October 12, 2005
Medical Necessity
Inspired by the debate on Health Business Blog, and mainly the comments between Susan and Hgstern.
The question is: Is infertility considered medical necessary for health care coverage?
It depends on how you define medical necessity. If you define it as needing treatment or you will die, no, infertility is not medical necessary. But by that definition, reconstructive surgery following a mastectomy is not medically necessary either. But thanks to the Women's Health and Cancer Rights Act of 1998, it is federally mandated that reconstructive surgery be covered not only on the breast where the mastectomy was preformed, but also on the other breast to achieve symmetrical appearance if the plan covers mastectomy. Is this a bad thing? I think not. Will you die without reconstruction? No. Will it severly effect your quality of life? Certainly.
It is the same with infertility. You won't die without fertility treatments, although, there is an increased risk of breast cancer in women who do not have children or have their first child after 30. (Interesting note, that article shows that multiples reduce the risk of breast cancer)
Personally, I don't believe in insurance companies reviewing for medical necessity at all. I think that treatment needs to be left up to the patient and the provider. Particularly if you are working within a network of providers approved by the insurance company. It's a bit underhanded to have a provider in network then not trust them to provide the best care for the patient. I feel especially qualified to have this opinion since it was my job for two years to determine what was and wasn't medically necessary for an insurance company. And let me tell you, I left every day feeling that we weren't doing what was right for the patients.
For one, the process leaves a bit too much to interpretation. Yes, there are guidelines, policies, and criteria that are used. But each person can have a different interpretation. Even if something is orginally determined to not be medically necessary, often on appeal it is overturned when a different physician reviews it.
I understand how an insurance company could consider infertility treatments as not medical necessary. However, it is a quality of life issue for many people, just like the reconstruction following a mastectomy. I think the bigger problem is that they are limiting coverage based on diagnosis. Many make the argument that infertility coverage is too expensive. However, Resolve has found that in Massachusetts (which has a mandate) infertility was one of the lowest costs, only $2.49 per member per year. And if the complaint is cost, I would bet that a cancer diagnosis would be pretty darn expensive too. Yet you never hear of a insurance company not covering cancer treatment. Or heart disease. How is my messed up uterus any different?
Yes, IVF is no doubt expensive. Painfully expensive without coverage. But if a health plan had comprehensive infertility coverage, I bet the number of people seeking IVF would actually go down. IVF is not the most appropriate action for a large portion of the infertile population. However, if you have limited resources, many people will go for the "big guns" to increase their chances. And if they only get one shot, the temptation to transfer multiple embryos is greater as well. For an example, let's look at my case.
I am very lucky to live in a state that mandates IVF coverage. However, that is ALL they mandate. My insurance plan will also cover 3 IUIs in my lifetime. Now, my fourth IUI was somewhat successful. It resulted in a pregnancy, but not in a baby. However, I'm out of IUI coverage now, but my insurance will cover up to three IVF attempts. So guess what I'm doing? An IUI would be less expensive for the insurance company, and be a completely appropriate action with a good possible success rate, but since they've limited my coverage, I'm going for the $10,000 procedure instead of the $2,000 procedure. Now, does that make any sense? My out of pocket costs are actually less to do IVF than IUI, especially since my medications are covered as part of the mandate and I had to pay out of pocket for them for the IUIs.
So is infertility treatment medically necessary? Probably not in the eyes of the insurance plan. But is that what should determine coverage? I don't think so.
Posted by jlraynes at October 12, 2005 02:08 PM
Trackback Pings
TrackBack URL for this entry:
http://mt.rayners.org/mt-tb.cgi/708
Comments
Posted by: Megan at October 12, 2005 05:43 PM #
x=? what the hell is that? its not what I typed...
erg...here it is again.
don't even get me started. blah blah blah-viagra, reconstructive surgery, surgical sterilization-blah blah blah. no, none of it is essential to my life but I don't want to live a life of bare minimums. I want to be happy, dammit. Why is that so much to ask?
Posted by: Megan at October 12, 2005 05:45 PM #
I agree completely. It just makes no sense that it's not infertility coverage is not provided by a majority of insurers/employers. And it pisses me off. But because infertility is often dealt with in silence, no one's running to Congress to demand regulations in large numbers. Sure, I talk about it online openly but most definitely not with my co-workers, family and other peer groups. We're not a mobilized advocacy group like groups advocating for cancer research and benefits. Too much of the media portrays us as mentally askew (case in point the tv show Inconceivable) in our "crazed" efforts to get pregnant, making it difficult to generate a great deal of public sympathy and support. Add to the mix the dismal numbers of women in positions of corporate power (and I'm not blaming this on men but just saying it could be a factor). We're not the ones with the power over how the benefit plans are being written by companies.
Sorry to rant - but this is something that gets me going.
Posted by: Lori at October 12, 2005 08:05 PM #
I do think that infertility should be covered...I went and read the comments and blog mentioned - I'm pretty sure I recently read a journal article that indicated that REs and couples made more conservative choices when there was insurance coverage. If you know you have more than one shot at this, you're more likely to play by the "rules".
I do think much of the problem is the fact that infertility isn't discussed in an informed and truthful way in the media. The public has no idea how many people are actually having difficulty conceiving. Plus they see the sensational stories of multiple births, and that's what they think insurance will be paying for.
As a speech therapist, we run into the "medical necessity" issue. Often physical therapy will be covered when speech therapy will not.
Posted by: Larisa at October 12, 2005 10:28 PM #
Rant ON! I was having this very discussion with Sarge just today, viagra and all. I totally agree that reproductive sevices ought to all be covered. I really believe they will be sometime in the future but it will probably be too late for me to take advantage of them. But hey, at least they'll be around for my daughters...oh, wait...
How do you find out if your state mandates coverage?
Posted by: Flicka at October 12, 2005 10:34 PM #
I spent so many hours on the phone with BCBS as we were starting IVF. Keep in mind the diagnosis my partner got was that she was infertile. End of story. So, it seems like if you have that diagnosis, your fertility treatments should be covered. Or your gestational surrogate cycle-- It annoys me that we pay out of our pocket for insurance, pretty much never use it, and now we have a legitmate reason but there's no coverage.
We were, however, lucky since we added prescription drug coverage right before starting the cycle, and the drugs themselves are covered. Whew. I'm pretty sure that paying for all the drugs plus the cycle would mean that could not afford to do this, which would be very sad for us both. We recognize that we have a little extra luck in our extra uterus, but still...
I have a similar rant that if men had periods, menstrual products would totally be free.
Posted by: Katie/WannaBeMom at October 13, 2005 10:03 AM #
Posted by: Molly at October 13, 2005 10:40 AM #
Nicely put - to make your point a RESOLVE study done just a few years ago said that less than 5% of the IF population needs IVF. If lesser treatments were covered, more people would be set. Thankfully, the advocacy groups are growing, and trying to make their mark. I've spoken to Many, MANY people regarding insurance coverage, hoping for a someday federal mandate. I hope one day it happens.
Posted by: Katie at October 13, 2005 10:55 AM #
Great post. I've struggled to articulate why I think IF should be covered. Next time I'll just send people your post. We moved on to the IVF big gun after the clomid/IUI cycles because of money. If we did the injectible IUI route a few times, we wouldn't have the funds for IVF.
p.s. Did you hear that Inconceivable was cancelled already?
Posted by: zhl at October 13, 2005 01:37 PM #
Great post, Jenn! Wonderfully put.
For those of you who feel strongly about this, please please please consider getting involved with Resolve. Julie Salz Greenstein became Resolve's Director of Governmental Affairs at the beginning of this year, and she is working hard on insurance/advocacy. One person can't do this alone, but together we can make a difference.
There were also two bills introduced to the U.S. House of Representatives this year about infertility coverage. You can read more at http://www.resolve.org/main/national/advocacy/insurance/facts/facts1.jsp?name=advocacy&tag=insurance
Flicka - On the following page, there is a link to states that have infertility insurance mandates and a link to states in which bills related to infertility insurance are currently being proposed: http://www.resolve.org/main/national/advocacy/insurance/index.jsp?name=advocacy&tag=insurance
Posted by: Rebecca at October 13, 2005 03:11 PM #
Hear ye, hear ye, Jenn! I have very good infertility coverage - 3 lifetime IVF attempts - and it freed me to do a single-embryo transfer, thereby nearly eliminating the risk of multiples. If I was paying for it out of pocket, I would have pushed to transfer at least 2 of my 3 embryos. Taking into account prematurity risk and NICU stays, a typical twin pregnancy is many times more expensive than a singleton pregnancy plus two or three additional IVF attempts.
Insurance coverage will lead to lower numbers of embryos transfered, helping the health of the babies born from IVF and the mothers. It will also lower health care risks overall (taking into account the insurance payments plus patient copays).
Posted by: Susan/holdingpattern at October 14, 2005 02:04 AM #
Hear ye, hear ye, Jenn! I have very good infertility coverage - 3 lifetime IVF attempts - and it freed me to do a single-embryo transfer, thereby nearly eliminating the risk of multiples. If I was paying for it out of pocket, I would have pushed to transfer at least 2 of my 3 embryos. Taking into account prematurity risk and NICU stays, a typical twin pregnancy is many times more expensive than a singleton pregnancy plus two or three additional IVF attempts.
Insurance coverage will lead to lower numbers of embryos transfered, helping the health of the babies born from IVF and the mothers. It will also lower health care risks overall (taking into account the insurance payments plus patient copays).
Posted by: Susan/holdingpattern at October 14, 2005 02:04 AM #