Fertility and the New Employee Value Proposition

Employees switch employers for a variety of reasons – changing jobs because benefits were not good was one of the top five reasons employees cited for leaving in 2021.

In a survey by America’s Health Insurance Plans (AHIP), nearly half of respondents (46%) said the health plan was either a deciding factor, or a positive influence, in the decision to take their current job, and 56% reported health coverage was the reason they stayed.

Employers cite “staying competitive to recruit and retain top talent” as one of their top reasons for offering fertility and family planning benefits. Fifty-nine percent of employers indicate fertility coverage is necessary to compete in the labor market – and 68% of adults say they would switch jobs for better fertility benefits according to Barclay’s 2021 Healthcare Disruptive Series.

Historically, fertility and family building benefits have been limited. Early benefit designs put dollar caps on treatments, which not only stigmatizes the disease, but can lead providers and/or patients to choose to maximize their benefit by transferring multiple embryos to increase the odds of a successful pregnancy. This practice can lead to more multiple births that can, in turn, lead to high-risk pregnancies, costly c-section procedures, and costly NICU stays. Dollar cap designs can also lead to patients skipping vital tests or lab work to avoid hitting their spending cap.

Members typically have a separate cap on total medical and pharmacy spend, which can result in caps being met at different times. Offering fertility treatment with a cap on the benefit is unique to fertility – many other diseases don’t have dollar caps in place and don’t limit the benefit to specific groups within a population.

While employers who offer traditional, dollar caps on fertility and family building benefits are well-intentioned, they could be further stigmatizing infertility and creating stress for patients who are left to navigate restrictive plans on top of the already complex medical journey. Many plans don’t offer emotional support or personalized care navigation. The plans may also require the patients to pursue less effective fertility treatments, such as intrauterine insemination (IUI), before attempting more effective fertility treatments like in-vitro fertilization (IVF).

The fertility medication issue

Medications are integral to fertility treatments and are very costly, costing approximately $8,000 per treatment cycle. Most fertility medications are self-administered injectables that require a specialty pharmacy to fill the prescription.

As important of a role that medications play in an individual’s treatment plan, the process by which they are filled in the traditional fertility benefit model is also flawed. Multiple authorizations are often required for the member to receive the medications essential to their treatment plan: both from the insurance carrier and the pharmacy benefit manager.

Multiple authorizations cause delays in receipt of the prescriptions critical to the individual’s treatment. Delays of 10 days or more for approval and receipt of medications are not uncommon. Fertility treatments are particularly time sensitive. Delays of even a short duration can result in missed cycles, requiring individuals to put off treatment until the next menstrual cycle once they have the medications in hand.

The storage and administration of fertility medications is complex. Some medications require refrigeration, while others do not. Injections must be performed by the individual or their partner, who likely has little to no training on how to administer medications properly. Individuals often turn to online resources to help them through the process, but rarely have any dedicated resources available to them from the benefit provider should they have any questions about either the medications or how to administer them. Issues related to medication can further contribute to the anxiety felt by patients going through an already stressful process.

When first offering or enhancing a fertility benefit, it’s important to find a vendor who manages an integrated pharmacy program (where they can maintain waste management protocols to save money on medications) or one that can integrate with the current PBM for streamlined medication authorization, claims, and dispensing.

How Infertility Impacts Employers

When companies offer health care benefits for infertility, it is typically a one-time, fixed financial amount (e.g. $15,000 lifetime maximum per member for fertility treatment). This set dollar cap benefit can include complex medical protocols and pre-certification requirements. In some cases, the financial benefit is exhausted before a successful pregnancy is achieved.

In many cases, an employer chooses dollar cap benefit models because they are aiming to control costs. Employers need to understand that with a dollar cap benefit, the fertility spend is not always accurately identified in medical spend. If a dollar cap benefit model is in place, patients and their providers can often work around hitting those caps by coding services to medical (not fertility). This means employers are often paying much more for fertility services than they think.

Case in point: lab work and ultrasound services are often submitted (and paid) as general medical claims without an infertility diagnosis. For example, an IVF freeze-all may be billed separately from anesthesia and a frozen embryo transfer may be billed separately from a sonogram. In instances when the anesthesia and sonogram are rendered in conjunction with the fertility treatment but are billed to general medical (not fertility), employers are given an inaccurate view of their true fertility spend.

Dollar cap benefits also cause more stress and anxiety because they drive a scarcity mindset where members are required to fill out a financial attestation, spend time with billing coordinators, figure out how much services will cost, and keep track of care and cost all on their own. Members may opt for less costly, less effective fertility treatments or choose to forgo tests and technologies that can improve the likelihood of a healthy singleton pregnancy. Choosing to transfer multiple embryos in order to achieve pregnancy with fewer rounds of IVF can have costly results, including high-risk prenatal care, pregnancy complications, preterm deliveries, and NICU stays. This removes opportunities for evidence-based decision-making between a patient and their provider, and it presents a time-consuming and stressful situation for patients and employers.

The medical costs of multiple births compared to a single child are exponential in nature - $21,000 for a single child compared to $105,000 for twins and over $400,000 for triplets, with medical expenses for multiple births often exceeding $1 million. Multiple births can also contribute to decreased productivity and increased disability claims. Parents with multiples are at a 4.4x greater risk of being away from work longer because of extended hospital stays, additional medical care, and treatment for chronic conditions. Lost productivity related to preterm births represents $5.7 billion in costs.

Additionally, dollar cap benefits are inequitable. Different people need different treatments and levels of medication. Based on their home geography, some people may be able to afford more treatment than others. Lastly, by offering fertility with a dollar cap benefit as opposed to offering it the same way employers do other complex medical care furthers the stigma around fertility.

Employer Strategies

A Business Group on Health survey of large employers found that nearly 85% of large employers are planning to implement at least one strategy to support family building and women’s health, such as expanding fertility and family building benefits, ensuring coverage of prenatal care, or addressing postpartum depression.

But that doesn’t mean employers are taking on major additional costs. According to a Mercer survey, 97% of employers report adding infertility coverage did not result in a significant increase in medical plan costs.

There are a variety of fertility and family building benefit solutions on the market that may be offered through a health plan or point solution provider. Each solution varies in plan design, network type, member experience, pregnancy outcomes, and cost.

Benefit designs

Dollar cap benefit or reimbursement benefit

• Organizations have historically provided fertility benefits through a dollar cap benefit, offering medical and/or pharmacy treatment costs up to a lifetime maximum which can range between $5,000 and $100,000+ per employee.
• If done through a carrier, benefit services/treatment options vary depending on the plan and often require precertification or a diagnosis of infertility, and patients may be required to receive care from a very narrow network of providers. Other dollar cap benefits don’t have any limitations on care and allow patients to receive care from any provider, but as a result, lack utilization management tools to ensure patients are receiving the right care.
• Dollar cap benefits may not fully reimburse the cost of treatment and may prompt providers and/or patients to make treatment decisions based on cost instead of outcomes.
• If medications are included, members may need to use a wallet card to submit reimbursement expenses.
• While most carrier-based plans offer fertility benefits as a pre-tax benefit, some outside vendor plans only provide a post-tax benefit, which can create payroll and regulatory considerations.
• Dollar cap benefits are not best practice for complex conditions in healthcare and are not common outside of infertility. As a result, this requires patients learn a new healthcare model and it also can unintentionally treat fertility differently than other chronic diseases like cancer and diabetes.

Cycle-based solutions

• Typically bundles provider and laboratory services into a cycle that makes it easier to understand treatment and insurance options and ensures caps are not exhausted mid-treatment.
• Plans vary widely including what defines a “cycle.” To compare plans, it is important to understand what is and is not included, including treatments and technologies.
• If medications are included, members may need to use the carrier’s specialty or mail order pharmacy.
• Some benefit models cover only certain procedures and may not pay for medications, genetic testing, and other services, which are a critical and often costly component of treatment.

Network models

Curated and actively managed networks

• In this network model, the benefit solution contracts with individual providers to build their network, removing any conflict of interest that pushes patients to choose one clinic over another.
• The benefit solution also actively manages the providers in its network.
• Providers must adhere to rigorous standards of inclusion, go through a credentialing process, use the latest technologies, and employ best practices to be included in the network (or risk being removed from it). This ensures consistent provider quality, allows the benefit solution to have direct access to outcomes data for accurate reporting, and ensures the safest and most effective practices – such as single embryo transfer – are in place at their provider clinics.

Clinic-owned with a network layer

• Under this network model, the benefit solution owns a group of clinics and contracts with additional non-owned clinics to fill in geographic gaps in their network.
• When a benefit solution owns a clinic, they’re incentivized to drive as many patients to that clinic as possible. This creates an inherent conflict with non-owned clinics who have no incentive to join the network and won’t want to share data with their competitor.
• This also leaves patients with little choice or access in terms of which provider they can choose. Carrier network with Centers of Excellence (COEs)
• This is a common model offered by large insurance carriers or vendors. Like clinic-owned models, they drive patients to a select group of specialist providers known as “centers of excellence.”
• COEs are limited in location and variety, so they offer employees little access or choice when it comes to finding a provider.
• Many top fertility clinics avoid carrier networks because they generally take a one-size-fits-all approach, they require complicated pre-authorization and utilization reviews, and they have restrictive policies that make it hard for some groups to get care.

Discount network for reimbursement 

• This benefit is usually a post-tax reimbursement or a “wallet” of funds patients use at select providers.
• Discount network benefits rely on a dollar cap benefit that turns fertility into a financial decision instead of a medical one.
• They have no quality control when it comes to their provider network. They have no ability to capture outcomes data from providers and therefore ineffective reporting for clients.
• They may offer an expansive network, but since it’s a reimbursement that can be used anywhere, there is no way for a benefit offering this setup to guarantee service quality.