Infertility Insurance Coverage

I’ve been sitting on writing this post for a while because I recognize it won’t be a popular opinion in the community.  Though a recent piece by Pam of Silent Sorority expressed a similar opinion. My hope is that people will hear me out and won’t take offense to it.  

One of the challenges people face in going through infertility is how to pay for the expensive cost of treatments.  Many in the community say that infertility should be covered by insurance.  Resolve and other infertility organizations advocate for infertility coverage.  Advocacy day is an annual event where Resolve goes to DC to meet with elected officials to advocate for infertility with one of the topics being infertility coverage.  My personal opinion is that advocacy is misplaced.

I don’t believe that infertility treatments should be fully covered by insurance.  Before the rage starts at me, please here me out.  I’m not against people having the opportunity to become parents.  I’m against infertility being covered because it doesn’t address the issue of why infertility costs so much to treat.  If infertility were to be covered by insurance the cost to fund it would be placed in insurance premiums.  Thus though it would be covered the overall cost for insurance would be higher.  Either way people would be paying for it.  

Instead of advocating for infertility coverage we should be asking the fertility industry why does treating infertility cost so much?   Now I’m not saying that the fertility industry doesn’t deserve to be fairly compensated for their work but they should at least provide an explanation of why it costs so much and what can be done to lower costs.  

The way medical providers are paid now is that they charge based upon the services and/or procedures they provide.  Regardless of whether the health care provided cures the patient the provider gets paid the same amount.  For them the financial incentive is to conduct as many procedures as possible.  This is where the major issue is with how health care is delivered today.  

To me providers should be paid based upon the outcome of the services they provide (Outcome based payment model).  For instance a couple who goes to an RE for an infertility diagnosis would be charged a flat fee.  From there rather than the couple being charged for every IVF, ICSI or IUI administered the provider would be paid one dollar amount if no pregnancy was achieved and a high dollar amount if a successful pregnancy was achieved.  This will incentivize the provider to first conduct a full proper diagnosis and second recommend the most effective treatment.  The good providers would be the most highly compensated ones while the weaker ones wouldn’t be.  

Overall the cost of providing infertility services would decrease thus making it more likely to be covered and lower any out of pocket costs to patients.  The bonus is couples would be more likely to be properly diagnosed helping greatly in the emotional department.

So instead of advocating for infertility coverage I believe we should instead advocate for the model that providers are paid by change from a Service Fee based model to an Outcome based model.  I hope this piece leads to a good dialogue and gives us all food for thought.


37 thoughts on “Infertility Insurance Coverage

  1. sbear2014

    Interesting perspective. I also don’t believe it should necessarily be covered, and wouldn’t ask anyone else to assume a share of the costs of my treatments through higher premiums for all. I think diagnostic costs should be covered fully (and for many, they are), but I could see how reforming the industry as you described could result in better diagnostic treatment, improve some of the emotional aspects of treatments by having accurate expectations, and in turn result in better outcomes. Perhaps then it would be more reasonable to ask insurance to cover the cost of treatments.

  2. valleyally

    Whether we pay out of pocket or it’s covered… We all still end up paying whether through taxes or insurance premiums. The added stress to the system would need to be picked up by all.

    Where I am living they just announced a new low cost IVF clinic bringing the cost of a cycle to around $4000. Because Of our struggle with IF People have been asking me my thoughts about the new clinic model… Quite frankly it bothers me because it assumes IVF is the solution for everyone and it isn’t. If we hadn’t gone through our clinic with a proper lab and RE we wouldn’t have gotten our diagnosis. Multiple cheap IVFs would have been a waste so where’s the motivation to properly diagnose. It’s a sticky topic for sure!!

    This is for sure a loaded topic. At the end of the day, it’s not fair any of us have to go through this.

    1. gsmwc02 Post author

      So true on the cheap clinic being misleading. You’d have to see what their success rates are and as you said IVF isn’t always the best treatment.

      You’re right it’s not fair we have to go through this but at the very least we should know we are receiving the best possible care with an honest diagnosis.

  3. journeyformybaby

    I agree to the point that the cost is astronomical with no logical reason why it should cost $15,000+ per ivf cycle on average. I had coverage for my cycles and discovered that my insurance was only required to pay about $2,500 per cycle (and my out of pocket expense was roughly that as well) while someone without insurance would have a self-pay amount of $15,000+ (not even including another $4,000 in meds in my case). Hardly seems fair that the uninsured couple would be paying more than the insurance company has to pay. If the drs are satisfied with receiving $5,000 from insurance and copays for a cycle, why does it cost so much more for the self-pay patient??

    However, I am afraid if drs were paid more based on success of treatment, they may start taking only the cases that look easy to treat and finding loopholes around treating those who would require more extensive testing and procedures. Much like the money back guarantee packages seem to be more readily available to couples who are likely to succeed quickly. Just a thought….

    1. gsmwc02 Post author

      The reason for the insurance discounts is because that is what the insurance carrier has negotiated with the provider. The provider is guaranteed to be paid whereas with someone who doesn’t have insurance they don’t necessarily know that they will be paid and factor in some uninsured won’t and the ones that can will help fill that gap.

      On your point about doctors taking the easy cases, I could see that. But they could not turn down diagnosing a patient. It would force them to be honest with their patients as to the chances of conception and recommend the proper treatment not the most expensive procedure.

  4. RJ

    Fascinating perspective. I’m glad you posted this as it’s not something I would have considered. Personally, I find that the cost of health care in general is astronomical whether it’s for infertility, cancer, surgery…you catch my drift. This fee-for-service is a great way to even out the costs in general and ensure that everyone has reasonably priced services and gets the same care and treatment. It also encourages doctors in all specialities to think about what tests and services they are ordering and take cost and savings into account. It’s not fair that some people can afford to get treated while others are just left to fend for themselves and either drown in medical debt or suffer through their condition.

    However, I do think that infertility and RPL should be covered the same way any other disease would be covered (whether it’s in the fee-for-service model or the standard American model). Otherwise I think that infertility will not get the attention it deserves as an actual disease. I feel the general population just sees it as an unfortunate occurrence and that does not help any of us. Just because it’s not life threatening does not make it a real disease. There are plenty of non-life threatening things that are covered by insurance; why not this?

    Thanks again for sharing, I’m looking forward to reading other replies and opinions.

    1. gsmwc02 Post author

      See that I agree with that it should be treated as other diseases are. I don’t buy the idea that it’s not a life threatening or it’s a lifestyle treatment. Because to me with that logic diabetes and other diseases caused by obesity shouldn’t be covered because that is a lifestyle choice.

      1. RJ

        Excellent point, there are a lot of diseases that are due to lifestyle that are covered. It spins me into wanting to preach about how important lifestyle choices are in general and how we need to focus on preventative medicine (but that is not on topic, especially since I don’t think a lot of infertility and RPL are preventable).

      2. gsmwc02 Post author

        When you have substance abuse women getting pregnant easily I don’t think that infertility other than age related is as preventable as people make it out to be.

  5. Mamalife

    Interesting point. I come from a province in my country where we get complete coverage for 1 cycle for it except the drugs and most diagnostics are covered by public health for subsequent cycles. I personally feel insurance should cover 2 cycles however thr Dr’s should stop charging an arm and leg for every procedure they perform. If payment becomes outcome based as you suggest, Dr’s wont accept half the infertility cases which wil hurt more.

      1. Mamalife

        They can also make women into baby makers, eg to maximise success a dr could make a women produce 30-40 eggs. When it is a money game , ethics fly out of the window.

      2. gsmwc02 Post author

        True but if it ends up leading to complications in the women then the doctor’s would be risking their incentive.

      3. Mamalife

        How about a case where
        A) i go to a dr who stims me highly and 35 eggs are retrirved. 20 make it to the freezer
        B) i get over stimulated ovaries, which thr dr treats me for and asks me to rest out 4 cycles to givr
        My body a break
        3) we do a fet and i carry twins.

        Is that a success? Should thr dr be compensated?

        Sorry, I am just bored and this is interesting conversation πŸ™‚ feel free to ignore πŸ™‚

      4. gsmwc02 Post author

        The other part of outcomes based is the most efficient treatment and using a treatment that causes another condition which isn’t efficient. Good example.

        Ask and comment away. I love the dialogue. πŸ˜€

  6. jonsie13

    I feel as if insurance should pay for infertility treatments, as long as it covers some of the ridiculous things it covers. But, unless there is a total overhaul, none of it will make sense.
    I paid more for meds than I did to my Dr for my ivf cycle. That is a real injustice. My ivf was around $10k to my Dr, and when I look at everything that went into it, every nurse, admin, embryologist, lab tech and Dr that had to be paid for the times they worked on my case, I wondered, how did the office actually profit at all?
    For the record, my insurance covers nothing with regards to infertility, after diagnosis.

      1. jonsie13

        Oh, I’m sure they are. Mine is not. It’s a private office owned by 2 doctors.

      2. jonsie13

        My miscarriage, that happened in a hospital, cost our insurance company over 15k. I can’t wrap my brain around that one!

      3. gsmwc02 Post author

        Having worked in the industry for 13 years I’ll say that both insurance companies and providers are equally guilty. But in the news you only hear about insurance company profits and rarely about big hospital profits.

      4. jonsie13

        That is so true.
        Our local big hospital is part of our university system. I’m not sure how, or if that makes any difference at all. But, what I can’t understand, is how my miscarriage, at 12 weeks, dnc, etc. was charged out at more than the birth of my son, delivered via c-section. Same hospital, same Dr. No emergency room involvement. Just seemed odd to me.

  7. clwalchevill

    Weighing in as someone where nothing (not even diagnosis) was covered. From the beginning, we were told that infertility was on par with cosmetic surgery and was a “lifestyle” choice. So everything, from the work up to the eventual diagnosis and pregnancy, was completely out of pocket. And it was very angering to hear that we had to foot the bill when other diseases and medical treatments were covered. It has been financially crippling.

    That said, I do agree that there is a push in the industry towards maximizing profits over actual patient care. This is true of healthcare in general at the moment and it makes me wonder how many people are being over medicated/undergoing unnecessary treatment as a way of profiting the industry. So yes to modifying the model.

    But it needs to be holistically. With infertility, there is a taboo. Holding off on coverage until the system is more fair just means we stay with the status quo. People won’t be diagnosed because they can’t afford that diagnosis (we paid almost $2000 for a diagnosis of unexplained infertility and our old REs wanted to charge us an addition $800 for an RPL panel). So if I had to chose, I chose to push for universal coverage followed by reforming the whole system.

    1. gsmwc02 Post author

      Agreed on it needing to be holistically. I’m all for diagnosis being covered. To me that acts as preventive medicine beyond fertility related conditions many times other health conditions can be detected.

      Personally we were lucky that we had an HSA that allowed us to use those dollars to pay for any out of pocket costs. Not everyone is that lucky.

      Great feedback. Thank you so much.

  8. Pamela

    Great discussion here, Greg. Thanks for opening up the floor. As the guest post on my blog made clear there needs to be much greater scrutiny about how fertility issues are diagnosed. As I make clear in my latest blog post ( today’s rapidly-expanding fertility industry (projected to be $27B for IVF alone by 2022) seems much more concerned with how to get more cycles on the books than in actually working with individuals to find out if they’re good candidates.

    As you make clear, the clinics are compensated north of $15,000-$20,000 per cycle β€” depending on how many add-on services are involved. The clinic earns regardless of outcome. What’s most troubling, though, is patient/consumers won’t find the number of failed cycles in the marketing materials. I riff on this much more in this podcast:

    At the end of the day, clinics need to be held to the highest standards — whatever happened to ‘do no harm’ ?

    1. gsmwc02 Post author

      Thanks Pam. As you alluded to we are called patients but in reality we are consumers that need to advocate for ourselves and be an informed consumers.

      Thank you so much for being a pioneer in questioning this all.

  9. snowdroplets

    Interesting post and discussion. Here’s my thoughts – I strongly believe that infertility diagnosis and treatment should be covered by insurance just like other medical conditions are covered. Sure, the costs are too high (like nearly everything in health care these days) and there’s many ways that services should be improved (again, like nearly everything in health care). That said, I see infertility as a medical problem. Ours certainly is. People with infertility should be able to have health insurance coverage to diagnose the problem and coverage to provide treatments if successful treatments are possible. Just like my premium payments go toward covering the costs of other women’s childbirth. That’s how the system works. I’m happy to pitch in for her. My premiums even help pay for some guy’s viagra. I’m happy for him. That’s how insurance works. Some people pay more than they use. Others use more than they pay. We all benefit from the safety net and healthier, happier lives. It’s all complicated, but I think there are reasonable solutions that don’t leave infertile people on a limited income stranded without hope of a child for lack of funds. We need infertility to be taken seriously, we need more medical research, we need better treatments (at reasonable costs?), we need more information, and we need health insurance coverage! Thanks for getting me really thinking about this.

    1. gsmwc02 Post author

      Thank you for the feedback. However, it still doesn’t get address the issue of cost of treating infertility and how the care is delivered. Covering it will still lead to the same issues of misdiagnosis and people being pushed into treatments that don’t address their conditions.

  10. Lisa (@AmateurNester)

    Interesting perspective! And kudos to you for having the guts to publish! I think there are so many factors that play into the outrageous cost of it all. I don’t have anything to add or counter. I need to sit on this a bit. But I just wanted to say thanks for giving us some good things to think about. Dialogue is so important!

  11. Pingback: Room for Dissent on IVF? - Silent Sorority

  12. ProsperityAndCalamities

    Reading this post and the comments made me think of the topic in a completely different way – a science fiction kind of way. Obviously, infertility treatments are meant to help a woman get pregnant. But is the goal the pregnancy or the baby? If it’s the pregnancy, then would it count if doctors were able to transplant a 4 month baby into a woman? (That’s where my sci-fi thoughts kicked in, what if doctors could “grow” a baby then transplant it before birth). If the goal is the baby, should adoption be covered by health insurance? My questions are not meant to be offensive in any way, I’m just really thinking through this whole topic.

  13. stephnicole

    Eh, I think it’s hard to use a value-based payment model for infertility– and it wouldn’t necessarily be cheaper. If you even tried, it would have to be VERY risk-adjusted, which would be challenging. And I agree that the ethics would get very squishy. You need to make sure you’re incentivizing the right behavior, along with the outcome. I actually support a very basic coverage model– something like a $100,000 lifetime limit for ART infertility treatments per enrollee/carrier. Another piece is pharma/the drugs. Maybe the general outrage over pharmaceutical prices will help us?!


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