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Page 3: Paying the price for infertility

The case of Aetna: What happens when you have something everyone wants?

Aetna U.S. Healthcare was a pioneer among insurance companies, choosing to offer expensive infertility coverage in a basic benefits package sold to employers.

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In January 1995, Aetna says it became the only U.S. insurer to offer advanced reproductive technology (ART) in its basic HMO and POS plans. Thus, any employer that purchased Aetna's basic plan was able to automatically secure coverage for such high-tech infertility treatments as in vitro fertilization (IVF), gamete intrafallopian transfer (GIFT), and zygote intrafallopian transfer (ZIFT) — treatments that cost upward of $10,000 for each attempt.

An infertility primer

The honeymoon lasted three years. Aetna got more than it bargained for. Countless couples desperate for coverage apparently persuaded their employers to purchase Aetna's basic plan — offered only as a group health benefit, not as an individual policy — so that they could take advantage of the costly infertility treatments. And they did, en masse. And so in April 1998, Aetna dropped ART coverage from its basic plan (except in states that mandate such coverage for all insurance plans).

Today, the company won't come right out and say it was "swamped," but it does concede that people chose the plan solely for the infertility benefits. "Obviously, we were hoping other insurers would be offering this benefit, and that never happened," says Aetna spokesperson Betsy Sell. "People would join the plan just to access that particular benefit."

How did Aetna know that? "When somebody joins the plan and leaves right after using the infertility services," Sell explains. "One of the things managed care companies stress is getting members in for the long term. When someone leaves after a year or so, the preventive and wellness programs we have in place don't have the full effect for them."

Cost was an issue, too, of course, although Aetna is reluctant to admit its decision to yank ART coverage from the basic plan had anything to do with expense, and it won't release any figures. "It is a benefit that is certainly more expensive," Sell says.

Aetna took it on the chin when it dropped ART. Two consumer advocacy groups — Resolve (the National Infertility Association) and the American Society for Reproductive Medicine (ASRM) — publicly blasted the company, calling it irresponsible and contending its decision was as arbitrary as deciding to cover a patient's broken right leg, but not the left leg.

Just a week after Aetna announced it was dropping ART services from its basic plan, the company said it would still provide coverage of ART through a rider that employers could purchase for extra money. At the time, company president Michael J. Cardillo said decisions about which benefits to purchase should be made by the employers who must fund them, not the insurance companies. Aetna's basic group health plan still provides coverage for some infertility treatments, such as surgery, medications, and artificial insemination.

CIGNA follows Aetna's lead

CIGNA, too, offers infertility coverage as a rider that employers can buy only in addition to a regular health insurance plan. The cost of the rider depends on the particular contract with each employer. Employers set the co-pay cost and can establish limits on how many trials of certain procedures will be offered.

"If employers want infertility coverage in their health plans, they'll get it."

While unhappy with Aetna's ART decision and the lack of widespread insurance coverage for infertility, ASRM spokesman Sean Tipton says the finger of blame must also be pointed at employers. "Coverage isn't driven by insurers nearly as much as it's driven by employers," he says. "If employers want infertility coverage in their health plans, they'll get it."

 

Study shows benefits may actually reduce costs

In 1997, William M. Mercer Inc. issued a revealing study, "Infertility as a Covered Benefit," undertaken at the behest of the firm's corporate clients considering offering infertility services. "Offering a comprehensive infertility treatment benefit with appropriate utilization controls may actually reduce costs and improve outcomes by eliminating the use of costly, inappropriate, 'covered' procedures and allowing specialists to use the most effective, efficient treatment for a specific type of infertility," the study concludes.

The study notes that in 1995, about one-quarter of companies with 10 or more employees provided coverage for infertility treatment, and that such coverage is most prevalent in the Midwest and Northeast. Of large employers with HMO plans, it says, 22 percent offer some sort of infertility benefits.

Mercer estimates that the cost of adding in vitro fertilization (IVF) treatment to a standard benefits package in 1995 would add $3.14 to the premium per member per year. And adding ART would cost $2.49 per member per year. The study even takes into account that costs could rise if infertility treatments led to multiple births — not an unusual event when women take fertility drugs. The study says that additional costs resulting from the increased incidence of triplets as a result of ART, including the obstetric and neonatal charges, would be just 67 cents per member per year.

Adding a managed care component — that is, setting controls about which treatments are appropriate for which patients — would reduce the costs even more, the study says. That's because the reduction in the use of high-cost procedures like tubal surgery would offset the cost of including IVF as a covered benefit and improve success rates. Back to Page 1.

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