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The journey to conception is a long, difficult road...
Conceiving Infertility Benefits
MCOs are left to distinguish between personal choice and medical necessity
Few healthcare decisions are as highly personal -- or as hotly debated -- as those related to infertility.
In this area, the American Society for Reproductive Medicine (ASRM) estimates that about 6.1 million
American women and their partners -- approximately 10% of the U.S. population that is of
reproducing age -- are infertile, a condition defined largely by the inability to conceive after trying to
do so for one year. * However, with infertility's causes split roughly evenly between male factors,
female factors, and those related to both partners or to unknown causes, identifying the exact nature
of a couple's problem can be a difficult and time-consuming process. Add to this the fact that
remedies such as in vitro fertilization can easily cost upwards of $10,000 per cycle with no guarantee
of success, and it's not hard to understand why patients to date have often faced an uphill climb in
accessing treatments.
"In a time of escalating costs, infertility has been taking hits because it can be expensive," says
Richard Kopher, MD, a reproductive endocrinologist with HealthPartners. "And although patients
would certainly take exception to this, it's viewed by some less as an illness than a semi-elective
treatment." Accordingly, he states, "Some underwriters and insurance plans say, 'This is something
we can do without.'"
To help patients overcome such sentiments, a total of 13 states presently mandate that health insurers
either offer or cover some level of infertility treatments (similar rules apply to plans seeking to be
federally qualified).
And according to an October 1999 report titled Drive for Insurance Coverage of Infertility Treatment
Raises Questions of Equity, Cost, current technologies can successfully treat more than half of
couples experiencing infertility. But despite this fact, the same report, published by the Alan
Guttmacher Institute, a New York-based research organization that studies reproductive issues,
asserts that most couples experiencing infertility do not seek or receive treatment.
Those that do seek treatment, on the other hand, often find that health plan policies and procedures
leave much to be desired. "Whether it be infertility or anything else, it seems HMOs aren't very
proactive in identifying what's not covered," says Taylor Ohlsen, president of Health Ready, an
Aurora, Colo.based firm that works through doctors to provide patients with financing for infertility
and other treatments. "I guess they see it as a negative to highlight what they don't cover," Ohlsen
says. "But it just leaves the patient to kind of stumble their way through finding what their options are."
Other common patient complaints center around how benefits are structured and administered. Diane
Clapp, national medical information director for RESOLVE: The National Infertility Assn., says, "It's
difficult for patients when there are requirements in terms of coming from the gynecologist or ob/gyn
to the specialists. In other words, patients may have to wait a number of months or they may have to
have certain tests done before proceeding. That can be a first-line frustration."
Once patients are involved in infertility treatments, she continues, "frequently if you're an HMO patient
you don't have much leeway in terms of seeking treatment or second opinions from other
reproductive endocrinologists in the field. And I think because this particular area of medicine is such
an art form, not a hard science, consumers really do want to see other doctors if treatment has been
unsuccessful."
Headaches for MCOs. Such desires can cause migraines for MCOs. As Sam Ho, MD, vice president
and corporate medical director for PacifiCare Health Systems, states, "Health plans have a fiduciary
responsibility for employers," who decide what level of service to offer their workers based on factors
including medical costs and premium levels. In such a scenario, Dr. Ho adds, "The role of the health
plan is figure out what is the basis for managing a benefit that has some finite expectations or pricing
around it, how to maximize the healthcare benefits within that budget, and where does infertility fit in
all that?"
As technological capabilities and consumer desires continue to converge, questions like the above
frequently yield few clear answers. On one hand sit naturally occurring problems like endometriosis.
In such cases, Dr. Ho says, "Maybe removing some of the endometriosis and some of the surgical
scarring which occurs as a medical consequence of the disease becomes a medically necessary
treatment so a couple can conceive. That makes sense."
Increasingly, however, the healthcare industry is confronted by patients whose infertility stems not so
much from medical matters as from personal choices. For example, in cases that involve reversing
voluntary sterilization procedures such as vasectomies and tubal ligations, Dr. Ho asks, "Since the
procedures were entered into voluntarily, is that something that would be reasonable to cover so that
they can conceive after changing their mind, so to speak?"
Similar issues arise when one considers single women and same-sex couples who pursue medical
assistance in conceiving children.
"At some point over the years, employers and purchasers of health plans have made decisions as to
what's a reasonable and affordable ground to stand on," Dr. Ho says.
"Having children or not having children is not an illness. So the compromise has been that if there are
medically related reasons that fertility has been prevented, then maybe we can treat those, but nothing
more than that because otherwise we are redefining the whole healthcare benefit" to potentially include
everything from cosmetic procedures to aromatherapy, he says. And in a culture that increasingly
wants coverage for lifestyle decisions, Dr. Ho says that "at some point, our society, not the health
plans or HMOs, is going to have to draw the line."
An age issue. Other challenges already affecting MCOs stem from changes in the age at which people
are choosing to bear children. In general, baby boomers have chosen to delay childbearing in order to
focus on their educations and careers. They're also more proactive about healthcare than their elders.
"Many individuals in the boomer generation are attempting conception in their mid- to late-30s and
early 40s," observes HealthPartners' Dr. Kopher. "The typical patient I see in my office is 42, just got
married, and wants to have babies. And it gets kind of hard at that age."
Due to natural inefficiencies, on average less than a third of patients age 40 and up are able to
conceive on their own within six to 12 months. This fact leaves large numbers of patients seeking
diagnostic services at the very least.
Fortunately for such people, employer attitudes -- while not exactly loosening -- aren't tightening as
much as they have in the past. That's largely because the strong U.S. economy has created a labor
market in which employee benefits represent an important tool for recruiting and retaining workers.
As part of the trend toward somewhat richer benefits packages, PacifiCare's Dr. Ho adds, "Many
employers are dropping HMOs entirely and just offering PPOs, along with more open-ended delivery
systems in terms of physicians, pharmaceuticals and specialists."
Defined contribution. Another factor that ultimately might boost patients' access to infertility care is
the defined contribution benefits model. In this scenario, the patient can pick and choose from a menu
of benefits based on what he or she is willing to pay, with an employer's contribution potentially
covering 50% or more of that amount.
The defined contribution model hasn't taken off as quickly as it was expected to, however. That's
largely because in a tight labor market, employers might fear that offering such programs will be
perceived as taking away benefits. As a result, it might fall to other factors to help healthcare
consumers address infertility problems.
In 1998, the Supreme Court opened the door for patients to sue for infertility treatments under the
Americans with Disabilities Act by ruling that reproduction is a major life activity. More recently, three
bills regarding infertility treatments were introduced in Congress. Specifically, Senate bill S 2160 and
HR 2706 would, if passed, require all insurers to provide coverage for diagnosis and treatment within
specified limits.
The third bill, HR 2774, applies Only to federal employee plans. With Congress winding up this fall, it
would be virtually impossible for any of these measures to pass this year. "But the fact that three bills
were introduced in this session of Congress is great in itself," says RESOLVE's Wachenheim.
In contrast, the managed care industry remains wary of legislation. While the total impact of mandated
infertility care would be difficult to measure, few dispute that cost increases would be part of the
picture. When costs are prorated over an MCO's entire patient population, HealthPartners' Dr. Kopher
states, "in vitro fertilization alone is probably about $3 per member per month."
Nevertheless, insurers' experience in Massachusetts, which in 1987 passed one of the nation's most
comprehensive infertility coverage laws, suggests the price tag might not be as high as some
anticipate. An evaluation of one health plan's experience published in The Journal of Reproductive
Medicine in 1997 found that despite a utilization rate much higher than the U.S. average, annual cost
per employee was still about $3. A larger study of the state's insurers (published in Fertility and
Sterility in 1998) showed that despite an increase in coverage and utilization, expenditures didn't
outpace overall inflation. This was due to factors such as higher success rates and service discounts
achieved under managed care provider arrangements.
Such findings should provide relief to MCOs as they face continued pressure from patients. Just as
technical advances have spurred demand, Deborah Wachenheim, RESOLVE's government affairs
director, says that "infertility patients have become more active in terms of being advocates for
themselves and for the larger community of infertility patients," in part by making their wishes known
to their employers, insurers and legislators.
Thus she says that in the future, "I think that managed care companies are going to be hearing a lot
more from their members about the need for this kind of coverage."
~~~~~~~~
By John Jesitus
MCOs are left to distinguish between personal choice and medical necessity
Few healthcare decisions are as highly personal -- or as hotly debated -- as those related to infertility.
In this area, the American Society for Reproductive Medicine (ASRM) estimates that about 6.1 million
American women and their partners -- approximately 10% of the U.S. population that is of
reproducing age -- are infertile, a condition defined largely by the inability to conceive after trying to
do so for one year. * However, with infertility's causes split roughly evenly between male factors,
female factors, and those related to both partners or to unknown causes, identifying the exact nature
of a couple's problem can be a difficult and time-consuming process. Add to this the fact that
remedies such as in vitro fertilization can easily cost upwards of $10,000 per cycle with no guarantee
of success, and it's not hard to understand why patients to date have often faced an uphill climb in
accessing treatments.
"In a time of escalating costs, infertility has been taking hits because it can be expensive," says
Richard Kopher, MD, a reproductive endocrinologist with HealthPartners. "And although patients
would certainly take exception to this, it's viewed by some less as an illness than a semi-elective
treatment." Accordingly, he states, "Some underwriters and insurance plans say, 'This is something
we can do without.'"
To help patients overcome such sentiments, a total of 13 states presently mandate that health insurers
either offer or cover some level of infertility treatments (similar rules apply to plans seeking to be
federally qualified).
And according to an October 1999 report titled Drive for Insurance Coverage of Infertility Treatment
Raises Questions of Equity, Cost, current technologies can successfully treat more than half of
couples experiencing infertility. But despite this fact, the same report, published by the Alan
Guttmacher Institute, a New York-based research organization that studies reproductive issues,
asserts that most couples experiencing infertility do not seek or receive treatment.
Those that do seek treatment, on the other hand, often find that health plan policies and procedures
leave much to be desired. "Whether it be infertility or anything else, it seems HMOs aren't very
proactive in identifying what's not covered," says Taylor Ohlsen, president of Health Ready, an
Aurora, Colo.based firm that works through doctors to provide patients with financing for infertility
and other treatments. "I guess they see it as a negative to highlight what they don't cover," Ohlsen
says. "But it just leaves the patient to kind of stumble their way through finding what their options are."
Other common patient complaints center around how benefits are structured and administered. Diane
Clapp, national medical information director for RESOLVE: The National Infertility Assn., says, "It's
difficult for patients when there are requirements in terms of coming from the gynecologist or ob/gyn
to the specialists. In other words, patients may have to wait a number of months or they may have to
have certain tests done before proceeding. That can be a first-line frustration."
Once patients are involved in infertility treatments, she continues, "frequently if you're an HMO patient
you don't have much leeway in terms of seeking treatment or second opinions from other
reproductive endocrinologists in the field. And I think because this particular area of medicine is such
an art form, not a hard science, consumers really do want to see other doctors if treatment has been
unsuccessful."
Headaches for MCOs. Such desires can cause migraines for MCOs. As Sam Ho, MD, vice president
and corporate medical director for PacifiCare Health Systems, states, "Health plans have a fiduciary
responsibility for employers," who decide what level of service to offer their workers based on factors
including medical costs and premium levels. In such a scenario, Dr. Ho adds, "The role of the health
plan is figure out what is the basis for managing a benefit that has some finite expectations or pricing
around it, how to maximize the healthcare benefits within that budget, and where does infertility fit in
all that?"
As technological capabilities and consumer desires continue to converge, questions like the above
frequently yield few clear answers. On one hand sit naturally occurring problems like endometriosis.
In such cases, Dr. Ho says, "Maybe removing some of the endometriosis and some of the surgical
scarring which occurs as a medical consequence of the disease becomes a medically necessary
treatment so a couple can conceive. That makes sense."
Increasingly, however, the healthcare industry is confronted by patients whose infertility stems not so
much from medical matters as from personal choices. For example, in cases that involve reversing
voluntary sterilization procedures such as vasectomies and tubal ligations, Dr. Ho asks, "Since the
procedures were entered into voluntarily, is that something that would be reasonable to cover so that
they can conceive after changing their mind, so to speak?"
Similar issues arise when one considers single women and same-sex couples who pursue medical
assistance in conceiving children.
"At some point over the years, employers and purchasers of health plans have made decisions as to
what's a reasonable and affordable ground to stand on," Dr. Ho says.
"Having children or not having children is not an illness. So the compromise has been that if there are
medically related reasons that fertility has been prevented, then maybe we can treat those, but nothing
more than that because otherwise we are redefining the whole healthcare benefit" to potentially include
everything from cosmetic procedures to aromatherapy, he says. And in a culture that increasingly
wants coverage for lifestyle decisions, Dr. Ho says that "at some point, our society, not the health
plans or HMOs, is going to have to draw the line."
An age issue. Other challenges already affecting MCOs stem from changes in the age at which people
are choosing to bear children. In general, baby boomers have chosen to delay childbearing in order to
focus on their educations and careers. They're also more proactive about healthcare than their elders.
"Many individuals in the boomer generation are attempting conception in their mid- to late-30s and
early 40s," observes HealthPartners' Dr. Kopher. "The typical patient I see in my office is 42, just got
married, and wants to have babies. And it gets kind of hard at that age."
Due to natural inefficiencies, on average less than a third of patients age 40 and up are able to
conceive on their own within six to 12 months. This fact leaves large numbers of patients seeking
diagnostic services at the very least.
Fortunately for such people, employer attitudes -- while not exactly loosening -- aren't tightening as
much as they have in the past. That's largely because the strong U.S. economy has created a labor
market in which employee benefits represent an important tool for recruiting and retaining workers.
As part of the trend toward somewhat richer benefits packages, PacifiCare's Dr. Ho adds, "Many
employers are dropping HMOs entirely and just offering PPOs, along with more open-ended delivery
systems in terms of physicians, pharmaceuticals and specialists."
Defined contribution. Another factor that ultimately might boost patients' access to infertility care is
the defined contribution benefits model. In this scenario, the patient can pick and choose from a menu
of benefits based on what he or she is willing to pay, with an employer's contribution potentially
covering 50% or more of that amount.
The defined contribution model hasn't taken off as quickly as it was expected to, however. That's
largely because in a tight labor market, employers might fear that offering such programs will be
perceived as taking away benefits. As a result, it might fall to other factors to help healthcare
consumers address infertility problems.
In 1998, the Supreme Court opened the door for patients to sue for infertility treatments under the
Americans with Disabilities Act by ruling that reproduction is a major life activity. More recently, three
bills regarding infertility treatments were introduced in Congress. Specifically, Senate bill S 2160 and
HR 2706 would, if passed, require all insurers to provide coverage for diagnosis and treatment within
specified limits.
The third bill, HR 2774, applies Only to federal employee plans. With Congress winding up this fall, it
would be virtually impossible for any of these measures to pass this year. "But the fact that three bills
were introduced in this session of Congress is great in itself," says RESOLVE's Wachenheim.
In contrast, the managed care industry remains wary of legislation. While the total impact of mandated
infertility care would be difficult to measure, few dispute that cost increases would be part of the
picture. When costs are prorated over an MCO's entire patient population, HealthPartners' Dr. Kopher
states, "in vitro fertilization alone is probably about $3 per member per month."
Nevertheless, insurers' experience in Massachusetts, which in 1987 passed one of the nation's most
comprehensive infertility coverage laws, suggests the price tag might not be as high as some
anticipate. An evaluation of one health plan's experience published in The Journal of Reproductive
Medicine in 1997 found that despite a utilization rate much higher than the U.S. average, annual cost
per employee was still about $3. A larger study of the state's insurers (published in Fertility and
Sterility in 1998) showed that despite an increase in coverage and utilization, expenditures didn't
outpace overall inflation. This was due to factors such as higher success rates and service discounts
achieved under managed care provider arrangements.
Such findings should provide relief to MCOs as they face continued pressure from patients. Just as
technical advances have spurred demand, Deborah Wachenheim, RESOLVE's government affairs
director, says that "infertility patients have become more active in terms of being advocates for
themselves and for the larger community of infertility patients," in part by making their wishes known
to their employers, insurers and legislators.
Thus she says that in the future, "I think that managed care companies are going to be hearing a lot
more from their members about the need for this kind of coverage."
~~~~~~~~
By John Jesitus