Why you should care
Cutting reimbursements for erectile-dysfunction treatments might lower health care spending, but it comes at a steep price.
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You’ve seen the commercials: An attractive couple, a little gray behind the ears, flirting as they play tennis, giggle in a photo booth or stroll beside a sun-dappled lake. Cue the hip-swaying blues track. The ads promise an easy solution to a prickly problem — how hard it can be for some men to get it up.
And insurance companies have only made it harder, with swelling numbers excluding erectile-dysfunction treatments from their plans or limiting access to them. It’s not just silver foxes over 50 who are affected. Men with diabetes, kidney disorders and a host of other conditions make up an estimated 70 percent of the 20 to 30 million men in the U.S. who struggle to get and stay hard, according to UCSF Medical Center data. Many doctors worry that stiffening restrictions could delay treatment for these underlying conditions — whose symptoms often include erectile dysfunction — or push men to embrace riskier alternatives, like penile implants.
It’s become more common for individual plans to categorically exclude sexual dysfunction treatments.
When Viagra debuted in 1998, insurance companies worried that reimbursing the drug could saddle them with hundreds of millions of dollars in annual costs. As part of an overall strategy to lower health-care spending, increasing numbers of insurers have reduced coverage of Viagra and other erectile-dysfunction drugs in recent years. Sexual dysfunction is often “considered not to be essential to activities of daily living, so it’s a common target,” says Amy Boyle, vice president of marketing for urology care at Coloplast, a penile implant manufacturer. Many insurers view Viagra and the like as “lifestyle drugs” that enhance normal sexual performance but don’t alleviate a medical condition. Plus, “no one’s ever pushed” Medicare to cover them, says Don McLeod, a spokesman for the Centers for Medicare and Medicaid.
But many doctors argue that erectile dysfunction is a medical condition that hints at other health problems, like diabetes and heart disease, which damage the capillaries that engorge the penis with blood. Neurological disorders, kidney disease, prostate cancer surgery and some antidepressants can also cause erectile dysfunction. Even absent those conditions, University of Indiana urologist Jason Kovac notes that erectile dysfunction can erode romantic relationships and lead to anxiety and depression. “Sexual health is a part of normal health,” he insists.
Although policies vary, it’s become more common for individual insurance plans to categorically exclude sexual dysfunction treatments, Boyle says. And plans that do cover these treatments can still be cost-prohibitive, covering just five or six pills a month. Even with coverage, faster-acting injections price out at about $80 a vial, while penis pumps — tubes that use air to draw blood into the penis — hover in the hundreds of dollars. (Medicare will stop covering pumps under its Part B plan in July.) Penile implants, a last resort, can cost tens of thousands of dollars, even with insurance.
Some men might find broaching the already taboo topic with their doctors useless if they can’t afford the treatment anyway.
It used to be that insurers were willing to make exceptions based on physicians’ recommendations, but the practice has become far less common, Boyle says. James Dupree, an assistant professor of urology at the University of Michigan in Ann Arbor, has noticed that his patients’ plans require more documentation to obtain prescriptions, even for older meds like Viagra.
To be sure, some insurance plans do cover treatments for sexual dysfunction, and insurers say they look for clinical evidence and guidelines from specialty medical societies before they roll out policies like these. “Treatment plans will base their coverage decision on how safe and effective they are,” says Clare Krusing, a spokeswoman for America’s Health Insurance Plans (AHIP), a health insurance industry trade association. Krusing also notes that documentation is meant to minimize health care spending and make sure patients are given safe, appropriate treatments. Beyond this, though, it’s worth pointing out that women’s birth control treatments aren’t always covered — so why should they be a done deal for men?
But men would argue that the soft coverage leaves patients with few options other than to suck it up, sink into debt or wade through a drawn-out appeals process. Kovac refers his patients to a local compound pharmacy, which buys the base medication — containing all the necessary ingredients — and manufactures it into pill form (although compound pharmacies can be risky, since they often purchase drugs overseas). Some patients turn to foreign online vendors with questionable standards, or to herbal remedies and supplements, which aren’t always FDA-regulated.
And growing numbers of men now don’t even broach the taboo topic with their doctors if they’re convinced they can’t afford treatment. As a result, they miss an opportunity to discuss their diet, blood pressure and other possible underlying causes, Dupree says, which could “hopefully stop a decline that would have otherwise resulted in a stroke or heart attack.” In fact, having erectile dysfunction can predict that a man will exhibit heart disease symptoms within five years, the Cleveland Clinic says.
Kovac says that struggling to pay for erectile-dysfunction treatments is “very frustrating” for his patients. Many are young men who got it up just fine before undergoing prostate cancer surgery, while Dupree sees men on meds for severe depression who then suffer erectile dysfunction as a side effect. Patients may go home with free samples from pharmaceutical companies only to discover they can’t afford to stay on them.
The greatest source of frustration? Doctors know how to correct erectile dysfunction. “Imagine you have a condition that there’s a known treatment for, and you can’t treat it because you can’t afford to,” Kovac says. “There are options available, and they’re not covered.”