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California and the West

State Investigates Kaiser's Refusal to Provide Viagra

Health: Critics of HMO say many men forgo treatment of serious problems, fearing loss of sexual function. Firm says coverage would drive up costs.

July 03, 1998|MAX VANZI | TIMES STAFF WRITER

SACRAMENTO — The state Department of Corporations is investigating whether the Kaiser Permanente health maintenance organization is violating state law by refusing to cover the cost of providing the impotence drug Viagra, officials said Thursday.

A corporations department spokeswoman, Julie Stewart, said the agency "has been reviewing Kaiser's position regarding Viagra for over a month. A formal investigation was instituted as soon as we learned that Kaiser's decision to deny coverage was based on economic considerations."

Kaiser, the nation's largest nonprofit HMO, announced last month that--with rare exceptions--it would not include Viagra in covered benefits because the number of men rushing to obtain prescriptions for the drug threatened to drive up Kaiser's costs by $100 million a year.

Kaiser officials said Thursday that the HMO is in the process of changing its rules for providing Viagra, but there is no plan to offer the drug widely as a covered benefit. They said Kaiser is within the law in doing so.

The corporations department investigation was revealed Thursday, when four key legislators called on the agency to determine whether Kaiser is breaking the law and whether its license to operate in California should be lifted.

State requirements are clear, said state Sen. John Vasconcellos (D-Santa Clara), that HMOs must provide and pay for drugs deemed medically necessary for patients.

The Department of Corporations, the state agency that oversees HMOs, "can lift, and should lift" Kaiser's license to operate in California if the vast network of hospitals is found to be violating state regulations, Vasconcellos said.

In a letter to Corporations Commissioner Dale Bonner, Vasconcellos and three other lawmakers expressed their "grave concern regarding the decision by Kaiser Foundation Health Plans to exclude coverage for Viagra. . . . We request [that] you investigate the actions of Kaiser to determine" if a state law was broken.

The state's Knox-Keene Act requires HMOs to include treatment for medical necessities in covered benefits.

Among other things, Stewart said, the corporations department is reviewing contracts Kaiser has with employers to determine whether the HMO can legally exclude coverage for Viagra by spelling out the exclusion in the agreements.

Vasconcellos was joined at a news conference by two other legislators, Sen. Diane Watson (D-Los Angeles), chairwoman of the Senate Health and Human Services Committee, and Assemblyman Tom Bordonaro (R-Paso Robles), who is paralyzed and spoke on behalf of people with impaired physical conditions who, he said, depend on Viagra as a medical necessity. Also signing the letter was Assemblyman Kevin Murray (D-Los Angeles).

Often, said health activists also present at the conference, men with conditions such as prostate cancer have shied away from needed treatment rather than submit to procedures that may leave them impotent.

According to a letter from the widow of former Assembly speaker and state Treasurer Jesse M. Unruh, the state political legend himself chose such a route. Unruh, said Chrissie Unruh in a letter read aloud by Watson, "made the difficult choice to not have his cancerous prostate removed because of the lack of the quality of life he would face after surgery."

Unruh died from complications of the disease 11 years ago.

That some HMOs refuse paid coverage for Viagra "is absolutely unbelievable at a time when impotence is finally being talked about," said Mary Lou Wright, who is disabled and is president of the Sacramento-based Mathews Foundation of Prostate Cancer Research.

Wright and others, including Harin Padma-Nathan, a professor of urology at USC, said that Viagra, far from being merely a drug to enhance sexual stamina, is an essential and preferred alternative to more complicated and expensive procedures that allow impotent men suffering other physical impairments to achieve erections.

Like Unruh, many men forego needed treatment for serious conditions for fear of losing sexual potency, the drug's proponents said. Viagra is the answer for such men, they said, as well as for those suffering lifetime disabilities who lack the self-esteem that comes with the ability to perform sexually. They include people with spinal chord injuries, heart disease and diabetes.

"My concern," said Bordonaro, is that without coverage from insurers and HMOs, Viagra will "become a medicine for rich white men" who can afford to pay for the drug on their own.

A spokeswoman for Kaiser, Kathleen McKenna, said that currently, Kaiser pays the $8 to $10 per pill cost of the drug only if the prescribing physician declares that the patient would "suffer adverse health effects" without it.

About 5% of Kaiser patients using the drug meet that condition, she said. The rest pay for the drug themselves. A total of 5.5 million Californians are enrolled in Kaiser health plans.

In future contracts, Viagra will be excluded as a covered benefit, McKenna said, although Kaiser will cover the cost of Viagra treatment within large employee groups, but only at added cost to the employer, she said.

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