Adding a fertility benefit for your members is a great way to provide comprehensive family building coverage that supports growing families in your ranks. A quality benefit can provide equitable access for your members while protecting their financial wellbeing – but there are also ways to drive down costs for organizations who are providing this coverage.
Here are three factors to consider when adding or expanding your organization’s fertility benefit:
1. Claims leakage
Fertility treatments are complex, often requiring multiple steps. If a member is undergoing IVF, for instance, you may see multiple claims covering the treatment, anesthesia, and other components of care. However, if one of those components – let’s say anesthesia – is not properly coded to a fertility treatment, it may fall under general medical instead. That claim is now a “leak.” It’s still being processed, but that anesthesia claim is no longer associated with your overall fertility care costs. When the time comes to balance the books, you’re not getting a full view of your fertility spend.
This is also common in cases where members have dollar-cap or dollar-max coverage. When claims leak, they do not count toward that dollar maximum and can result in the organization spending above and beyond that capped limit.
One of the most effective ways to stem claims leakage in fertility is through cycle-based or “bundled” coverage models. These models combine all treatments, labs, and other care components into cycles that code every associated claim to fertility. This removes the removes the incentive for patients or providers to find ways to work around the dollar caps and gives organizations a more accurate handle on what they’re paying for fertility care.
2. Pharmacy waste
Like fertility treatments, fertility medication can be complicated. Stimulating a patient for egg retrieval, for instance, can require medications for anywhere from a few days to multiple weeks. The daily dosage requirements can also vary per patient due to changes in how that patient is responding to the medication. And because members can’t miss a dose without risking a delayed treatment cycle, physicians tend to overprescribe these medications to ensure the patient has an adequate supply. This practice often leaves patients with stores of unused medication, paid for by the organization and destined for disposal.
The best way to combat medication waste in fertility care is to seek out benefits that offer integrated pharmacy solutions and waste management protocols. Benefits that actively manage their provider networks and maintain dispensing protocols can adjust medication shipments to match exactly what the member’s provider has prescribed. This eliminates the need for overprescribing and reduces overall medication spend, while still ensuring the patient has exactly what they need for treatment.
3. High-risk pregnancies
High-risk pregnancies are a major cost driver when it comes to fertility spend. These often occur when a member has received a transfer of more than one embryo (Multiple Embryo Transfer or “multiples”). These multiple births often result in pre-term deliveries that require costly c-section procedures and extended NICU stays. In fact, the average cost associated with a singleton birth ($38,000) is dwarfed by the costs attributed with twins ($161,000) and triplets ($608,0000), with some multiples leading to million-dollar visits.*
How can a fertility benefit mitigate these high-risk pregnancies? By focusing on single embryo transfers (you’ll often see this referred to as “SET” or “SET rate”). When shopping for a new benefit, be sure to look for a vendor that focuses on ensuring single embryo transfers are the standard for care. Multiple embryo transfer is appropriate in some cases, but, for most treatments, a single embryo transfer is the safest path forward and is a best practice for effective care. A benefit that focuses on singleton births and that can provide care during pregnancy can do much to reduce the risks and costs associated with these pregnancies.
Want to know more about what to look for in a quality fertility benefit? Check out “Demystifying the fertility and family building benefit space.” It’s got helpful tips for exploring provider networks, common coverage models, and meaningful clinical outcomes (like SET rate).
Interested in learning more about a fully supported fertility experience for your members? Contact us: Stacey Hofert, Stacey.Hofert@progyny.com 847-372-9959 or Ron Abrahall, RN Ronald.Abrahall@progyny.com 631-294-2012.
*These are based on the costs noted in the American Journal of Obstetrics and Gynecology (AJOG): Healthcare expenses associated with multiple vs singleton pregnancies in the United States – American Journal of Obstetrics & Gynecology (ajog.org) as well as the annual health care inflation/CPI data from the U.S. Bureau of Labor Statistics for Medical Care.
Ron Abrahall has held both elected and appointed union positions since 1982. He has served as a representative for the New York State Nurses Association, a former president of USW 9544, past President of BMFNHP AFT/ NYSUT, NYPD officer and a Neuro-Surgical Intensive Care RN.
