Should Insurance Cover Viagra?
WebMD News Archive
June 19, 2000 -- A dollar spent on Viagra is spent just as efficiently as a dollar spent on kidney dialysis. a new study shows. Experts agree that the math is right, but whether it justifies insurance coverage for the male potency drug is a bone of contention.
"There is a significant loss of quality of life that comes from erectile dysfunction ," the lead researcher of the study, Kenneth J. Smith, MD, tells WebMD. "One thing that motivated me to look at this is that I am a primary care doctor. I am seeing men with erectile dysfunction having to fill out insurance forms to justify Viagra treatment. What prompted the insurance carriers to set up so many barriers for some men to get Viagra who would clearly benefit from it? I see Viagra use more as a health issue and a quality-of-life issue than as a lifestyle issue."
Smith, who is associate director of the internal medicine residency program at Mercy Hospital of Pittsburgh, based his calculations on several key assumptions, such as the average age of the Viagra user and the average number of times he would use it per month.
Researchers also took into account that this medication would not work for some men and that some men would have side effects. In every case, they chose figures that would make it harder to show a cost benefit for the drug. Even so, Viagra was a good deal when measured in quality years of life gained.
"We used in our baseline analysis a cost of $52 [1998 dollars] for six pills per month," Smith says. "You would need to spend $244 per month -- 20 pills -- before Viagra would become cost-ineffective." The results were published in this month's issue of the journal Annals of Internal Medicine .
Such figures make Viagra more cost-effective than renal dialysis, cholesterol -lowering medication, or heart bypass grafting, Smith says. He admits, however, that unlike these other conditions, erectile dysfunction is hardly life threatening. But he argues that insurance carriers pay for many other illnesses -- such as migraine headaches -- that affect the quality but not the length of a person's life.
"It looks like when insurance companies were deciding whether to cover Viagra, they probably didn't use a cost-effectiveness analysis [to make the decision]," he says. "It would appear that their decisions have been arbitrary."
In an editorial, Michael R. McGarvey, MD, says Smith and colleagues did their math the right way. But McGarvey, who is chief medical officer for Horizon Blue Cross Blue Shield of New Jersey, says they drew the wrong conclusions about what this means for insurance coverage.
"My personal feeling is that we really need to re-examine the whole issue of what we should be expecting health insurance to do for us," McGarvey tells WebMD. "It should be aimed at providing health services that are of proven value for serious and expensive conditions. We should re-examine the use of health insurance for interventions that 'enhance' our lives."
McGarvey says that Americans expect their health insurance to provide more benefits than ever before. These expectations are partly due to new technologies, he says -- and partly because people fortunate enough to be able to afford health insurance are getting spoiled.
"I think because insurance has become so incredibly complicated, most Americans are reasonably confused about the coverage they have and don't have," he says. "The expectation is that it should cover whatever they want, as often as they want it. Americans tend to have very high expectations and are very unhappy when these expectations are thwarted in any way."
McGarvey points out that there is a limit to what insurers can do. At current rates, one in five Americans will be uninsured by the year 2008. The question the nation must face, he says, is whether less extensive health insurance should be given to more people, or more extensive health insurance should be given to fewer people.
"We are confronting a national embarrassment which is the number of people that are uninsured," McGarvey says. "We know health insurance is an important but increasingly expensive component of our lives. We need to think about it and exercise some judgement in making and adhering to some difficult decisions. As you add more and more and more benefits, insurance will become less and less affordable and people will drop out of the insurance pool. And that is bad for a growing number of people."
Smith agrees that McGarvey is raising important questions. "The points that Dr. McGarvey makes are very good ones -- and we are looking at two sides of the same coin," he says. "I don't think that you can base insurance coverage just on cost-effectiveness. There are other factors. But it should certainly be a factor."
- New research shows that Viagra is cost-effective for improving quality of life, but there is still debate about whether health insurance should pay for this drug.
- One researcher argues that insurance companies pay for treatment of other illnesses, such as migraine headaches. that aren't life threatening, so Viagra should be covered as well.
- Another expert argues that Americans who have health insurance expect too much, and that adding more benefits only increases costs, which increases the number of uninsured.
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