Sarah Patterson, a 27-year-old nurse, suffered four miscarriages over the last four years because of several medical problems, including a condition that causes cysts to form on the ovaries. After her second loss, she said, her husband asked for a divorce because he could not handle the stress.
"I was heartbroken and devastated," said Ms. Patterson, her voice quavering as she began to cry. "It took me about six months or so before I decided I am going to be a mom, whether I am on my own or whether I had a partner by my side."
Though young, Ms. Patterson said she felt a sense of urgency because one o f her conditions had the potential to deplete her egg reserves. Her doctor recommended in vitro fertilization, in which an egg is fertilized with sperm in a lab and transferred into the uterus. Her health insurance, through the California exchange, does not cover infertility, so she is working extra shifts to save the estimated $15,000 to $25,000 it will cost her for just one cycle of I.V.F.
She said transferring two embryos into her uterus at once could improve her chances of becoming pregnant and perhaps save her money. But carrying multiple babies has extra risks. "A high-risk pregnancy scares me," said Ms. Patterson, who lives in Southern California.
As many people with fertility issues quickly learn — 7.4 million women used infertility services from 2006 to 2010 — few employers and insurers pay for many procedures, including in vitro fertilization. Though 65 percent of businesses with more than 500 employees will pay for an initial evaluation by a fertility specialist, just 27 percent cover in vitro fertilization, according to a 2013 study conducted by Mercer, a consulting firm. (That number was 23 percent in 2012.) Drug therapies were covered by 41 percent of large employers, according to the study.
And although 15 states require insurers to provide some degree of infertility coverage or offer the option of coverage to those buying plans, many of those mandates impose restrictions on who can qualify, raising questions about who should be covered by infertility insurance.
In Arkansas, Hawaii, Maryland and Texas, for instance, coverage is required only if a woman's eggs are fertilized with her spouse's sperm, according to Resolve, a consumer advocacy group, which lists all of the states' requirements. So single women, unmarried partners, men with sperm issues and married lesbians with medical conditions causing infertility are exclude d.
Some large insurers' standard definitions of infertility appear to be more inclusive. They cover people regardless of their relationship status, as long as their infertility is the result of a medical problem. One common definition says a patient is deemed infertile if she fails to achieve or sustain a pregnancy after a year of trying naturally, or through a certain number of attempts at artificial insemination at her own expense. (Aetna makes women try a dozen times if they are under 35, while Cigna requires six attempts.) But these insurers do not go as far as covering, say, women without fertility problems who for one reason or another are using donor sperm.
And plenty of insurance policies exclude gay couples and single women — particularly those who have trouble getting pregnant through artificial insemination — because they define infertility as an inability to become pregnant through sexual intercourse, according to Cathy Sakimura, family law director and supervising lawyer at the National Center for Lesbian Rights. (But she said some medical procedures, like correcting a blocked fallopian tube that compromised fertility, would often be covered.)
Of the states that mandate coverage, only eight — Arkansas, Connecticut, Hawaii, Illinois, Maryland, Massachusetts, New Jersey and Rhode Island — require some level of coverage for in vitro fertilization, according to Resolve. (All of the state mandates typically apply only to health plans regulated by the state. Large employers, which are typically self-insured, are not subject to the rules because they are federally regulated.)
Some states also make patients wait very long and seemingly medically unsound periods before qualifying for benefits for a condition in which the passage of time can be damaging. Hawaii requires a five-year history of infertility, according to Resolve, while several other states require a two-year history. And in New York, fertility patients must be covered by their insurance for at least a year before receiving coverage. (Group policies are required to cover certain diagnostics, but New York does not require insurers to cover in vitro fertilization.)
The mandates "are really old, outdated and they need attention," said Barbara Collura, chief executive of Resolve.
The Affordable Care Act did little to expand infertility coverage, experts said. While exchange plans require coverage of certain essential benefits, the act allows the states to define those terms. "In states that do not require plans to cover infertility, they rarely do," said Karen Davenport, director of health policy at the National Women's Law Center. "They are mostly doing the minimum."
The lack of insurance coverage often leads some women to take risks that will increase their chances of becoming pregnant, fertility experts say. Not only are they aching for a successful pregnancy, most do not have limitless money to spend on multiple in vitro fertilization cycles.
So some women choose to trans fer more than one embryo a cycle (which may be recommended for older women), hoping that at least one will be successful. But in the long run, some infertility experts say, this costs the insurers more money because women may choose clinics or options, like transferring too many embryos, which may not necessarily produce the best results. Having multiple babies increases health risks for the mother and children and often requires more costly medical care after birth.
"If you are paying out of pocket, you are pretty desperate to have that cycle work when you've paid $15,000 into an I.V.F. cycle," said Dr. Bradley Van Voorhis, director of the division of reproductive endocrinology and infertility at the University of Iowa Carver College of Medicine. "Although it appears to be an attractive proposition, what many couples fail to understand are the risks of prematurit y, including long-term health consequences and large increases in health care costs."
But some employers may be beginning to think longer-term as they see higher-cost claims associated with multiple births, which carry a higher risk of prematurity, cesarean sections, a need for neonatal intensive care and other complications. Brenna Haviland Shebel, a director at the National Business Group on Health, a membership organization of large employers, is researching infertility coverage on behalf of large employers. Some of those employers are thinking about adding coverage or at least providing services that help members select providers.
The reason, in large part, is to help control costs and improve results, she said. Employers may steer their employees to high-quality infertility clinics, including those that favor implan ting only one embryo in hopes of producing a single, healthy baby.
Aetna introduced a program along those lines last year for women whose policies already cover in vitro fertilization. The insurer said it would cover the entire cost of the first I.V.F cycle if one embryo was transferred instead of two or more. If that attempt fails, it will cover the cost of a second attempt using a single frozen embryo. (If the woman's plan limits the number of cycles covered, the second attempt will not count against that limit.)
The insurer said this approach tried to strike the right balance between success and safety.
That is precisely the balance most people are trying to strike as well, while shou ldering the costs entirely on their own. "What is the role of insurance?" asked Ms. Collura, of the advocacy group, Resolve. "Those are ethical questions. Those are medical questions. Those are societal questions."
0 comments:
Post a Comment