Hidden costs of infertility treatment in employee health benefits plans

OBJECTIVES: Many employers exclude infertility treatment from coverage unde r their health benefits plans. However, infertility treatment is often prov ided under other diagnoses or in association with therapy rendered for othe r disease processes. This study attempted to estimate those hidden costs an d to determine what the impact would be of providing coverage for infertili ty treatment. STUDY DESIGN: A 1-year retrospective analysis was carried out to isolate th e hidden costs of infertility treatment from specific medical claims data g athered from a large representative employer with no infertility benefit pr ovided. Data were analyzed in the context of the claims experience of a hea lth plan covering approximately 28,000 employees. Infertility treatment was excluded under this plan. Medical claims for specific procedures and diagn oses 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 Curr ent Procedural Terminology codes and 68 international Classification of Dis eases, Ninth Revision codes were used for the analysis. Clinical practice e xperience was used to set boundaries (conservative and moderate estimate) r egarding the likelihood of a given treatment being associated with infertil ity. This was compared with 100% covered charges to generate claims per emp loyee per month. Procedures covered operative, diagnostic, and laboratory s ervices. 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 tha t indicated possible infertility treatment. These covered the areas of lapa roscopic and hysteroscopic surgery, lysis of adhesions, neosalpingostomy, c yst drainage, oocyte retrieval or embryo transfer, echography, and various hormonal analyses. Sixty-eight International Classification of Diseases, Ni nth Revision codes indicated the possibility of infertility treatment. Thes e included endocrine disorders, various uterine pathologic conditions, pelv ic pain, endometriosis, pregnancy loss, irregular menses, and various ovula tory dysfunctions. The retrospective analysis found that 35 Current Procedu ral Terminology codes were involved in claims highly indicative of infertil ity services, such as 56353, hysteroscopic division of uterine septum, and 58345, transcervical fallopian tube catheterization. According to the 35 Cu rrent 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 e stimate. 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 employe e data, the cost of providing coverage for infertility treatment has previo usly been shown to vary between $0.20 and $2.00 per member per month. Throu gh appropriate cost sharing, managed care, and algorithms, infertility cove rage 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.