From the Washington Post: Impotence Pill: Who Will Pay?
By Justin Gillis
Washington Post Staff Writer
Wednesday, April 22, 1998; Page A01
As thousands of men besiege their urologists demanding to try
a new $10 pill that treats impotence, insurance companies and
big employers find themselves confronting a thorny question:
Are they going to pay for it?
Most of them don't know yet, and the final answer will
depend in part on whether doctors exercise restraint in
prescribing the drug over the next several months. Some
doctors say they are getting calls from patients who aren't
impotent but want to try the drug, Viagra, to see if it
improves sexual performance.
Most of the doctors say they are resisting these entreaties
because Viagra could pose unknown risks. They say it's all
they can do to see long-standing patients and men with
clear-cut impotence who are calling for attention. Urologists
are establishing waiting lists. At a Georgetown University
clinic, the phone system had to be adjusted to handle a flood
of inquiries -- "press 3 for Viagra" -- and the waiting list has
topped 300.
"In the 20 years I've been involved in urology, I've never
seen anything like it," said James B. Regan, the head of
Georgetown's Erectile Dysfunction Treatment Program. "If
we were in the military, I think we would call in and say our
position is being overrun."
Despite the best efforts of good doctors, it's already clear
that some people are going to make indiscriminate use of the drug.
It's being hawked on the Internet, over 800 lines and in sex
magazines, as people claiming to be doctors offer to sell
prescriptions to men hundreds of miles away, no questions
asked.
Insurance companies are paying attention, having been down
this road before. In the 1980s, when a cream called Retin-A
designed to treat disfiguring acne proved useful as well for the
cosmetic task of reducing wrinkles, insurers began demanding
strict proof that prescriptions were medically necessary before
they would pay.
Viagra has been widely available throughout the country for
little more than a week. Estimates of the drug's initial
popularity have ranged all over the map, but it's clear that
many thousands of prescriptions are being written every day.
If this initial demand lasts, Viagra could become the
biggest-selling drug of all time. Here's some elementary math:
Viagra costs $10 a pill at the drugstore. A man takes one pill
an hour before he plans to have sexual relations. Imagine that
a typical man uses it twice a week, and that the drug is taken
by 5 million men, an estimate some urologists believe will
prove to be on the low side.
Viagra's retail sales in that case would exceed $5 billion a
year in the United States. Up to now, a drug was defined as a
blockbuster if it brought in $1 billion a year worldwide.
The stock of Pfizer Inc., the drug's manufacturer, soared to a
record of $121.75 a share yesterday as investors excited
about Viagra's prospects snapped up shares. Pfizer,
meanwhile, is fighting a rear-guard action to stop snake-oil
salesmen from capitalizing on the drug's popularity. It has
gone to federal court to block an Atlanta company from
distributing what Pfizer says is a worthless pill called Vaegra.
An herbal concoction called Viagro is being sold on the
Internet.
Unanswered so far is whether the drug can enhance sexual
performance rather than just treat impotence. Pfizer says it
doesn't know and has scientific data that shed only indirect
light on the question.
In research studies, impotent men were questioned about
their sexual satisfaction and were found, not surprisingly, to
be depressed and unhappy. Treatment with Viagra brought
them up to normal levels of happiness compared with men
who weren't impotent, but it didn't seem to take them to
satisfaction levels beyond the norm.
Some urologists say they suspect, however, that Viagra will
indeed improve sexual performance in middle-aged or elderly
men with relatively normal function, giving them the sort of
sexual vigor they enjoyed at age 19 or 20. Several urologists
say that about 5 percent to 10 percent of the calls they're
getting are from men who don't have clinical impotence but
want to try the drug.
Viagra, whose generic name is sildenafil citrate, works by
enhancing the natural mechanism that leads to an erection.
When a man is sexually aroused, certain tissues in his penis
relax, allowing blood to flow in and distend the organ. Viagra
works by elevating the level of a chemical that causes the
tissues to relax.
Viagra has no effect if a man is not sexually stimulated.
The drug may be useful for impotence stemming from several
causes. Doctors emphasize, however, that it's vital before a
man uses the drug to rule out such serious medical conditions
as diabetes and heart disease, for which impotence can be a
warning sign.
A Pfizer spokesman urged that doctors should carefully
question any man who is receiving a Viagra prescription about
the use of nitrite inhalants, nitroglycerin for angina or other
drugs that may pose a risk.
In combination, Viagra and nitrites can lower blood pressure
to a dangerous degree, causing fainting or other problems.
For now, men who present their insurance cards at drugstores
to pay for Viagra are having no problems. But several
national insurers and industry consultants say it's an open
question whether this will continue.
If most prescriptions are indeed being written to treat clinical
impotence, insurers are unlikely to balk. In fact, many of
them could wind up saving money. That's because some of
the older impotence treatments, such as penile implants,
involved surgery that could cost $15,000 to $20,000. That's
enough to cover a lot of Viagra pills, even at $10 apiece.
If it turns out, however, that Viagra use becomes widespread
among men who don't really need the drug, insurers are likely
to start demanding medical proof before they will pay. That
would force a man to present documentary evidence,
probably including a letter from his doctor, that he is
impotent.
Benefits consultants say they're not being Scrooges -- they
contend the industry simply has to draw a line somewhere to
keep a lid on medical costs, and better sex through chemistry
may be a good place to draw it.
"Maybe some people would rather have this than a Lexus,"
said Helen Darling, a benefits analyst with Watson Wyatt
Worldwide, a consulting firm.
"But they should do it with their own money."
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