Aetna believes its new fertility program will improve the chances of conception for infertile couples, while controlling costs
Aetna believes its new fertility program will improve the chances of conception for infertile couples, while controlling costs. The national insurer is relying on preferred providers to deliver optimal services.
About 10% of U.S. women younger than age 44 have difficulty getting pregnant or maintaining a pregnancy, according to the Centers for Disease Control and Prevention, and many try in vitro fertilization (IVF). The cost of one IVF treatment averages $13,000 for medical care and prescriptions-with no guarantee that the IVF cycle will result in a live birth.
Because they believe it will increase their chances of conception, many women opt to have more than one embryo transplanted during an IVF treatment. The practice can increase the risks for mother and baby, as well as increase the cost of care, says Joanne Armstrong, MD, senior medical director and head of women’s health at Aetna.
About 140,000 IVF cycles are performed in the United States each year, and an estimated 33% of all IVF cycles result in twins and a little less than 1% result in triplets. Twins and triplets are costly because the pregnancies are high risk to the mother and more likely to result in preterm births that require a stay in the neonatal intensive care unit (NICU). And some of the NICU babies have life-long medical conditions, such as cerebral palsy.
“A single baby is born preterm about 11% of the time,” says Dr. Armstrong, who is an obstetrician and gynecologist. “Twins are born preterm about 60% of the time, and triplets about 94% of the time. Prematurity is tied to cost. The delivery of singleton baby is about $11,000, delivery of twins is about $77,000 and triplets is about $300,000.”
In addition, the cost of prenatal care for mothers carrying twins or triplets is higher because they are at higher risk for problems, such as gestational diabetes, and have more Cesarean sections. If women can be persuaded to have a single embryo transplanted during a cycle, many of these costs could be reduced, Dr. Armstrong says.
Aetna created an Institute of Excellence (IOE) network for infertility services. To achieve the designation, the fertility clinic must meet many clinical criteria, such as having an eSET (elective single embryo transfer) program and being a member of the Society of Assisted Reproductive Technology (SART), which certifies the laboratory and embryology work.
“The goals of the clinical criteria are to optimize two outcomes that are important to patients and clinicians,” Dr. Armstrong says. “You want to have live birth rates. After all, that is why people have IVF-to have babies. But you want to do it as safely as possible, and safe is defined as singleton babies.”
Coverage of infertility varies widely among insurance plans.
“For those that have coverage, it might be for one cycle of IVF,” Dr. Armstrong says. “IVF is costly, so patients might not be willing to [transfer] just a single embryo.”
If an Aetna member whose plan includes infertility benefits agrees to eSET and does not conceive after the first attempt, Aetna will cover a second attempt. The procedure will not count against the member’s IVF benefit limit.
“Two cycles using single-embryo transfer-one fresh and one frozen-results in similar success rates as a traditional cycle using two or more embryos,” she says.
Aetna included this eSET benefit in all fully insured plans with IVF coverage. Self-insured plan sponsors have the option to offer the benefit to their covered employees.
“Including an IVF rider in an insurance plan might increase upfront costs of the plan,” says James D. Cross, MD, head of national medical policy and operations at Aetna.“But it will lower overall health care costs if the woman only has a single baby.”
Regardless of insurance coverage, many infertile couples seek IVF. Insurance companies cover the pregnancies and births regardless of the method of conception. If mom opts for multiple embryo transfer and has triplets instead of a one baby, she drives up the total claims costs.
“If the patient does well, doesn’t have complications and gets a good result, then she will have less medical cost exposure,” Cross says.