On the one hand, health plans are marketing themselves as concerned about the whole individual and the family, committed to early intervention and holistic care. And they’re aggressively recruiting the elder market, with billboards everywhere showing silver-haired seniors smiling broadly.

Yet some health plans say sex isn’t necessary, especially if the cure costs around $10 a pop, or perhaps if the person inquiring seems to the health providers to be too senior for sex. Is sexual functioning an extra, right there with liposuction and face-lifts? Or is it part of living a fully healthy life?

Some plans say they’ll give you Viagra, but for a price. Just ask your employer for the high-end plan. (Can you imagine the letter the employee would end up writing to the HR director, asking that the company consider switching to the more expensive plan? "Some of my fellow employees are interested in having the enhanced health benefit that includes drugs that promote normal sexual functioning. They have asked me to inquire if this might be possible with our company soon.")

Viagra has support from many quarters. The Clinton administration has said the states must include Viagra in their Medicaid programs. Some states are threatening to prosecute insurers who don’t cover the drug. Consumer groups say fear of treatment-related impotence causes many men to postpone prostate exams and other cancer work-ups when symptoms first arise.

The questions raised with Viagra are no different from those that come up with hundreds of other formulary and treatment decisions made every day, but with far less attention—and fewer jokes. Decisions from high up the food chain of healthcare organizations frequently favor finances over the patient’s full functioning. The question of medical necessity can be interpreted in many different ways. Is the relatively expensive drug Zofran medically necessary to treat nausea in the patient on chemotherapy? Is a cleft lip repair medically necessary or just cosmetic? Is birth control—or tubal ligation—medically necessary?

What’s ironic is that, in the long run , the discovery of wonder drugs and new technologies ultimately cuts healthcare costs and resolves problems that once were far more complicated. If learning that a drug can minimize the side effects of treatment diminishes a patient’s reluctance to seek health care, then that alone could ultimately reduce the financial risk health insurers sustain. But that’s tougher to cost out.

What’s a luxury? What do you think?

Barbara Bronson Gray, MN, RN
Editor in Chief