Treatments for many disorders can be very expensive, and if there are no useful objective tests, it may be difficult to convince insurance companies to pay for it based upon the subjective views of the patient.
Jan. 7, 2000 (Indianapolis) -- Treatments for many disorders can be very expensive, and if there are no useful objective tests, it may be difficult to convince insurance companies to pay for it based upon the subjective views of the patient. An article in the January edition of The Journal of Urology suggests that standard tests for erectile dysfunction (ED) are not helpful in diagnosis, and this may impact on the reimbursement of treatment expenses.
"In our experience, evaluation of male sexual dysfunction has gained other dimensions and moved from pharmacostimulated testing to a more complex approach to male sexual health," writes lead author Kurt Lehmann, from the urologic division of the Kantonsspital Baden in Switzerland. "Soon we will have to prove or disprove patient sexual dysfunction to support application for treatment reimbursement. We need instruments that are reliable, minimally invasive, and specific to discriminate patients from men who want to increase sexual performance."
The researchers evaluated 77 patients who sought treatment for ED. Assessment included patient reported data on sexual erections (rigidity, capability of vaginal penetration, duration), standard clinical and laboratory tests, and other diagnostic tests such as intracavernous injection and sonography. Data was compared on the basis of whether vaginal penetration was possible, feasible only with manual assistance, or possible but not long enough for satisfactory performance.
Of the 77 patients studied, 36 were unable to perform vaginal penetration, 28 needed manual help, and 13 had erections sufficient for penetration but were not satisfied by their performance. In contrast, response to diagnostic tests could not discriminate among the groups even though their self-reported symptoms varied widely.
"In these days of cost containment and therapy oriented evaluation, further tests that increase expenses are contraindicated unless they can prove the presence and degree of ED," writes Lehmann. "Our study indicates that pharmacostimulation tests do not fulfill these criteria. We urgently need widely accepted instruments for evaluation of patients with ED because reimbursement will be coupled with strict limitations."
Although he agrees with this article that there is no method of objectively verifying ED, Ira Sharlip, MD, medical director of Pan Pacific Urology in San Francisco, tells WebMD he thinks most of the reimbursement problems in the U.S. are tied to the cost of treatment rather than the inability to objectively establish the diagnosis.
Sharlip says, "These insurance companies don't understand that we don't have a test that clearly establishes the pathophysiology [the cause of the problem] of ED in more than 50% of the cases. If I don't write something, then they deny payment. Their experts just don't understand that for most men, there frequently is no [known cause]."
Neil H. Brooks, MD, a family physician in private practice in Vernon, Conn., agrees that insurance companies put roadblocks in the way of paying for Viagra (sildenafil). He also thinks these restrictions are related more to economics than to the lack of an objective test.
"With sildenafil, some programs will pay for four or six pills a month, and I'm not sure how they made that determination," says Brooks in an interview with WebMD. "Even if we had the objective studies, they cannot tell if the person will actually be able to perform. If [insurance companies] don't want to contractually pay for it, just exclude it. Don't make silly rules about it that don't make any sense."