Insurers Should Pay for Viagra, Regulators Told
Insurers should not be allowed to deprive patients of innovative drug therapies such as Viagra on the grounds of cost, patient advocates and drug manufacturers argued at a state hearing Thursday.
But managed care representatives countered that cost-effectiveness is a legitimate concern, and strongly opposed any form of mandated pharmaceutical coverage.
The all-day hearing in Los Angeles was called by the state Department of Corporations, which regulates managed care in California, to explore the growing controversy surrounding coverage of new drugs.
The debate flared in June after Kaiser Foundation Health Plan decided not to cover Viagra, the enormously popular anti-impotence drug, except in rare instances; the HMO feared that a patient stampede would drive up its costs as much as $100 million a year.
The department is investigating whether that decision violates a state law that requires companies to cover medical necessities. A number of state legislators urged department Commissioner Dale E. Bonner earlier this month to “take whatever action is necessary to prevent denial of care to HMO members based solely on their ability to pay.”
In sometimes emotional testimony Thursday, patient advocates argued that the decision by Kaiser, the nation’s largest HMO, sets a dangerous precedent in that money may come to figure improperly in medical decisions.
“Do we want to have a two-tiered medical system, where those with money get the care and those without it don’t?” asked Cycy Lambert, mother of a 26-year-old quadriplegic and an advocate for patients with spinal cord injuries.
Lambert quoted from a statement from her son, Robbie, who said that his disabled friends do not even discuss Viagra among themselves for fear of causing rifts between those who have coverage for it and those who don’t.
Attorney Steven Cooper, whose firm filed the first lawsuits against managed care companies that denied coverage of Viagra, told the panel: “Cost should not play a role [in coverage decisions]; medicine should play the only role.”
Yet HMO representatives argued Thursday and at a hearing in San Francisco on Tuesday that cost cannot realistically be excluded from consideration.
“There is no greater threat to affordability, and therefore no greater threat to access, than the rapidly escalating costs of pharmaceuticals,” said Dr. Sharon Levine of Kaiser at the San Francisco hearing.
“Unless we develop a broad societal consensus about how to find a balance . . . between the benefit derived and the cost incurred . . . we risk undermining the very concept of an insured pharmacy benefit.”
Similarly, a medical director from PacifiCare of California said Thursday that although the company reviews drugs based primarily on their safety and efficacy, cost-effectiveness is a factor. Dr. Cheryl Tanigawa said legislative mandates for coverage could lead purchasers to “reduce or eliminate pharmacy benefits due to cost considerations.”
Cooper discounted such arguments as “the parade of horribles” that the industry pulls out to counter every argument for greater oversight. “It’s all . . . nonsense,” he said.
Yet, as panel members pointed out, plans are not legally required to provide pharmacy benefits.
Some speakers argued that the state could help matters by coming up with a legal definition of “medical necessity” instead of leaving the term open to interpretation. Bonner acknowledged that views of medical necessity may vary widely, and cited Viagra as a good example.
“One of the ironies . . . with Viagra is that when you ask the layperson on the street, in many minds it does not meet the definition of medical necessity,” he said.
Pfizer Inc., Viagra’s manufacturer, made every effort to rebut that view.
“There has been the suggestion that Viagra is a ‘recreational’ drug,” said Dr. Michael Magee, senior medical advisor for Pfizer. “When I was a urologist in private practice, my patients . . . weren’t looking for an enhanced sexual performance; they were hoping to restore the ability to have an intimate relationship with a loved one. . . . It is clear that Viagra is providing very real benefits to men and their partners.”
He said the drug is an effective treatment for male impotence resulting from such conditions as diabetes, prostate cancer, heart disease and hypertension.
Yet he did not shy away from the cost issue. In fact, he insisted that Viagra meets that test as well because it is “one-third the cost of existing FDA-approved therapies.”
A Kaiser representative fired back during a break in the proceedings that even if one accepts Magee’s estimates, Viagra still would cost Kaiser a minimum of $76 million annually.
