Viagra Shows the Potency of Insurers

The simple e-mail posting on an Internet discussion group about sexual impotence asked an intriguing question.

"My insurance is paying for eight Viagra pills every 30 days," read the message from "Theodore." "Are they trying to tell me something?"

Although Theodore didn't answer his own question, the implication seemed clear: His insurance company had determined that sex twice a week--not once a week, not once a month--was about right. If he wanted more frequent sex, he'd have to pay for it himself.

Of all the reverberations triggered by the anti-impotence pill Viagra--ranging from an apparently endless supply of jokes to new marital dynamics among senior citizens--one of the most important is more subtle.

Viagra has brought into sharp focus the increasing role that health insurers, by default, play in deciding what's important to society. Through a process that largely takes place behind closed doors, health insurers decide what to cover, shaping the behavior of millions of Americans.

Employers, who pay for most health insurance in this country, also play an important role in the process. They can decide whether a particular benefit, such as contraceptives, will be included in workers' health packages. This influence is increasingly felt as employers pressure insurers to reduce medical costs and premiums.

Health insurers traditionally have made important decisions for people, but in most cases the judgments are straightforward. They pay to inoculate children against measles or for an operation to treat cancer. They generally don't pay for cosmetic surgery--a breast enlargement, for example--or for baldness or diet drugs (except when obesity poses a severe health risk).

But as medical technology moves at a dizzying pace, where is the line between "medically necessary" services and those that simply enhance our lives by making us feel or look better, or enable us to enjoy an active sex life? And who should draw this line?

Today, medical innovations, the climate of medical cost containment and a new generation of so-called quality of life drugs--of which Viagra is only the beginning--have driven the debate into new territory.

And some observers, including managed care executives, are questioning the role of insurers.

"We find ourselves in the role of being private regulators and making public policy by HMO," said Alan Hoops, chief executive officer of PacifiCare, the big HMO based in Santa Ana. "We're in the business of constantly passing judgment on the societal value of a given protocol."