Insurance Coverage Concerns: In Vitro Fertilization and Intrauterine Insemination

Since the first baby was born via in vitro fertilization (IVF) in July 1978, the procedure has become more common and more accepted throughout the world for women suffering from infertility. In 2013, the Pew Research Center released a report that found 12% of survey respondents considered IVF morally wrong, 33% considered it morally acceptable, and 46% did not consider it a moral issue.

IVF is the main type of assisted reproductive technology (ART) that the Centers for Disease Control and Prevention (CDC) defines as fertility treatments, in which the eggs and sperm are handled outside of the body. In 2012, there were 176,247 ART cycles performed at 456 clinics in the United States that resulted in 65,160 live births, according to the CDC. That same year, the Society for Assisted Reproductive Technology said there were 165,172 ART procedures resulting in 61,740 live births and that 99% of the procedures were IVF.

Cost Analysis
Still, IVF has not received widespread health insurance coverage because of its high costs. Payers are more likely to cover intrauterine insemination (IUI), which is cheaper and less complex than IVF. The American Society of Reproductive Medicine lists the price of an IVF cycle as $12,400. A survey from Resolve: The National Infertility Association found that the average cost of an IUI cycle was $865 compared with $8158 for an IVF cycle using fresh embryos but not accounting for the costs of medications.

Although the upfront costs of IVF are higher, Barbara Collura, chief executive offer, Resolve, said IUI leads to more multiple births and more side effects and that changes in IVF procedures have led to fewer complications. According to a recent article published in New England Journal of Medicine, there was a 70% reduction in the transfer of ≥3 embryos during IVF from 1998 to 2011 (P<.001) and a 33% decrease in the proportion of triplet and higher-order births attributed to IVF (P<.001) during the same period [2013;369:2218-2225].

“It is so goofy to us that insurers are very happy to cover the downstream costs of multiple births [related to IUI], whether that is prenatal care, bed rest, hospitalization, premature birth, all of the potential risks,” Ms. Collura said in an interview with First Report Managed Care. “They are going to cover all of those expenses, but they are not going to cover the procedure that is better controlled, which is IVF, than artificial insemination and that has a far lower multiple births rate.”

Infertility Rates on the Decline?
The World Health Organization defines infertility as a reproductive system disease in which women cannot get pregnant after ≥12 months of regular unprotected sexual intercourse. It also refers to women who cannot get pregnant, cannot maintain a pregnancy, or cannot carry a pregnancy to live birth. In addition to IVF and IUI, other treatment options for infertility include surgery and medications women can take to produce ovulation.

A survey from the National Center for Health Statistics found that 1.5 million married women between 15 and 44 years of age (6% of that population) were infertile between 2006 and 2010, down from 2.4 million women (8.5% of that population) in 1982. From 2006 to 2010, 12% of women in that age category had impaired fecundity, which was defined as physical difficulty getting pregnant or difficulty carrying a pregnancy to live birth. The impaired fecundity rates were 11% in 1982 and 15% in 2002.

A CDC preliminary report from 2011 found there was a 40% success rate of ART leading to live birth in women <35 years of age. The success rate was 32% for women 35 to 37 years of age, 22% for women 38 to 40 years of age, 12% for women 41 to 42 years of age, 5% for women 43 to 44 years of age, and 1% for women ≥44 years of age.

Fifteen states have mandates to cover or offer fertility treatment to some degree, but only 6 have mandatory, comprehensive IVF coverage: Connecticut, Illinois, Maryland, Massachusetts, New Jersey, and Rhode Island. Arkansas and Hawaii also have limited IVF mandates (Table). Companies offering self-insured health plans are exempt from the mandates, as legislated in the Employment Retirement Income and Security Act of 1974. With health plans typically covering IUI but not IVF, most people cannot afford IVF.

“[IUI] is done in a completely uncontrolled environment,” Ms. Collura said. “You have no idea what is going to happen and how many embryos are going to be created. Everybody is completely in the dark. You have insurance plans that are saying, ‘We are not going to cover IVF at all,’ so patients [say], ‘Well, I will do a million artificial inseminations because I cannot afford the IVF.’ Or you have plans that say, ‘The only way we will cover IVF is if you do so many cycles of artificial insemination.’ All of these are ways that insurers are pushing people toward artificial insemination whether they have tried to or not, and so patients are left with little options, to be quite honest.”

Legislative Efforts
Advocates have pushed for more IVF coverage, but their recent efforts have been denied in a few states. For instance, bills in the Pennsylvania and Missouri legislatures regarding infertility and IVF did not pass. In October 2013, California governor Jerry Brown signed a bill into law that protected infertility insurance coverage decisions for homosexuals, although he vetoed a bill that mandated fertility preservation to freeze embryos, eggs, or sperm for patients with cancer and other diseases.

The Patient Protection and Affordable Care Act also does not require coverage for infertility treatments.

“There [have] certainly been a few things bubbling up as it relates to infertility and IVF, but it has not gotten very far,” Ms. Collura said. “I think the biggest obstacle that we are facing is a lack of knowledge regarding what the research is showing. I think there are a lot of opportunities for insurers and managed care companies to sit down with physicians in the community and really become better educated about what is going on and how we can produce better outcomes.”

In May 2013, similar bills were introduced in the Senate and House of Representatives. The legislation, sponsored by 2 Democratic senators and 56 Democrats in the House of Representatives, would amend the Internal Revenue Code and allow for a tax credit for out-of-pocket costs related to IVF and fertility preservation if a person is diagnosed with infertility and the procedure is performed by a licensed physician, surgeon, or other medical practitioner.

If the legislation does not pass Congress by December, it will not be law. Still, infertility is likely to remain a major issue and receive attention, as more people are willing to discuss what was once a taboo subject.

“We feel infertility [is] affecting women at all ages,” Ms. Collura said. “What we are seeing, frankly, is just more people being open and talking about it, whether they are in their 20s or 30s or are waiting until later in life. I really think that we are seeing people of all ages speaking out.”—Tim Casey