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The Economics Of ViagraA new blockbuster drug raises important questions about what isviewed as “medical necessity” by insurers.
Viagra has been on the marketfornearlytwoyears.
Everyone knows its name. It had the fastest initial salesgrowth of any pharmaceutical product following its April 1998 launch in the United States (although its record has since beensurpassed). As the first approved effective oral treatment for erectiledysfunction (ED), Viagra has had a powerful and freeing impact onpublic discussion of sexuality and has spawned a near-infinitenumber of jokes.
The magnitude of Viagra’s sales has, perhaps, driven third-party payers to look for new rationales to avoid paying for it. Viagra isdescribed by some as a “lifestyle” drug, supposedly distinguishablefrom serious, important medical therapies. In contrast, not onlythose suffering from ED but also medical authorities recognize that COMMENTARY it is indeed a serious medical condition, often caused by other seri-ous medical conditions. Viagra and its experience in the health caremarket raise questions as to where a line might be drawn betweenserious medical conditions and health-related quality of life, andwhether such a borderline is even meaningful.
n Background. An estimated thirty million men in the United States and 100 million men worldwide are affected by ED, the failureto achieve and maintain an erection sufficient for satisfactory sexualexperience. In a large U.S. survey it was found that 52 percent ofmen ages forty to seventy reported some degree of ED.1 Although therate and severity of ED increase with age, age itself does not appearto be the primary cause. Nearly 80 percent of ED is associated withorganic causes.2 Age-related illnesses such as vascular disease anddiabetes, the medicines taken to treat those illnesses, and the long-term effects of smoking and alcohol abuse all contribute to increas-ing prevalence. Additional risk factors for ED include athero-sclerosis, diabetes, severe depression, and injuries and surgery,including radical prostatectomy and spinal cord injury.3 n How Viagra works. Viagra (sildenafil citrate) works, in re- sponse to sexual stimulation, by increasing the blood flow to the Alison Keith is director, economic policy analysis, in Corporate Strategic Planning andPolicy, of Pfizer Inc. 2000 Project HOPE–The People-to-People Health F penis. In clinical trials 74 percent of patients on Viagra reportedimproved erections, compared with 16 percent of those on placebo.4 Extensive experience, both in clinical trials and in use after ap- proval, has shown Viagra to be well tolerated. In clinical trials Via-gra did not result in increased rates of myocardial infarction or otherserious cardiovascular events during either short- or long-termtreatment.5 Further, there is no epidemiologic evidence that Viagraadds to the cardiovascular risk inherent in sexual activity. There is abroad base of experience from which to draw this epidemiologicconclusion: In the first year and a half of marketing in the UnitedStates, more than 15.6 million prescriptions of Viagra had been filled.
As evidence of satisfactory use, refills accounted for nearly half ofthese.6 The use of Viagra in combination with organic nitrates is contra- indicated because of a potentially serious decline in blood pressure.
This contraindication, which is particularly relevant for patientstaking cardiovascular medications (some of which contain nitrates),has been clearly communicated to physicians and the public. Amongthe most common side effects revealed in clinical trials were head-ache (16 percent), facial flushing (10 percent), and indigestion (7 percent). In addition, some mild and transient visual effects were n Viagra’s competitors. Prior to the introduction of Viagra, the alternative prescription treatments were mostly non-oral medica-tions. In the United States, for example, the primary alternativeswere penile prostheses; vacuum constriction devices; penile injec-tion therapy; transurethral suppositories; and professional counsel-ing. In many countries traditional remedies such as yohimbine arealso used.
n Viagra sales. Viagra was first launched in April 1998 in the United States, shortly after the Food and Drug Administration(FDA) granted approval, and is now being sold in more than fiftycountries.8 More than $400 million worth of Viagra was sold in itsfirst quarter on the U.S. market; in the week of 8 May 1998—onemonth after launch—more than 300,000 total prescriptions werewritten for Viagra.9 Since then Pfizer has maintained a list price of $7per tablet. Viagra is substantially less expensive than its pharmaceu-tical competitors: Muse, the transurethral suppository, and Caver-ject, the penile injection. Viagra has an average wholesale price of$8.75 per pill, while, on the same basis, Caverject and Muse arepriced at $20–$30 per treatment.10 Prescriptions peaked and leveled off in the quarters following Viagra’s launch. One reason was the information men gained bytrying the drug. Some discovered that Viagra was not effective for “The single most revealing measure of an innovation’s economicvalue is the market’s response to it.” them. Others, who did not actually suffer from ED but who (with adoctor’s authorization) had tried it anyway, confirmed that Viagrawould not confer exaggerated sexual prowess. In addition, use mayhave been limited by increased public awareness focused on thecardiovascular safety issues in men taking Viagra, particularly onthe deaths and serious adverse events that were reported to theFDA. However, no causal link has been established between Viagraand the reports of death, and the FDA “continues to believe Viagra issafe and effective if used according to the updated labeling.”11 European registration was granted by the European Medicines Evaluation Agency (EMEA) in September 1998, and sales began inmost European countries shortly thereafter. Only in Sweden, theRepublic of Ireland, and, for limited uses, the United Kingdom doesthe government health system cover purchases of Viagra. In mostcountries sales have shown some leveling off after an initial peak, aswas the U.S. experience.12 Approvals and launches in Latin America followed shortly after COMMENTARY the drug’s approval and launch in the United States, and Viagra isnow available in a number of Asian countries, Australia, New Zea-land, and Canada. Japan’s approval, in January 1999, was unprece-dented in two respects. First, the six-month approval was the mostrapid Japanese approval ever. Second, for the first time Japan ac-cepted data from clinical trials conducted elsewhere.13Evidence Of Value For ConsumersThe single most revealing measure of an innovation’s economic valueis the market’s response to it. On this measure, Viagra offers a strik-ing example: Sales of the drug grew very rapidly after launch, andthose of its competitors fell dramatically. The introduction of Viagraessentially quadrupled the market for treatment of ED (in dollarsales) in the United States in eight months.14 At the same time,Viagra cut sharply into the sales of other ED treatments, whoseprescriptions fell by about half.15 Viagra now accounts for 92 percentof new prescriptions to treat ED.16 The evidence is bolstered by the fact that many Viagra purchasers pay the full price out of their own pockets, since insurance coveragefor Viagra is far from universal in the United States. Fifty-eightpercent of U.S. Viagra prescriptions are paid for out of pocket—much higher than the average for all drugs, 22 percent.17 By contrast, 70 percent of prescriptions for Muse are covered by some kind ofinsurance.18 This is true not only in the United States but also in most other countries, where most government-run health plans do not coverViagra purchases. Indeed, in many countries a high-price black mar-ket for Viagra existed before the product was legally available, indi-cating that consumers were willing to pay more than the marketprice. News stories reported black-market prices of $20–$30 per pillin some countries (for example, Malaysia, Hong Kong, and Thai-land) and even in the $50 range in China.19 One reason for the speedyJapanese approval of Viagra was for the government to establishcontrol over the market for the drug, since a black market wasthriving in Japan, including purchases over the Internet.20Why Incomplete Insurance Coverage?In view of the evidence that Viagra makes consumers better off, whydo so many third-party payers resist covering it? In principle, onemight argue that a health insurer should be willing to cover anytreatment that its members would choose to pay for, especially ifmembers would be willing to pay a premium to cover the cost. Why, then, the exclusions and limitations on coverage? To set the context for discussion of this issue, it is instructive to review several insur-ers’ coverage decisions for Viagra.
n The United States. Outpatient prescription drugs are some- times, but not always, covered by insurance in the United States.
Overall, 40 percent of Viagra prescriptions are covered by third-party payers, and 2 percent are covered by Medicaid.21 Only abouthalf of all U.S. health plans reimburse members for at least someViagra pills.22 After Viagra’s introduction, for example, Aetna/U.S. HealthCare and Prudential quickly decided to refuse coverage.23 Kaiser Perma-nente, the nation’s largest not-for-profit health maintenance organi-zation (HMO), initially decided not to cover Viagra, citing cost.
California’s Department of Corporations, which regulates healthplans in the state, contested Kaiser’s decision. In late December 1998Kaiser agreed to cover Viagra and resolve grievances with plan mem-bers who were denied prescriptions for Viagra during the sixmonths that it was not on Kaiser’s formulary. Kaiser also agreed topay the state $250,000 to help pay for investigation costs.24 The staterejected Kaiser’s broader request to drop coverage for all ED treat-ments, but it agreed that Kaiser could (continue to) charge a 50percent copayment for Viagra—higher than copayments for otherdrugs.25 It also determined to separately consider whether Kaisercould raise its premiums by $1, allegedly to cover the added cost of Viagra, or instead to offer employers the option of paying extra foremployees’ Viagra coverage.
Even though the law appears to be clear that states must cover Viagra for Medicaid patients, actual implementation has not fol-lowed suit. Eleven states have still not approved Viagra reimburse-ment for Medicaid patients, even though Viagra is an FDA-approveddrug and the Omnibus Budget Reconciliation Act (OBRA) of 1990requires states to cover all such medications.
Some plans that do provide coverage for Viagra have set limits on the quantity that will be reimbursed. Oxford Health Plans decidedin summer 1998 that the limit would be six pills per month. United-Healthcare’s coverage was, depending on the individual plan, up toeight pills per month; patient copayments were to range from $5 to$25.26 Other health plans set the limit at four pills per month.
Individual consumers have taken health plans to court over Via- gra coverage. The first class-action lawsuit was filed in May 1998 onbehalf of members of Oxford Health Plans and other plans. The suitalleged that by refusing to provide full coverage for Viagra, insurancecompanies and their plan administrators had breached their fiduci-ary duty under the Employee Retirement Income Security Act(ERISA) to provide coverage for any drug that is deemed “medically COMMENTARY necessary.” The number-of-pills restriction is also being challengedin court. A federal judge planned to file a class-action suit againstthe federal government (his employer), challenging the limitation offour pills per month as too low. He had previously filed suit to forcethe plan to cover Viagra at all, after which the plan changed itspolicy to the four-pill standard.27 n The United Kingdom. Following Viagra’s Europewide grant of a marketing authorization by the European Commission in Septem-ber 1998, the U.K. Department of Health (DOH) advised NationalHealth Service (NHS) doctors not to begin prescribing it until pre-scribing guidelines were issued. This guidance was ruled unlawfulby the U.K. High Court in May 1999. However, publication of guide-lines was delayed. Meanwhile, physicians were frustrated becausethey believed that they should prescribe Viagra when it was medi-cally appropriate. The General Practitioners Committee (GPC) ofthe British Medical Association (BMA) stated that “doctors hadbeen placed in an untenable position because of the inconsistencybetween the interim departmental advice and their professional ob-ligations.”28 The GPC announced that it would issue its own guide-lines at a 21 January 1999 meeting if no government guidelines hadappeared by then.
On 21 January itself the government issued its proposal for the funding of all ED treatments in the NHS: Viagra and other treat- ments would be reimbursed only for men with selected etiologies ofED (spinal cord injury, radical pelvic surgery, prostatectomy, diabe-tes, and multiple sclerosis but not kidney disease, liver disease, thy-roid disease, depression, or circulatory conditions).29 Cases coveredby this ruling constitute only about 15 percent of all cases of ED inthe United Kingdom.30 New government proposals came into force 1 July 1999, which limited the availability of Viagra and all other ED treatments onNHS prescriptions via Schedule 11 to the regulations setting outgeneral practitioners’ (GPs’) statutory terms of service. Schedule 11allows the DOH to dictate to a doctor the groups of patients who areable to receive a prescription for a particular type of treatment in theNHS. Two groups of patients may receive treatment for their EDthrough the NHS, using Schedule 11: (1) men with the followingconditions—diabetes, multiple sclerosis, Parkinson’s disease, andpoliomyelitis; men treated for prostate cancer; men who have had aprostatectomy or radical pelvic surgery; and men treated for renalfailure (transplant and dialysis), severe pelvic injury, single geneneurological disease, spinal cord injury, or spina bifida; and (2) anyman who was receiving treatment for ED in the NHS as of 14 Sep- tember 1998. Although this is not actually specified under Schedule 11, the DOH has said that men judged to be suffering from severedistress as a result of their ED will be able to receive NHS treatmentin a hospital setting following assessment by a specialist.
n Japan. Viagra was approved for use in Japan in January 1999. In March the Japanese government announced that Viagra would notbe reimbursed under the national health system. The rationale isthat although Viagra improves the quality of life, it does not cure anunderlying condition.31Reasons For Excluding Or Limiting CoverageAmong the reasons one might identify for resistance to coverage areconcerns that an innovation is not effective, that it is not safe, that itis not cost-effective, or that it is simply too costly. The newestreason offered is that it is not really a “medical treatment” at all, butrather a “lifestyle enhancement” and therefore outside the realm ofthe health insurance contract.
n Efficacy, safety, and cost-effectiveness. Compelling evi- dence exists of Viagra’s efficacy for its intended use. Hence, efficacyhas not been a concern. Furthermore, while some insurers may haveraised safety as a concern, it seems implausible that this is the actualsource of concern, because of the evidence that Viagra is safe whenused appropriately.
It is also not likely that concern over cost-effectiveness is driving limitations on coverage. Indeed, for men already being treated forED, the switch to Viagra is very likely cost-saving. As mentionedabove, Viagra is considerably less expensive than pharmaceuticalalternatives and undoubtedly less costly than surgery.32 Indeed, theBMA noted that in Britain Viagra is “cheaper and more acceptablefor patients than alternative treatments and highly cost-effectiveper QALY [quality-adjusted life year] terms.”33 n Cost. The most obvious driver of refusal to cover Viagra is concern over the rise in spending that accompanies this kind ofinnovation. When an attractive new therapy for a condition manypatients care about but were heretofore unable to treat adequately isintroduced, total expenditures for treatment are certain to rise. Theclassical insurance-generated cost-increasing forces of moral hazardand adverse selection also may come into play.
n Moral hazard. Moral hazard was one of the reasons put for- ward for the decision in the United Kingdom. According to theDOH Standing Medical Advisory Committee’s report, “Diagnosis oferectile dysfunction depends on self-reporting, so it may be difficultto avoid additional costs for men who do not have erectile dysfunc-tion and who wish to try to enhance normal performance.”34 Thisconcern, however, should be defeated by the recognition that con- COMMENTARY sumers quickly recognize that the product does not “enhance nor-mal performance.” Still, moral hazard accounts for some of the increase in demand for Viagra, but probably only a minor fraction. It appears that themoral-hazard justification for limiting coverage may have been over-stated. For example, Kaiser’s initial estimate of the cost impact ap-parently assumed that every man in Viagra’s target populationwould take thirty pills per month. Kaiser argued that covering Via-gra would cost at least $100 million per year, impairing its “ability tocover other vital health care needs” and requiring premium increasesthat would make health insurance too expensive for many.35 TheState of California challenged the $100 million estimate, findinginstead that the pill was likely to be consumed at a much lower ratethan initially assumed.36 And the estimate of thirty pills per monthstands in stark contrast to actual average prescription size of eightpills, typically considered a thirty-day supply.
n Adverse selection. Although adverse selection was not men- tioned as an explanation for not covering Viagra, health plans mighthave been concerned that men coming to the doctor to get Viagramight be treated for the first time for other serious conditions aswell. In the past only a small fraction (14 percent) of men with EDsought treatment for it.37 Viagra appears to be changing this: Accord-ing to IMS Health, the number of American men who sought help “A bit of thought reveals that the distinction between lifestyle andmedical necessity is arbitrary at best.” from a doctor about a penile disorder rose 75 percent, from 2.8million in 1997 to 4.8 million in 1998.38 If men with undiagnosedhypertension, diabetes, or other such conditions were brought intotreatment earlier by Viagra, the health benefits might be substantial,but costs would rise as well, at least in the short term.
Insurers apparently feared having to divert resources from other medical conditions to treatment of ED; Kaiser stated this explicitlyin the Wal Street Journal.39 A British government spokesman ex-plained publicly that its reimbursement decisions were driven bycost considerations and were designed to keep expenditure ontreating impotence at roughly the current level.40 Of course, thealleged encroachment of ED treatment on treatment for other condi-tions need not happen if overall budgets can be increased to coverthe additional ED treatment costs. But Kaiser said that a sufficientpremium increase in the future was not feasible, either, since thesize of the necessary premium increase would put the cost of its plans out of reach for too many people.41 This does not appear to be a full explanation. Any insurance plan—whether a private managed care organization or a govern-ment—covers a mixture of treatments only some of which are rele-vant for any individual patient. Women will not need treatment forprostate cancer, nor men for ovarian cancer. Anyone who choosesnot to have children will not use a delivery room. Therefore, theprediction that the average premium increase attributable to Viagrawill be unacceptable to buyers or taxpayers rests on the argumentthat demand is simply so responsive to coverage that no appropri-ate, stable premium increase can be established. This conclusionseems clearly contradicted by the evidence from the marketplace.
n Medical necessity versus lifestyle. Finally, can insurers’ de- sire not to cover Viagra be traced to their desire to exclude it be-cause it is merely a “lifestyle enhancement” and not a treatment for areal medical condition? To an economist, this explanation also has ahollow ring. A bit of thought reveals that the distinction betweenlifestyle and medical necessity is arbitrary at best.
In many forums, the coverage debate has turned squarely on the question of what treatments are or should be considered medicallynecessary. The State of California stated, in its opposition to Kaiser’soriginal decision not to cover Viagra, that its insurance regulationsrequire insurance to cover medically necessary goods and services and to provide health coverage to patients “unhindered by a plan’sfiscal concerns.”42 In addressing this issue in a class-action case, anattorney asked, “Is sexuality a mere ‘convenience’ or a vital humanfunction?” He noted that since health insurance providers had “his-torically provided unlimited coverage for more invasive and painfulbut equally expensive treatments for impotence,” the decision not tocover Viagra was driven by financial considerations.43 One can easily argue that Viagra is a medically necessary treat- ment. ED is a prevalent condition that interferes with an importantcomponent of human health. The impact of ED extends beyondsexual activity itself. Anger, depression, and anxiety resulting fromED can impair the quality of life of both affected men and theirsexual partners and can cause harm to personal relationships. Also,patients assess ED as a serious health condition. At a meeting spon-sored by the World Bank at the World Health Organization in 1995,attendees were asked to rank the average handicap stemming from avariety of conditions.44 ED was ranked similarly with infertility,rheumatoid arthritis, and angina.
The debate over “lifestyle” conditions and treatments is really a reflection of a larger question of the continuum from immediatelylife-saving treatments to those that make life more pleasant by im- COMMENTARY proving health-related quality of life. The apparently easy distinc-tion between conditions that affect real health and those that merelyaffect lifestyle is, in fact, arbitrary. Certain activities—in this case,sex—are viewed by some as personal options that are not inherentlypart of the definition of good health and therefore should not beincluded in health insurance. Cosmetic improvements, such as bald-ness remedies, weight-loss programs, and cosmetic surgery, are in-cluded in this bundle.
However, the same options apply to a wide range of medical conditions that are commonly considered legitimate health con-cerns. On one end of the spectrum, treatment for smoking cessationmay be considered a lifestyle issue; in fact, quitting smoking is one ofthe most beneficial things that one can do to improve one’s long-term health prospects. One could also argue that treatment for ar-thritis or migraines primarily affects lifestyle and not the ability tosurvive. In the extreme, one might argue that recent innovations inthe treatment of stroke are principally lifestyle enhancements,aimed at preventing a lifestyle burdened by immobility or other lostfunctions. The point, of course, is that virtually all medical treat-ment affects patients’ ability to live the lives they prefer. There issimply no bright line distinguishing lifestyle from medical necessity.
An arbitrary distinction betweenhealthandlifestyle will be increasingly out of place as chronic conditions cometo the fore with increasing prevalence, as populations age, and as new technologies emerge to treat or manage these conditions.
If these new technologies are to be allowed to provide the benefitsthey promise, insurers must do a better job of aligning coveragedecisions with their members’ true valuation of the benefits—thatis, their willingness to pay.
Viagra is a registered trademark of Pfizer Inc. Muse is a registered trademark ofVivus Inc. Caverject is a registered trademark of Pharmacia & Upjohn Company. 1. H.A. Feldman et al., “Impotence and Its Medical and Psychosocial Correlates: Results of the Massachusetts Male Aging Study,” Journal of Urology 151, no. 1(1994): 54–61.
2. Ibid.; A.E. Benet and A. Melman, “The Epidemiology of Erectile Dysfunction,” Urologic Clinics of North America 22, no. 4 (1995): 699–709; M.M. Foreman andP.C. Doherty, “Experimental Approaches for the Development of Pharma-cological Therapies for Erectile Dysfunction,” in Sexual Pharmacology, ed. A.J.
Riley, M. Peet, and C. Wilson (Oxford: Oxford University Press, 1993), 87–113;and “NIH Consensus Development Panel on Impotence,” Journal of the AmericanMedical Association 270, no. 1 (1993): 83–90.
3. Benet and Melman, “The Epidemiology of Erectile Dysfunction.” 4. I. Goldstein et al. for the Sildenafil Study Group, “Oral Sildenafil in the Treat- ment of Erectile Dysfunction,” New England Journal of Medicine 338, no. 20 (1998):1397–1404; and H. Padma-Nathan, W.D. Steers, and P.A. Wicker, “Efficacyand Safety of Oral Sildenafil in the Treatment of Erectile Dysfunction: ADouble-Blind, Placebo-Controlled Study of 329 Patients,” “FBCalifornian-Italic”International Journal of Clinical Practice (September 1998): 375–379.
5. A. Morales et al., “Clinical Safety of Oral Sildenafil Citrate (VIAGRA) in the Treatment of Erectile Dysfunction,” International Journal of Impotence Research 10,no. 2 (1998): 69–74.
6. As evidence of satisfactory use, refills now account for more than half of all prescriptions. S. Pomerantz, “Viagra Market Update, Week Ending 11/26/99”(New York: Pfizer, 13 December 1999).
7. Pfizer, Viagra Product Monograph (July 1998).
8. T. Trucia and S. Pomerantz, “Viagra World Wide Market Update, Au- gust–September 1999” (New York: Pfizer, 1999).
9. IMS Health, Retail and Provider Perspective, 1998, and National Prescription 10. 1999 Drug Topics Red Book (Montvale, N.J.: Medical Economics Company, 1999).
The Red Book provides average wholesale prices (AWPs), which add a distribu-tion margin to the manufacturer’s price.
11. Food and Drug Administration, “Pfizer Updates Viagra Labeling,” FDA Talk Paper T98-83, available online at www.fda.gov/cder/consumerinfo/viagra/default.htm.
12. Trucia and Pomerantz, “Viagra World Wide Market Update, August–Sep- 13. “Japanese Women’s Groups Angry after Health Ministry Approves Viagra,” Tokyo, Dow Jones News (26 January 1999).
14. M. Duffy and S. Pomerantz, “Viagra Market Update, Week Ending 12/18/98” (New York: Pfizer, 15 January 1999).
16. Pomerantz, “Viagra Market Update, Week Ending 11/26/99.” 18. Ibid.
19. “Viagra Sold Illegally in Malaysian Nightclubs, Pharmacies,” Kuala Lumpur AFP (8 March 1999); T. Sulien Duffy, “Viagra Hits Hong Kong, but Will ItReplace Traditional Impotence Cures?” Hong Kong, APW (10 February 1999);S. Wannabovorn, “Thais Say Massage, Herbs, Give That Viagra Feeling,”Bangkok, Reuters (11 May 1999); and “In the Absence of Viagra, Here’s toGreat Brother,” Hong Kong, AFP, Dow Jones News (15 January 1999).
20. “Japanese Women’s Groups Angry.” 21. Pomerantz, “Viagra Market Update, Week Ending 11/26/99.” 22. M. Grunwald, “U.S. Judge Asserts Need for More Viagra Coverage,” Washington 23. N. Jeffrey, “Prudential HealthCare and Humana, Citing Safety, Won’t Pay for Viagra,” Wall Street Journal, 6 July 1998.
24. “Kaiser Settles Grievances with Members Denied Viagra,” Sacramento, Dow 25. R. Rundle, “Kaiser Permanente Will Raise Rates to Cover Costs of Providing Viagra,” Wall Street Journal, 4 January 1999.
26. N. Jeffrey, “Kaiser Permanente Decides It Won’t Cover Viagra Pills,” Wall Street 27. Grunwald, “U.S. Judge Asserts Need for More Viagra Coverage.” 28. J. Chisholm, “Viagra: A Botched Test Case for Rationing,” British Medical Journal 29. Ibid.
30. N. Timmins, “Financial Grounds Used to Ration Viagra,” Financial Times, 24 31. “Viagra Not to Be Covered by Health Insurance,” Tokyo, Japan Economic 32. Data from IMS America (18 May 1999).
35. Jeffrey, “Kaiser Permanente Decides It Won’t Cover Viagra Pills.”36. D. Griffith, “Viagra for Now,” Sacramento Bee, 29 December 1998; and “Kaiser Must Cover Viagra, California State Rules; HMO to Pay $250,000,” F-D-CReports, “The Pink Sheet” (4 January 1999).
37. Pfizer, Men’s Health Survey, 1997, in Viagra Outcomes Research Support 38. See O. Middleton, “Viagra Sales Slow from Pace of 1998 Launch,” Wall Street Journal, 29 March 1999, citing IMS Health data.
39. Jeffrey, “Kaiser Permanente Decides It Won’t Cover Viagra.” 41. Jeffrey, “Kaiser Permanente Decides It Won’t Cover Viagra.” 42. State of California, Department of Corporations, Press Release (28 December 43. Middleton, “Viagra Sales Slow from Pace of 1998 Launch.” 44. C. Murray and A. Lopez, eds., The Global Burden of Disease (Geneva: World Health Organization, 1996), 39, Table 1.3.
Iatrogenic impotence and rectal dissectionI. Lindsey and N. J. McC. MortensenDepartment of Colorectal Surgery, John Radcliffe Hospital, Headington, Oxford OX3 9DU, UK(e-mail: email@example.com and firstname.lastname@example.org)Colorectal surgeons are becoming ever more aware of thenear the pelvic plexus, and during deep dissection of thedetails of the surgical anatomy of the rectum andanterior asp