Hidden costs of infertility treatment in employee health benefits plans.

OBJECTIVES: Many employers exclude infertility treatment from coverage under their health benefits plans. However, infertility treatment is often provided under other diagnoses or in association with therapy rendered for other disease processes. This study attempted to estimate those hidden costs and to determine what the impact would be of providing coverage for infertility treatment. STUDY
DESIGN: A 1-year retrospective analysis was carried out to isolate the hidden costs of infertility treatment from specific medical claims data gathered from a large representative employer with no infertility benefit provided. Data were analyzed in the context of the claims experience of a health plan covering approximately 28,000 employees. Infertility treatment was excluded under this plan. Medical claims for specific procedures and diagnoses in 1996 were analyzed by using Current Procedural Terminology codes in conjunction with International Classification of Diseases, Ninth Revision codes to estimate the hidden costs of infertility treatment. Forty-one Current Procedural Terminology codes and 68 International Classification of Diseases, Ninth Revision codes were used for the analysis. Clinical practice experience was used to set boundaries (conservative and moderate estimate) regarding the likelihood of a given treatment being associated with infertility. This was compared with 100% covered charges to generate claims per employee per month. Procedures covered operative, diagnostic, and laboratory services. These figures were used to compute a range of cost for infertility treatment per member per month.
RESULTS: Forty-one Current Procedural Terminology codes were identified that indicated possible infertility treatment. These covered the areas of laparoscopic and hysteroscopic surgery, lysis of adhesions, neosalpingostomy, cyst drainage, oocyte retrieval or embryo transfer, echography, and various hormonal analyses. Sixty-eight International Classification of Diseases, Ninth Revision codes indicated the possibility of infertility treatment. These included endocrine disorders, various uterine pathologic conditions, pelvic pain, endometriosis, pregnancy loss, irregular menses, and various ovulatory dysfunctions. The retrospective analysis found that 35 Current Procedural Terminology codes were involved in claims highly indicative of infertility services, such as 56353, hysteroscopic division of uterine septum, and 58345, transcervical fallopian tube catheterization. According to the 35 Current Procedural Terminology codes, $603,807.95 would have been paid if 100% of the charges had been covered; this would have resulted in a claim per employee per month of $1.12 by conservative estimate to $0.60 by moderate estimate. Computed cost figures per member per month showed the hidden costs of infertility to range between $0.27 and $0.50.
CONCLUSION: On the basis of various cost studies, rate filings, and employee data, the cost of providing coverage for infertility treatment has previously been shown to vary between $0.20 and $2.00 per member per month. Through appropriate cost sharing, managed care, and algorithms, infertility coverage can be offered at a cost of $0.40 to $0.50 per member per month. This analysis indicates that at least some employers already pay this much even when infertility is specifically excluded under the plan.