really should be rebranded as an average diabetes specialist as that seems to be their main area of expertise.
After a long battle with the NHS you may be pulled of testosterone therapy and feel like you have no where to go.
Fortunately in the UK private options are legal if you have the mean.
Traditionally private care consisted of going to the Harley Street in London, or finding a local private doctor near where you lived. These private doctors most likely spend some time in the NHS and they normally operate their private practice part time and often treat these practices like a hobby. Very few private doctors even those purporting to offer TRT truly understand the intricacies of balanced TRT and many of them offer the NHS offering but a bit faster.
The NHS TRT offering is usually long lasting Testosterone Undecanoate offered as Nebido in a 4ml intramuscular injection every 12 weeks. This requires that you book in for your injection every 3 months or so. What normally happens is a slight improvement followed by a month of hypogonadal levels.
The other option the NHS offers is commercially prepared testosterone gels. These leave many patients with sub-optimal levels and a risk of cross contamination with partners, children or pets. Some patients do well with them and at the end of the day if you are fortunate enough to have the NHS pay for your TRT treatment it is hard to beat free. Despite this free healthcare many patients decide to venture back to the private side as you get what you pay for. When treatment leaves patients with a lack of libido, or poor erections the NHS offers very little. The NHS has been a political football and the ruling party usually shapes the funding and ethos of the organisation. The conservative party has been operating the NHS for the past decade and whilst they claim more funding and more doctors, they have also hollowed out and restricted many treatments that were previously available. One treatment is liothyronine or T3. They have forced patients who have been doing swimmingly for years on T3 either combo or monotherapy to come off.
They have been telling patients that it may lead to arrythmia, or certain heart conditions and forced them back on to T4. In addition they have attacked private doctors for offering T3. The NHS is not very good at negotiating fair prices and as a result of T3 being extremely expensive they have conspired to change the guidelines to suit their budget.
So for private TRT in the UK patients traditionally had to find an independent doctor willing to stick their head above the parapet and offer a faster route to treatment the NHS would normally provide. For the most part private meant NHS level service but faster.
Private was also linked to the insurance based model in the UK. This means that you still need to see you NHS GP to refer you to a private consultant or specialist in the UK.
Ironically in what American’s would refer to as collusion, these private doctors also spent half their time working in the NHS so these doctor’s a providing a substandard TRT service both for the NHS as well as their private patients.
Balance My Hormones – American Style TRT in the UK
The other type of private service is a concierge support clinic like Balance My Hormones. Balance My Hormones is a unique service based clinic model in that it offers the best in private cash based USA centric TRT with the realities and sensibilities of patients in the United Kingdom and the European Union. Balance My Hormones Clinics are regulated by an independent health regulator, and has to adapt the best of American TRT methods to UK and EU regulation and commercially available hormone preparations.
One example of this is the use of single use ampoules and not vials for testosterone treatment. Another area where Balance My Hormones is adapted for UK patients is in the approach to service and support. Patients get support from their Medical Case Managers as well as the doctor and this is all included in the cost of the monthly treatment plans. Blood tests are organised and can be purchased as part of a package for starting and continuing with TRT. The service assures you get exactly what you need for the proper monitoring of TRT and other hormonal issues.
In addition to blood testing, diagnosis and treatment the Balance My Hormones Service manages and organises all treatment from the pharmacy, and offers additional services for other hormonal treatments like thyroid, and auto-immune disease.