Business Week Cover Story...not as "blue blinded" as other media.
2 Excepts...
Business Week: May 11, 1998
Cover Story: COMMENTARY
COMMENTARY: IS THIS PRESCRIPTION NECESSARY?
The list of things that money can't buy has just shrunk by one. Now, millions of men who suffer from impotence have a $10 pill. It's a great day for medicine, not to mention male self-esteem.
But for health insurers, Viagra raises difficult questions. Should they reimburse patients for Viagra pills? If so, are five pills a month enough? Or 30? Do 95-year-olds qualify? What if a patient is only a little impaired? Should it matter if his impairment has psychological roots--and what he mainly needs is psychotherapy?
Sex is not what makes Viagra complicated. There are similar questions about mood drugs like Zoloft and Prozac, diet drugs, memory drugs, and growth hormones. For each, the issue is whether insurers--and by extension, society at large--must pay for drugs even if some patients taking them are not severely impaired but simply want to improve their lives. As modern medicine spits out more and more miracle drugs, these questions will grow in urgency.
THINK TANK. Let's start with a basic principle: In general, insurers should pay for treatments, not for enhancements. This distinction was made by Tufts University philosopher Norman Daniels, a medical ethics expert. The terminology became a touchstone for a recently completed study by The Hastings Center in Garrison, N.Y., called On the Prospect of Technologies Aimed at the Enhancement of Human Capacities and Traits. With $140,000 from the National Endowment for the Humanities, the ethics center spent two years thrashing out the issue with 20 leading thinkers from law, philosophy, sociology, and medicine.
It's easiest to understand the treatment vs. enhancement distinction with an example. Let's say two boys are candidates for growth hormone therapy because their full-grown height without treatment would be 5 feet 3 inches. The one whose shortness is caused by a brain tumor would qualify for reimbursement. The one who had short parents would not--for him, the therapy would be deemed an enhancement.
That intellectual framework could help quell the chaos over Viagra. Cigna Healthcare says that until it sets a permanent policy, it will reimburse for just six pills a month--and only for ''a preexisting, documented condition of organic impotence, which is currently being treated by other medical means.'' Kaiser Permanente probably won't limit the number of pills, but is leaning toward reimbursing only 50% of the cost. And so on.
Limits on reimbursement may seem arbitrary and unfair. But making tough calls is better than providing blanket coverage for unlimited usage at an enormous cost to policyholders--or going in the opposite direction and denying coverage for ''lifestyle'' drugs entirely. That would penalize people who truly suffer from dysfunction. And it would divide society by ensuring that only rich people could correct their sexual dysfunctions, treat their depression, combat their obesity, improve their memory, and raise tall children.
The treatment vs. enhancement distinction isn't perfect. It opens up the perplexing question of how to define normality: How bad does your sexual function--or your memory, or obesity--have to be before you're considered impaired? And there's the honesty question: Insurers could try to duck out of paying for treatments by construing them as enhancements, while many patients would persuade their doctors to write prescriptions for drugs they don't absolutely need. Scott-Levin, a Newtown (Pa.) health-care consultancy, says over 90% of patients' requests for depression treatments like Zoloft and Prozac are honored by their physicians.
While it's not the cleanest of distinctions, treatment vs. enhancement is a starting point for a much needed debate on who pays for what. The excitement over Viagra may be just the thing to get that debate rolling.
By Peter Coy |
