Evaluating Fertility and Family Building Solutions

When an employer is considering offering or expanding fertility and family building benefits, their health plan, benefits consultants, and solution providers can offer options and help direct decisions.

Employers are encouraged to review potential solutions carefully to ensure the benefit is comprehensive, equitable, and has demonstrated superior clinical outcomes. Managed, high-quality care saves money by requiring fewer, more efficacious treatments to achieve success, reduces downstream costs related to high-risk maternity and NICU stays, and attracts and retains valuable employees. To get a true picture of the cost of a fertility and family building benefit, employers should factor in the savings to the medical plan, such as a reduction in NICU costs related to premature or multiple births.

The solution should be well equipped to offer a variety of educational resources to engage members and provide employers with necessary reports – including actual outcomes. Benefits that offer supplemental education lead to better informed patients who can maximize their time with a provider – and quality reporting can give employers a full view of utilization, spend, and outcomes.

Ensuring Quality in Fertility Data

Understanding key fertility data points is critical when comparing solutions and evaluating outcomes. It is important that data comparisons are based on statistically significant data sets and real-time data is provided directly from providers, not “inferred” from claims.

Real-time data, right from the source: double-check data sources. Outcome data for fertility treatments is often inferred or estimated based on fertility claims after the fact. This can be misleading as some treatments may escape fertility coding in what’s known as “claims leakage,” meaning some rendered services for a particular fertility treatment are coded under general medical and not attributed to overall fertility spend. Take anesthesia, for example. If a patient undergoes an IVF treatment and the IVF procedure is coded to fertility while the required anesthesia is coded to general medical, the final tally for this fertility treatment will be inaccurate. Compound this across multiple claims, and it’s easy to see how claims leakage can quickly skew actual fertility spend.

Another downside to inferring outcomes from claims data is that a fertility treatment listed in claims data doesn’t necessarily mean that treatment was successful. Or, in the case where a member has a dollar cap benefit that they exhausted before they finished care – there would be no way to track that member’s final outcome. Look instead for data that comes directly from providers. Solutions who maintain a continuous data exchange with their provider network can offer valuable, accurate insights into actual outcomes, directly from the source. When benchmarking this data against national averages from the CDC (where fertility outcomes are mandatorily reported), employers can get a true sense of outcomes.

Statistically meaningful data: beyond data sources, consider the size of the data pool for case outcomes. Most solutions will provide a baseline for their outcomes measurements. IVF or IUI outcomes based on a pool of 1,000 cases could show a decent picture of outcomes, but those same figures derived from a pool of 10,000 or 20,000 cases are going to be much more statistically significant. Simply put, the larger the data set, the more reliable the outcomes story.

Benefit Plan Design

The key components of a managed fertility and family building benefit should include:

Accessibility for all members

Employers should ensure ALL members are able to access the benefit. It’s important to evaluate plan design and language to ensure there are no precertification or medical diagnosis requirements that would discriminate against single parents by choice, oncology patients, or members of the LGBTQIA+ community.

Dedicated support

For many, the path to parenthood is not easy and can be physically and emotionally taxing. It’s important to provide dedicated and personalized support that includes clinical education and guidance, emotional support, and assistance in directing members to high-quality care.

Culturally competent care

Every path to parenthood is unique. There are many cultural factors that can influence a patient’s fertility and family building experience. It’s important to ensure members have access to fertility providers who are as diverse as they are (which can be uncovered in an RFI or RFP process with a vendor).

High-quality, specialized provider network

Ensure members have access to high quality care through a managed network of reproductive endocrinologists, reproductive urologists, surgeons, and immunologists. Provider choice is critical to the member experience, including access to appropriate specialists as needed. Consider how the benefit provider is supporting best clinical practices and managing high-performing clinics.

Data-driven care

In addition to accurate reporting, benefits that have a real-time view into outcomes and treatment pathways can engage in early intervention with their members during crucial stages of treatment. For instance, if the vendor learns that a member has become pregnant, they can reach out to offer support or connect the member with pregnancy resources. This is also beneficial for patients who have underlying conditions that may make it hard to conceive or navigate a healthy pregnancy.

Benefits that have a continuous data exchange with their provider network can also have an influence on best practices within that network, allowing for more consistent care, high-quality treatments, and better clinical outcomes.

Demonstrated clinical outcomes

Clinical outcomes are the best indicators of fertility and family building success and an important driver of overall program savings and member satisfaction. Annually, fertility clinics across the U.S. send Assisted Reproductive Technology (ART) data to the CDC.

Employers should consider the following benchmarks when evaluating building benefits:

• Pregnancy rate per IVF transfer
• Miscarriage rate
• Retrievals per live birth
• Live birth rate
• Multiples rate
• Single embryo transfer rate

Clinics in a carrier’s network that meet or exceed benchmarks are considered high-performing fertility clinics.

Reporting

The family building benefit provider should provide actual outcomes data (not projections) specific to the employer's insured population as well as comparisons with CDC benchmarks.

Employer Action Steps

Use these Employer Action Steps to assess your populations’ needs; analyze data, evaluate current benefits strategy, and put an implementation plan in place.

For a downloadable version of the Employer Action Steps, click here.

Assess Your Population’s Needs

1. Ask employees about their fertility and family building benefit desires/concerns and whether the current fertility and family building benefit offerings (if there are any) satisfy their needs. Use surveys, study your population’s demographics, and review your claims data to get to the bottom of your employees’ needs.
2. Determine if those going through fertility care maxed out their medical and pharmacy benefits at different times using claims data and/or the carrier’s analysis/reports.
3. Consider the need for navigation and mental health benefits as well as accommodations for travel and time off because they are important components of a comprehensive fertility and family building benefit.

Use Data

1. Work with the carrier and/or consultant to determine if there’s a trend in NICU, high-cost maternity claims, and/or multiples births. This may point to a need to explore more comprehensive utilization management and cycle-based approaches to prevent multiple embryo transfers.
2. Use your claims data to determine the number of members accessing fertility benefits under your current structure as well as the incidence of multiple and/or premature births within this group.
3. Analyze how many members maxed out their fertility benefit without resulting in a pregnancy.
4. Calculate the costs associated with IVF under the current plan, including costs associated with premature and/or multiple births - remember some of the costs may be reflected in medical claims.
5. Benchmark the data against national averages from the CDC NASS 3.0 (National Assisted Reproductive Technology Surveillance System). Employers can pull outcomes data from their current carrier or provider and check how the data compares to national averages. Current vendors or carriers as well as potential partners should be able to provide this information.
6. Ask potential vendor partners to use real data to demonstrate how they could improve the fertility experience for your covered population.

Review Current Benefit Plan Design

1. If you have a fertility benefit in place, seek to understand if your current structure excludes members of populations who desire fertility but don’t fit into a “traditional” family model like the LBGTQIA+ community, single parents by choice, and those undergoing oncology treatment. Review summary plan definitions for eligibility requirements that may leave out employees, spouses, and dependents (those getting oncology treatment) that don’t meet the clinical definition of infertility – typically predicated on heterosexual family forming. Ask about step-therapy requirements, excluded services, and the out-of-pocket expectations of employees as a result.
2. Consider the needs of diverse employee groups, the benefits of offering mental health services, access to navigation advocates and additional benefits for surrogacy, adoption, and foster care.
3. Understand what is covered – procedures, medications, genetic testing, etc.
4. Ensure members have access to high-quality care through a managed network of reproductive endocrinologists, urologists, and specialty labs.
5. Evaluate what coverage is provided for male infertility testing and treatment.
6. Review differences in member experiences and coverage based on carrier, particularly if there are multiple carriers.
7. Understand what geographic and/or socioeconomic barriers to care may exist.
8. Determine if fertility benefits include proper accommodations, including travel assistance, time-off, leave policies, and bereavement time, if necessary.
9. Check to see if the plan encourages evidence-based care decisions and access to best-in-class providers and facilities within the network.
10. Analyze if the level of maternity coaching and education offered supports a continuous member experience.
11. Consider if specialized perimenopause and menopause care is offered to address the impact of hormonal changes on stages of family building and/or quality of life – with varied severity of symptoms often surprising employees in their 30’s and 40’s.

Choose the Right Vendor Partners

1. Ask potential partners to use plan data to demonstrate how their solution will improve outcomes and reduce medical spend, provide access to best-in-class providers, and personalize and improve the journey for the plan’s members.
2. Define clear outcomes data needs and make sure reporting is consistent, comes from members’ treatment cycles (not the vendor’s selected population), and includes more than just attaining a successful pregnancy.
3. Ensure cross referrals can be made between medical and point solutions, IVF vendors, EAPs, and leave partners.
4. Evaluate network relationships and level of quality management to ensure a consistent member experience.
5. Assess whether the vendor has the expertise to help establish pre-tax and post-tax aspects of plan design across fertility and family building services.
6. Weigh the member experience and treatment outcomes of a dollar cap reimbursement model versus a cycle-based solution. Have your vendor partners explain the differences in service models.
7. Consider benefit enhancements, such as adoption and surrogacy reimbursement, pregnancy care, postpartum support, doula reimbursement, travel, and specialty care for common conditions.
8. Look for vendors who are transparent about the financial aspects of the partnership, including pricing, estimated costs, and savings. Ask them to demonstrate how they can reduce the medical spend.
9. Ask vendors to share information on how they’ve worked with similar clients and how they can improve the patient journey for your members. Be sure to ask about their client renewal rate, as high renewals indicate client satisfaction with the vendor’s service.
10. Determine if vendor partners can close any gaps found when reviewing the current benefit design.
11. Ensure they can accommodate the diverse needs of your population.

Have An Implementation Plan

1. Ensure the vendor has an implementation plan in place, including transition of care for employees transitioning from a previous benefit and they properly integrate with other benefit partners and key stakeholders, i.e. navigation vendors, EAP, leave partners, and PBM if the pharmacy benefit is not integrated with fertility benefit.
2. Make sure all systems are updated as necessary. Educate internal stakeholders (payroll and managers) and external partners (EAP and leave administrators) to ensure they are aware and ready to support the benefit.
3. If applicable, determine how a patient’s past use of fertility effects the use of a new benefit offering. For example, if an employee previously maxed out their benefit, do they start over, or do past cycles count towards new caps?
4. Keep the program fresh by modifying and updating messages and using a variety of creative communication and educational mediums. Track the effectiveness of these communications and refresh your strategy regularly to keep the message fresh.

Continually Evaluate Your Plan

1. Once a benefit is in place (or if one has already been in place), define and review success metrics including increased employee satisfaction, savings, pregnancy rates, live birth rates, productivity, and singleton pregnancy rates. Other success metrics include reduced rates of premature births, costly NICU stays, and absenteeism. Other metrics include increased satisfaction of equity goals and recruitment and retention improvement. These metrics should be based on your specific population and results should be those of the population and not based on estimates or projections.
2. Measure whether the solution is saving money (including downstream costs).
3. Ask the vendor partner to collect (anonymous) input from those who used/are using the benefit for their level of satisfaction with the offering, including how their patient journey was impacted – positively or negatively.
4. Review offerings regularly and adjust as needed. Involve your partners in making improvements. Don’t be afraid to change course.
5. Take time to celebrate the successes and new families in your organization.

Employer Case Studies