The cost of infertility is becoming higher; another insurer turns away
Aetna discontinuing coverage of advanced treatment
When stockholders recently conveyed to Aetna one of the nation’s largest health insurers that they wanted a higher return on their investment, Aetna quickly reacted. The impact was felt at advanced reproductive technology centers across the country.
Aetna’s answer to lowering costs is for their U.S. Healthcare plan to eliminate coverage for advanced fertility treatments effective April 1, 1998. But many physicians, patients, women’s health centers, and advocacy groups say this is not only a poor health care decision, but a bad business decision as well.
"We’ve communicated to Aetna the importance of them continuing to provide the benefit for advanced fertility treatment. As a result, we’ve seen some backing off of their decision due to public pressure," says Sean Tipton, public affairs administrator at the American Society for Reproductive Medicine in Washington, DC.
Leaders of Resolve also contacted Aetna with their concerns. Resolve is a Somerville, MA-based national advocacy, support, and education group for people experiencing infertility.
As a result of consumer complaints, Aetna responded that it would make coverage available through an optional rider in which employers can pay extra to make the benefit available to employees. But opponents say this is impractical.
"Since this will be offered to such a small consumer base, it will be too expensive, so employers will probably not support it," says Stephen Corson, MD, reproductive endocrinologist, director of Pennsylvania Reproductive Associates in Philadelphia, and a clinical professor of obstetrics and gynecology at Thomas Jefferson University School of Medicine in Philadelphia.
Aetna defends its decision. Company officials cite the high cost of treatment in this $2.6 billion industry, that infertility treatments are not a medical necessity, and that more infertile couples gravitated to Aetna since it had one of the only health care plans that covered advanced infertility treatments. This, in turn, placed an unfair burden on their company vs. other insurance companies, they said. (For more information on the high cost of treating infertility, see Women’s Health Center Management, July 1997, p. 81.)
An industry’s responsibility
While advocates of infertility treatments are sympathetic to Aetna’s complaints, their answer is not for Aetna to drop coverage, but for other insurance companies to take responsibility by also offering the benefit. "It’s unfortunate that U.S. Healthcare is taking away a program that worked," says Corson. "But in all fairness, it’s the only company that offered this coverage for a large group of subscribers. As a result, they had a larger number of users compared to other insurers. Insurance companies that have never covered advanced infertility treatments are the ones that ought to be criticized."
Deborah Wachenheim, MPP, director of government affairs for Resolve, agrees. "We recognize that Aetna U.S. Healthcare took a leadership role in the insurance industry by voluntarily offering comprehensive coverage for infertility treatment unlike many other insurers, which either do not provide coverage or only do so because of some state laws that require insurance companies to offer employers the opportunity to buy coverage." (See list, p. 32.)
It’s unfair for one company to bear burden
But since Aetna had served previously as an industry role model by providing coverage, now that they are eliminating this benefit, they are instead sending a negative message to other insurers.
"We’re concerned that since Aetna has been a model company in covering infertility, other insurers now may rethink covering it when they see a large company pull back," Wachenheim says.
Aetna had been demonstrating what all carriers should do, Corson says. "And if they had continued this coverage, other insurers would have had to follow suit to stay competitive," he says.
Tipton adds, "Clearly, this is indicative of the entire insurance problem." He agrees that a few insurers should not have to carry the burden for the entire industry. For that reason, the American Society for Reproductive Medicine is lobbying Congress to pass legislation this year requiring all health plans in every state to provide coverage for fertility treatments.
Good business sense
It’s important to cover assisted reproductive technologies because insurance companies ultimately pay and pay more if they don’t, Tipton says. For example, health insurance pays for obstetric and pediatric services, which are affected by the decisions infertile couples may make if faced with large out-of-pocket costs.
"If a couple dealing with infertility has to pay for treatment themselves, then most likely they’re going to have one shot at pregnancy due to financial constraints," he says. "That places pressure on physicians to transfer a higher number of embryos to increase the chances of pregnancy, and thereby increasing the chance for multiple births. So a couple is having to choose between having no children and the risk of having triplets and most couples will choose triplets rather than none at all."
If a woman is pregnant with triplets, then she most likely will be put on bed rest or in the hospital, Tipton says. "In addition, her risk of complications and the amount of care she needs are much higher and insurance pays for all of this. We would contend that this shows poor business sense on the side of insurance companies."
Cost and benefit data have shown that across the board, the cost per member per year to cover advanced fertility treatments is less than $3, Tipton says."Even Aetna can’t say how much savings they will have from dropping insurance coverage for infertility treatments," adds Wachenheim.
The price is high for a treatment that few are covered for, placing a great financial burden primarily on the patients. Advanced fertility treatments cost in the range of $6,000 to $8,000 per cycle, with drugs costing about $2,000.
Ann Bowen, RNC, BSN, perinatal case manager of Women’s Center of Cox Health Systems in Springfield, MO, says the majority of patients at her center are not covered for infertility treatments by their insurance carriers.
"We’ve seen insurance cover a portion of the diagnosis but not treatment," she says. "It depends on how it’s diagnosed and the physician’s wording on the insurance claim, or if there are other contributing problems influencing infertility. But once a couple sees an endocrinologist, insurance refuses coverage."
Bowen suggests that insurance should at least pay for diagnostic testing to give couples adequate information for making a decision about childbearing.
"When a couple has been trying to conceive for years, they need to know what’s going on," Bowen says. "Then they can decide what option to take, whether it’s to accept living child-free, look into adoption, or try advanced fertility treatments. It’s a tough decision with any of these options."
Either couples have a good insurance policy, or they find a way to pay for infertility treatment, Tipton says. "People get very resourceful because the desire to have children is so strong. They work additional jobs and/or make personal financial sacrifices."
Plan of action
Advocates for infertility treatment said the answer to the insurance quandary is to pressure the industry for change, whether it be consumer-driven or policy-driven.
"The most important thing is creating public pressure to emphasize that fertility is a legitimate, serious disease," says Tipton. He encourages women’s health centers and their patients to support upcoming federal legislation requiring insurance coverage of infertility treatments. "Get politically active," he advises. "Work with the American Society for Reproductive Medicine and your local chapter of Resolve. Contact your Congressional representatives."
Help patients understand what’s covered
Tipton also recommends that women’s health centers work with patients to help them understand what their insurance covers. Corson says patients need to discuss their concerns with their employers and their company’s insurance representatives.
"Part of the reason insurance companies feel they can get away with this is because there’s still a stigma attached to infertility," Tipton explains. "We need to have more people talking about it. The number of people battling infertility is higher than many other diseases that insurance does cover and that are not as personally devastating."
Other diseases that are successfully treated often have patients who remain strong advocates, he says. "This is less likely the case with infertility, in which many couples want to close that chapter of the book’ and get on with their lives," he says.
Women’s centers also need to advocate for clients by being well-informed about their options, including adoption, says Bowen, who is also the coordinator for her local chapter of Resolve.
"Adoption benefits are another thing employers need to look into providing maternity leave and eligible adoption reimbursements," she says. "This is already a growing trend among many top corporations."
With enough pressure, Aetna will rethink its policy on covering fertility treatments, Corson says. "True, they are responsible to stockholders, but we’re talking about something that’s a couple of dollars a year. That’s not much."
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