For Infertility Treatments, Now You're Covered, No You're Not

By ANNE ADAMS LANG

It took Carla and Bruce P. three and a half gut-wrenching years of invasive medical treatments and more than $40,000 of their savings before Carla got pregnant in April. That makes them part of a small but growing population that beat what the New York State Task Force on Life and the Law recognizes as the "disease" of infertility.

Lucky? Indisputably. First because Carla, a legal assistant, and Bruce, a real-estate broker, succeeded when the biological odds are stacked against a 41-year-old woman conceiving even with high-tech intervention. Second because Carla's new insurance carrier, U.S. Healthcare, paid for the successful round of blood tests, sonograms, laboratory work, egg harvesting, in-vitro fertilization and implanting the resulting embryos. All this was performed by one of New York City's top reproductive medical teams, which was led by Dr. Cecilia Schmidt-Sarosi and her husband, Dr. Peter Sarosi, reproductive endocrinologists.

That insurance policy saved Carla and Bruce, who do not want their last name published, roughly $10,000 that they would have paid themselves if they had approached the managed-care company just one month later. On April 1, U.S. Healthcare, now merged with Aetna, and canceled its coverage of in-vitro fertilization and other high-tech fertility treatments, making it available to employers only through a rider. "Because we were one of the few programs covering IVF, women flocked to us who could not find coverage elsewhere," said Jill Griffiths, a spokeswoman for Aetna u.s.?? Healthcare. The policy, she said, was simply too expensive to continue.

"We contacted them in March and when I read that the company had stopped the policy, my heart just dropped," Bruce said. "But we lucked out. We got coverage on a shoestring, and we just got in under the wire."

Insurance carriers are mostly like poltergeists haunting the field of reproductive medicine. They materialize with ephemeral policies that are changed or are withdrawn in a flash. Only about two weeks ago, for example, Group Health Insurance, one of the largest carriers in New York, announced that it is withdrawing its coverage for all assisted reproductive technology.

"Unless they operate in states with mandates to cover infertility treatments, such as Massachusetts, Illinois and Maryland, managed-care and indemnity insurers have ignored fertility coverage and gotten away with it," said Dr. Norbert Gleicher, who founded the Center for Human Reproduction, a Chicago-based chain of fertility treatment centers. "That's imminently about to change."

Dr. Gleicher, who recently contracted with Oxford Health Plans to do a joint venture with Columbia University, gave three reasons for the new interest in fertility coverage:

• Viagra. The White House decision to require Medicaid coverage of the drug that treats male sexual dysfunction, and mounting pressure on private insurance companies to do the same, has opened the floodgates to sexual-discrimination suits. "Once insurance companies conclude they have to cover Viagra, how can they not cover female infertility drugs?" Dr. Gleicher asked.
• Legal precedent. A police officer sued the city of Chicago for violating the Americans With Disabilities Act, saying infertility is a disability. "A disability is an impairment of a body system that inhibits a major life activity," said Patricia Collins, the lawyer who won the class-action suit this year. "The only question is whether procreation is a major life activity. My position is, if work is a major life activity, I would hope procreation is as well." Judge Susan B. Conlon agreed and the city settled, saying it would follow Illinois's guidelines.
• Economics. "Smart insurance companies are recognizing that it may be in their interest to cover, even to a limited extent, infertility because it brings an underground economy in fertility services above ground," Dr. Gleicher said. He explained that doctors often perform infertility treatments, like tubal surgeries, and list them as a different, often more costly procedure so that patients can secure coverage.

In a study to be published in September, William M. Mercer, a firm of human-resource consultants, concludes that the hidden costs of infertility treatments range from 27 cents to 50 cents a month for each member of the insurance plan. "Depending on co-pay arrangements and how well the plans are managed, it would cost in the neighborhood of 40 cents to 50 cents to provide coverage," said Lisa Astor, a consultant at Mercer. "Our thoughts are that employers are already paying for infertility whether they know it or not."

There is also a wave of consumer anger over the right to reproduce that threatens to engulf lawmakers in several states, including New York. Assemblyman David S. Sidikman has introduced a bill that would require insurers to cover the diagnosis and treatment of infertility. State Senator Seymour Lachman recently introduced a similar bill.

"People who make $250,000 a year are the ones swinging the out-of-pocket costs for assisted reproduction," said Pamela Madsen, the executive director of the New York chapter of Resolve, a support and advocacy group for infertile individuals. "Maybe they have to give up the vacation. The more middle class are giving up their homes, and the working poor are out of it altogether."

Mrs. Madsen and her husband gave birth to two children using IVF and, she said: "I have four embryos at Mount Sinai waiting for me in the freezer that I can't access. I'm tapped out, mortgaged out, credit-carded out. And we were lucky. We got our babies. We still live in a one-bedroom apartment. We had a nest egg when we got married; we had health insurance, and the system wasn't there for us. We are the norm."

It infuriated her that the New York State Task Force of Life and the Law concluded that infertility is a disease, but refused to recommend coverage. "The task force," she said, "recognized a gap in insurance coverage, but essentially said, 'So what?' "

Even without legislation forcing coverage, assisted-reproduction technology specialists are gearing up for change. "We're seeing more and more patients going to centers, which increases the volume and lowers the price," said Dr. Mark Sauer, the director of Columbia University's divisioncq of reproductive endocrinology. "Corporate groups, for-profit groups and H.M.O.'s are learning to split the heavy overhead of a university program like research, and streamline certain operations."

Managed care, Dr. Sauer said, could act as a great leveler, making fertility treatments "possible for people without the kind of resources to go to a fee-for-service boutique practice."

Dr. James Grifo, the head of New York University Medical Center's divisioncq of reproductive endocrinology, said his group is negotiating, albeit reluctantly, with a managed-care company. "We would prefer to control our own fate," he said. The problem is that large institutions like universities have less seed capital. "It's more onerous for them to start and support these kinds of programs," Dr. Grifo said.

Economic pressure has whittled the number of large academic medical institutions where new reproductive technologies are incubated. The many that remain need high volume, said Dr. Zev Rosenwaks, a professor of obstetrics and gynecology and the director of the New York Center for Reproductive Medicine and Infertility at New York Hospital-Cornell Medical Center.

"We have over 100 staffers," Dr. Rosenwaks said. "You cannot run a program that's a good program, that has full research and all aspects of lab work without having a critical mass of patients."

The Cornell program has grown to 750 patients a year from approximately 250 patients in 1988 to 1989. That represents between 1,150 and 1,250 ova retrievals annually. "We're constantly re-evaluating the costs," Dr. Rosenwaks added, while trying to accommodate a changing economic environment. That requires market savvy, which means, he said, being patient-friendly, including securing insurance coverage for IVF.

By contrast, Dr. Schmidt-Sarosi, noting that small can be profitable, said that a successful fertility clinic doesn't need the "heavy machinery of an academic setting."

"What do I need an academic telling me how to run my clinic?" said Dr. Schmidt-Sarosi, who recently left the clinical practice at New York University to open her own practice. "Our prices are competitive and lower. I don't have the overhead of hospitals. Those of us who practice look at what is the out-of-pocket cost. We streamline, so that if a patient is going to use drugs, we do IVF faster. It's more efficient."

As for managed care, she said it will probably bring down IVF costs to $5,000 per ovulation cycle from instead of the current $10,000. That could lead her to In that case, she said, she would consider joining a network of small, high-quality clinics to negotiate with good insurance companies.

Other practitioners have devised a kind of money-back guarantee approach to lowering costs. At the Shady Grove Fertility Center in Rockville, Md., for example, patients pay $18,000 up front for three full IVF cycles. Embryos are frozen and transferred without additional charges. If a patient doesn't take home a baby, the money, minus a deductible of $1,250 per cycle, is returned. "Then you still have money for adoption," said Dr. Michael Levy, a founder.

Diane Aronson, the executive director of Resolve, warns that such programs could be an incentive for doctors to implant more embryos than is medically sound, to maximize the chances of pregnancy on the first round. Ms. Aronson is also concerned about the fiduciary aspects -- who holds the money and what happens to it -- and about the possibility of unscrupulous clinic administrators practicing a bait-and-switch in which they lure patients with the promise of a money-back guarantee only to tell them that they don't qualify for that particular program.

Defending his practice, Dr. Levy said that every program could potentially exploit the consumer. "In a fee-for-service, it's unnecessary procedures; in capitated policies with a monetary limit, it's not doing necessary procedures, and in shared risk, it's by treating patients differently than you would treat others," he said. "When we looked at our data on shared risk, we analyzed whether we transferred more embryos, and we put back exactly the same number in fee-for-service."

He added: "I'd be very happy if there was no need for shared risk. In France, where it's covered, they do five times the amount of IVF as we do. There's a lot of politics hidden in this issue."

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