Dr. Adamson’s article, “Identifying the Most Cost-Effective, High-Value Family-Forming Benefits” was published in the July/August 2024 issue of Journal of Compensation and Benefits.
Family-forming benefits is a leading employee benefit trend in group health and self- insurance coverage, reflecting a changing demographic landscape and evolving needs of working Americans in an increasingly tight labor market. But not all plans are created equal. In fact, there are serious differences that have an enormous impact on the cost, quality, and overall value of these benefits to employers and their workforces. In this article, the key points regard ing coverage and the realities, benefits, and potential obstacles of successfully bringing this critical benefit to end users are thoroughly discussed.
There are several reasons why family-forming benefits matter as much as they do in today’s competitive business climate. For starters, infertility is a very common problem that affects one out of six couples— with at least 10% to 20% of employees at some point in their lives facing a challenge in forming their family, which are significant numbers to consider. With an expanded definition of what constitutes a family, the impact of infertility is felt not just by heterosexual couples, but also many single individuals and members of the LGBTQ+ community—all of whom need help forming families throughout their lives.
Another major consideration is the high cost of infertility treatments. In vitro fertilization (IVF), for example, is $15,000 to $30,000, and surrogacy anywhere from $135,000 to $230,000. Furthermore, many fertility benefits programs charge an up-front per-employee-per-month (PEPM) fee for implementing services, an ongoing expense that can defeat an employer’s efforts to contain costs. Healthcare decision-makers and purchasers must carefully evaluate program offerings to ensure that the costs do not outweigh the benefits.
FROM STRESS REDUCTION TO HIGHER PRODUCTIVITY
The importance of the mind- body connection plays a major role. Women with infertility have high rates of anxiety and depression that are equivalent to women with cancer, heart disease, and Human Immunodeficiency Virus (HIV). That is an astonishing statistic and one that reinforces the need for emotional support in family-forming benefits.
It is also worth noting that while women tend to be more comfortable sharing some of these more serious medical diagnoses with friends and family members, they are much more private about doing the same for infertility. It is a very long, arduous, and often lonely journey for them when it comes to enduring doctor visits, imaging studies and injections—cycle after cycle.
Additionally, it is not just women who are affected. When women are suffering from infertility, their partners also suffer with documented increased rates of anxiety and depression. Also, the male partner is the primary cause of infertility in one-quarter of all cases and contribute significantly to the medical problem another quarter of the time. When this occurs, men often suffer the emotional burden of guilt and shame, usually in silence. These emotional consequences of infertility place major stress on marital and family relationships.
This financial, emotional, and professional burden of infertility on the individual and families can no longer be ignored. Family-forming benefits improve the emotional health of employees who embark on this personal journey, and we know how important that is for increasing employee engagement. Infertility directly is estimated to affect not only engagement but also productivity and satisfaction for one-sixth of couples in addition to singles and LGBTQ+ individuals.
HELPING LEVEL THE PLAYING FIELD
When employee engagement increases along with productivity and satisfaction, a surge of positivity flows throughout the organization, aiding the achievement of broader corporate goals. These goals include improving diversity, equity, inclusion and belonging (DEIB) goals, as well as addressing social determinants of health (SDoH). It is important to bear in mind that all marginalized communities lack the same access to quality and safe care relative to the majority population.
We know that having access to these benefits helps to improve company culture, and it is well documented that employers with a caring culture and higher employee engagement will have an easier time at recruitment and retention. Also, earning recognition as a family-friendly organization helps attain employer-of-choice status and bolster employee loyalty. This is especially important in a job market that has tightened over the past few years.
The good news is that employers are starting to recognize these challenges that their employees are facing, driven by the need to improve talent-management strategies. Reasons employers are offering family-forming benefits include that as many as 70% of millennials surveyed say they would change jobs for fertility benefits, while 61% of employees with fertility benefits report increased loyalty to their employer. In addition, 58% of benefit leaders believe that not offering fertility benefits by 2025 would be discriminatory. What is particularly important is that as many as 97% of employers say adding infertility coverage did not significantly increase medical plan cost.
INFERTILITY — A DISEASE
For many years, infertility was defined only as the inability to get pregnant after a year of trying. This definition was formalized in 2009 by the World Health Organization (WHO), which also considers infertility a disease—an important description that gives this condition greater standing when it comes to medical billing and coding, as well as public policy. Interestingly enough, the American Medical Association (AMA) did not define infertility as a disease until 2017.
Also in that same year, the International Committee for Monitoring Assisted Reproductive Technology (ICMART) expanded the definition of infertility to include any person who had an impairment of their capacity to reproduce, either individually or with his or her partner. This definition includes singles and those from the LGBTQ+ community, and also defines infertility as a disability as well as a disease. The WHO has not followed suit, continuing to limit its definition to heterosexual couples. However, it has called for fertility care to be available for everyone for whatever reason, including individuals and those in the LGBTQ+ community. For employers, there is both a business and moral imperative to support every path to parenthood, each journey being as unique and diverse as each employee.
A MORE THOUGHTFUL BENEFITS DESIGN
Perhaps not surprisingly, the information technology (IT) industry led the way on providing family-forming benefits—an investment that paid off for that particular talent war. Subsequently, these benefits have been included in many other sectors of the economy where they are seen as being provided by family-friendly employers. And the costs were not as high as anticipated. In fact, there were actually cost-savings involved because offering coverage helps employees make better decisions with fertility care. Without coverage, it is difficult to pay for treatment, so the expense prevents employees accessing needed care.
While more employers are realizing the importance of offering family-forming benefits, they need to recognize that cookie-cutter care for infertility simply does not work. How services are offered is just as critical as why they are offered. Providing family-forming benefits to infertile couples or individuals should come with access to quality, cost-effective care whose infertility benefits are as thoughtful as they are comprehensive. That means offering individualized and flexible packages that meet the needs of any patient, which also leads to a positive employee experience.
There are several caveats for employers to consider when designing their family-forming benefits. One of the problems with programs that target specific treatments, for example, is that they may not be helpful to everyone, and when some must be used before others are attempted, such as intrauterine insemination (IUI), it tends to be inefficient and wasteful. Restrictive criteria usually result in lower quality, inefficient care that is also not inclusive.
While including fertility in a general medical plan is better than no coverage at all, the problem is that they are not inclusive under the Affordable Care Act (ACA), which does not allow for some needed family-forming benefits to be provided. Donor sperm, eggs, embryos, or surrogacy often are not covered. Therefore, it will not be inclusive or comprehensive if offered this way, which is not as cost-effective, nor is the care as appropriately managed. Also, care in such plans is commonly not provided by specialists. So it is not as safe and there may be a higher risk of multiple births, which adds significantly to maternity and neonatal costs.
Family-forming benefits are not included in many of the major health plans, which is a major shortcoming. When they are included, there is a tendency to pursue earlier and simpler treatments such as IUI. But many of the major plans require patients to undergo anywhere from three to six cycles of IUI before moving onto another treatment such as IVF. While IUI may be appropriate for some patients, it is often not the case, and if they need IVF or sperm or egg donation, those benefits often are not covered.
Studies show that patients with health coverage for IVF make more appropriate deci- sions with their physicians. For example, the lack of IVF coverage may encourage transferring more than one embryo at a time, resulting in higher rates of pregnancy complications and increased cost. Therefore, a comprehensive benefits package is vital to ensure high-quality and safe treatment.
Another challenge is that employers do not know how much they are paying for family-forming benefits. When employees are infertile but not getting pregnant, and if they do not have family-forming benefits, an OB-GYN doctor may suggest ovarian stimulation, ovulation induction, or other treatments and code that out as endometriosis or fibroids or other diagnosis covered by the general medical plan. It is estimated that between 10% and 40% is wasted on this type of miscoding.
BUCA (Blue Cross/Blue Shield, UnitedHealth Group, Cigna, and Aetna) plans usually cover only about 20% to 25% of needed care, which is also usually rudimentary and does not provide what is needed. The quality is not being managed because care is not being provided by reproductive specialists, whose higher level of expertise ensures the better care. It is also important to steer clear of unnecessary treatment add-ons, which are common across infertility services.
IMPROVING THE INFERTILITY JOURNEY
The infertility journey can be complex with a number of components that include pre-pregnancy genetics, male testing and treatment, surrogacy, adoption, emotional support, and counseling—even lactation, childcare, and a return-to-work strategy. Having a comprehensive program in place is important to managing all these moving parts.
Ultimately, ensuring the best possible health outcomes will not only result in a healthy delivery with fewer complications but also save money. For example, ARC Fertility is proud of the fact the Validation Institute has documented ARC clinics’ twin rate as being 20% or more lower than non-ARC clinics with a savings to employers of $20 million a year.
Another key differentiator is a program design whereby the employer only pays when services are actually rendered, avoiding spreading PEPM charges across the entire employee population when only a small proportion of employees will use the service each year. This gives employers flexibility to choose the amount of subsidy they are willing to provide at a level that is affordable for their budget.
The average benefit subsidy is $20,000 to $25,000, but as little as $5,000 or as high as $50,000 or more can be contributed by the employer. Bundled treatment packages with discounted pricing that are fully transparent can go a long way toward making family-forming benefits affordable. Direct-to-consumer unsecured lending is another option for keeping the benefit affordable.
OFFERING EVIDENCE-BASED AND ETHICAL CARE
A guiding principle in designing coverage is to build a network around evidence-based and ethical care. That same thinking applies to partnerships with genetics, sperm, egg, embryo, and drug companies.
What happens prior to and in between doctor visits is equally critical to the success of a family-forming benefits program. Mindful that the U.S. healthcare system is complex and difficult even for savvy consumers of medical services, hand-holding navigation is important for guiding individuals and couples through their infertility journey.
We know that navigation is important for achieving seamless care, so having access to a personal navigator will help health plan members access the resources they need, including emotional support. Those interactions should include following up with the health plan member and providing ongoing support until the pregnancy or adoption is complete. It is important that the doctor and patient make the medical decisions in order to preserve the highest quality of care without interference from others, including short-sighted plan restrictions.
Balancing the use of technology with human expertise is yet another layer to consider when designing family-forming benefits. Since roughly 70% of all information is being delivered in a digital format, a fertility app should be made available that features one-on-one concierge care as part of high-touch supportive human navigation.
ASSEMBLING EDUCATIONAL RESOURCES
One of the biggest challenges Americans face is that they do not really understand reproductive health and what can be done to reduce their risk of developing problems, such as getting enough nutrition, exercising, and not smoking or using drugs, as well as planning when to have children before they grow old. Educational materials should be comprehensive and include FAQs, inclusive sections, comprehensive questions, personalized content, evidence-based information, prognostic tools, emotional support, and benefits information that include the cost of services. Outreach also needs to be made available for both men and women who want to start their own family with or without a partner.
Quality based on medical outcomes is incredibly important, as are decisions that are evidence-based and individualized for each person who is undergoing a fertility journey. This includes recognizing peer-reviewed studies that must submit to the rigorous process of research and clinical trials to produce evidence that achieves the desired outcome, which is a healthy single baby. Infertility is not addressed through a one-time intervention. Its resolution is part of an ongoing journey that includes planning treatment, accessing the appropriate resources, having navigation to answer questions between doctor visits, and having emotional support resources.
Offering affordable family-forming benefits that also can be personalized and feature high-quality providers checks multiple boxes for employers that are looking to attract and retain top talent. Taking a thoughtful approach to benefits design will help transform lives, one family at a time, and create more resilient and happy workforces that contribute to business success. Together, we can nurture life’s beginnings and create a future where safe fertility care is not a luxury but a fundamental right for all.
Journal of Compensation and Benefits E July/August 2024
© 2024 Thomson Reuters
*DAVID ADAMSON, MD FRCSC, FACOG, FACS is the Founder, Chairman and CEO of ARC® Fertility. A globally recognized reproductive endocrinologist and surgeon, he has over 300 publications to his credit. Dr. Adamson is a Clinical Professor, ACF at Stanford University and Associate Clinical Professor at UCSF. Additionally, he serves as the current Chair of the International Committee Monitoring ART (ICMART), a WHO NSA/NGO. He has been the recipient of numerous awards from professional and patient organizations for his outstanding contributions to reproductive medicine. He currently serves as President, World Endometriosis Research Foundation (WERF); and on the Executive Committee, International Federation of Fertility Societies (IFFS). His professional accomplishments include: Past President: American Society for Reproductive Medicine (ASRM); Society for Assisted Reproductive Technology (SART); American Association of Gynecological Laparoscopists (AAGL); Reproductive Medicine, International Federation of Gynecology and Obstetrics (FIGO); and multiple other professional organizations. Dr. Adamson champions comprehensive, affordable and high-quality family-forming benefits. His insights underscore that these benefits can enhance organizational culture, employee well-being and productivity, highlighting their significance for both employees and organizational success.