SART Fertility Experts - Financial Aspects of Infertility Treatment

The information and opinions expressed in this podcast do not necessarily reflect those of ASRM and SART. These podcasts are provided as a source of general information and are not a substitute for consultation with a physician. Welcome to SART Fertility Experts, a podcast that brings you discussions on important topics for people trying to build a family.

Our experts are members of SART, the Society for Assisted Reproductive Technology, an organization dedicated to ensuring you receive quality fertility care. Hello, my name is Brooke Rossi and I am a practicing reproductive endocrinologist and infertility practitioner in Columbus, Ohio. Today's SART Fertility Podcast series will focus on the financial implications of infertility treatment and IVF.

Today, we have Brad Senstra joining us. He is the Executive Director at Seattle Reproductive Medicine in Washington State. Prior to his recent position, he had a career in finance at Virginia Mason Medical Center in Seattle and has a Master's of Health Administration.

Brad, thank you so much for joining us today. Thanks, Dr. Rossi. I'm happy to be here.

Great. So, I would say one of the first questions or concerns that patients have when they start thinking about infertility treatment, and I would say even before they come in the door, is they are worried about how much it's going to cost. And maybe they've heard about it from friends or family, or maybe they've tried to look it up online, but this is a really important question and topic, I think, for a lot of our patients.

Do you have a sense of how many patients have coverage for infertility treatment, or how that's determined, or any thoughts on that? Sure. And it is an important question because patients do hear a lot about cost when it comes to fertility treatment, and it can be a real barrier for patients to even take that first step. So, appreciate the opportunity to talk a little bit about this.

And to talk about coverage starting off, I think is a good place to begin. The coverage typically is fairly available for the diagnostic phase of fertility assessment. So, obviously, if you're a patient looking to see a fertility specialist, it's important to contact your insurance company and make sure.

But for the most part, the new patient visit with the fertility specialist and diagnostic procedures, such as ultrasounds and uterine evaluations, are typically covered by most insurance plans. So, if a patient has insurance, they can call to confirm, but those are typically covered. When it comes to the actual treatment phase after the diagnostic phase, then the coverage from insurance is much more variable, and we can get into that.

But I think from an initial standpoint, a lot of the initial things that the patients come in for from an evaluation standpoint are covered by insurance. Yeah. So, I think one of the things I have noticed is that the coverage depends on... So, it's always kind of determined by the employer, but it also is dictated by the state in which the patient lives.

So, there are some states in the country, like Massachusetts or Illinois, where many patients have coverage for treatment because there's a mandate that they need to. So, for example, in Ohio, there isn't a mandate for treatment, but there is for testing. So, our patients have a mandate that their testing should be covered.

So, when you talk about testing, you know, we're talking about HSG or fallopian tube tests, semen analysis, blood work. So, hopefully, those things would be covered. I think the other thing to think about that sometimes patients might not realize is they'll think that it depends on the type of insurance they have, and it's not really the type of insurance, whether they have UnitedHealthcare or Aetna, has to do with their employer.

Absolutely. So, they need to understand that, too. Yeah, exactly.

And to your point, there are 19 states that have some sort of mandate for coverage. And if you're in one of those 19 states, the variation of coverage that's mandated by the state is across the board from very comprehensive to not very comprehensive at all. So, that's something that, you know, you need to research what your state needs to provide, you know, first and foremost.

But for all of those states that either have limited mandates or no mandates, you're exactly right. It's really down to the individual sort of type of insurance that you have that your employer itself chooses to cover. So, if you're not in a mandated state, the typical sort of off-the-shelf insurance plans from Blue Cross or Aetna would not normally include fertility coverage.

And the employer would need to choose what they would call a rider, you know, an add-on to that insurance, which a lot do, to provide that coverage. What I've seen, for instance, is a lot of the larger companies, especially the tech-based companies, you know, Amazon, Microsoft, those really large national companies, are sort of leading the way in providing this fertility coverage and actually becoming more and more comprehensive in their coverage. So, it really comes down to the employer and whether they cover that.

And I'll just throw a pitch in here. If you go to your employer and it's not covered, it's something that you may want to advocate for, because, again, it is up to the employer to be able to add that on to their insurance coverage. Yeah, I will.

I'm going to add on to what you said, actually, because I think that some of the laws and the mandates are in place now because patients have gotten together and gone at the state level and tried to have laws be changed. And I definitely agree. I agree with you on that.

Do you have a sense of how important this is for patients or how big of a barrier cost is? You know, when we think about, you know, sometimes the less invasive infertility treatments like intrauterine insemination, I mean, those sometimes can be hundreds of dollars, but we as clinicians worry that some patients, because IVF is more in the thousands of dollars, can't make it to that treatment. And it's a reason why they sometimes stop treatment. Do you have a sense of how big of a barrier cost is in a treatment? Yeah, you know, it is a barrier.

If you don't have the coverage, whether it be through the state mandate or through your employer, then coverage is a very big deal. Unfortunately, fertility is one of those rare, you know, disease states that isn't sometimes covered by insurance. So, what we look at is, I've done some studies, and, you know, any household income below $100,000, you know, typically struggles to find the resources to, unless they have other resources, to go to the IVF level.

And that's unfortunate. There are some things that we can maybe talk about that would aid patients in being able to move forward, but there is certainly a resource aspect to this that some patients just can't reach that level. Yeah, no, I think that's true.

And I would love to later on talk about some different options for patients. So, how do practices often talk about cost with patients? I think that this is a really hard subject to initiate with the patients, and I can understand that patients might hesitate or be embarrassed to ask how much something's going to cost ahead of time, or even to say that they may have some trouble paying for something. What have you seen, or what do you do in your practice to help ease that conversation for patients or to address those topics? I think you're exactly right.

The patients can be embarrassed or, you know, hesitant to sort of bring this up and sometimes wish that wasn't an issue, but it most certainly is. And I think practices really ought to bring this up as a subject as soon in the patient's journey as possible, so that everything is out on the table, and we're all talking logistically, you know, legitimately about what the options are. And also just take away any of that, as you mentioned, embarrassment or ideas that this could be a problem on the patient's side.

It's really not. It's something that we all want to solve together. The goal is... And to normalize it, right? I mean, I always want to make sure that patients know they're not... I mean, everybody has trouble paying for this.

This is not... Everybody has trouble paying for this. You know, it's a big deal, and we're here to help. And that should be the practice's role to really help.

We have, and I know a lot of practices have what's called a financial counselor role within the practice, and their full-time position for those staff members are to work with patients, A, to, you know, communicate clearly what the options are and what they're going to cost, but then secondly, and just as importantly, if not more, is to help the patients who need extra resources to go out and find those resources, because it can be a maze, you know, when you're talking about if there is insurance coverage, you know, is there pre-authorization required? Is there prior services, you know, prior to IVF required? All of these things that can get really confusing that we can help with with a financial counselor, or if there's not the coverage, you know, and the patient doesn't happen to have, you know, thousands of thousands of dollars under their mattress, you know, where can they go to help find, get some of those cash resources? So a lot of practices will have that financial counselor, and that should really be something that is, as I mentioned before, you know, talked with right up front. Yeah, I think that's important for the patients to understand. I don't think that most practices, I mean, patients can call their insurance and kind of get an overall idea about what their infertility benefits are, but as you know, I mean, as soon as you start asking specific procedures, CPT codes, all diagnostic codes, all that, it's really hard for the patient.

So often infertility practices have a person, and they kind of go behind the scenes, and they can tell the person, here's what you have coverage for, here's how much you have, here's your deductible, here's what you've met, and so patients also need to understand that many practices will help them with that. Absolutely. Yeah.

And remember, this is what these folks do all day, every day. Right, yeah. And you know, so it's not such a hardship to ask, can you help me with this? You know, patients should readily ask the practice to help because they know much more about this.

We deal with fertility and infertility and the costs that are on every day, where as a patient, it's hopefully, you know, once or twice in a lifetime type of thing. Right, exactly. We hope you're finding this episode of SART Fertility Experts helpful.

Remember, for more information on this and related topics, visit www.sart.org and click on the tab labeled patients. And now, back to SART Fertility Experts. Do you have a sense, and you know, I think this really varies from place to place, like if somebody wanted to do an IVF cycle, what have you seen are the average costs of that? Boy, when you say vary, it really varies.

And I've done a little bit of looking around just to see what the current state of things are. And there is sort of the bell-shaped curve, right? So there's the average that you see in most larger metropolitan marketplaces from, you know, $12,000 to $16,000. And there's so many variations now, it's even hard to just come up with even that.

But if you're just talking about the IVF process with a retrieval and a fresh transfer, you know, like I said, $12,000 to $16,000 is pretty common. But boy, you get out to the ends of that curve and there are some wild variations both on the top end for some premier centers or they promote themselves as such. And then some, what they call really low costs and I would say high volume type of centers, such as, and they like me to say this, you know, CNY in New York advertises very broadly that, you know, under $4,000 for an IVF cycle.

So it can really, really vary. Right. And I think patients also need to understand that, you know, some practices, you know, will kind of charge a package price.

Some of them kind of do more of like an a la carte. So, you know, if a patient doesn't need, you know, ICSI, which is a special way to fertilize a sperm, they may need, you know, they may save money there or, you know, how much medication somebody needs can really impact their amount of money they pay by several thousand dollars, you know, what other kind of testing needs to be done. So I have also seen that, you know, anywhere from, I don't know, eight to $15,000, I think is probably a fair assessment depending on, you know, the location and what the patients need.

Talk a little bit about what patients can do to try to manage this. So, you know, one of the things I think about with insurance is some patients have insurance coverage, but there can be rules, right? So what are some of the implications about sort of having insurance coverage? Or I would say the goods and the bads. The goods and the bads of insurance, you know, to your point, some of the insurances do have rules.

And I think the first thing with insurance coverage is to make sure what the specifics are of your particular insurance company. Because if you don't follow the rules, insurance companies will often not be super flexible and, you know, you could be out a significant portion of money. But the other thing is, you know, there's what I've seen is there's really two sort of different types of insurance out there.

And one is more of a dollars-based insurance. So you could have insurance and the insurance company says, hey, you have, you know, $10,000, spend it on what you want. And that can often drive patients to, you know, to your point to want to do lower cost sort of cycles and IUI cycles and so forth.

So they don't use up all that money all in one or, you know, sometimes it's not even enough for a full IVF cycle. But more commonly now, insurances are doing more of a cycle-based coverage. So you get two cycles covered or three cycles covered.

And what that does is really maximizes the chances for the patient to have a baby and doesn't bring in the, to your point, the a la carte sort of cost. So it's really important to understand what type of insurance you have and then talk with your provider about, you know, what's the best way to utilize those, that insurance resource. Right.

I mean, I know in our, sometimes we have patients who their medications, you know, are part of that chunk of money and it ends up actually being a better option for them to self pay for the medicines because they can get a lower price and to use their benefit for the IVF procedures. And so, and again, usually the practices work with the patients that are pretty good at knowing kind of how to navigate that system to help benefit the patients. But I do think it's good for the patients to kind of understand that part of things also.

Sure. But to your point, make sure you're not doing it alone. Because again, the practices have had a lot of experience with these insurance and what is the best use of the insurance dollars.

So seek that help for sure. What can you tell us about shared risk programs? There are some infertility practices that are, are offer patients shared risk. Can you talk about that? Sure.

You know, the, the most sort of solid definition of shared risk is where you would sign up for a program with up to so many IVF cycles. So a patient's, you know, or a practice will say, Hey, we have this program. You can have up to, you know, three IVF cycles until you have a baby.

And if you don't have a baby, then we're going to give you all of your money back. And that's kind of the shared risk. So if you become pregnant and have a baby on your very first cycle, you may be paid more than you would have sort of fee for service or a la carte, but you did take home a baby.

So, and so you're risk sharing with the practice. But on the other hand, if you go for three full cycles and, and do not take home a baby, as they say, then, you know, they would get either a full or partial refund. So I think under those scenarios, you really want to look at, you know, what the commitment level is from, from the patient's perspective.

If you're in for, you know, you're going to have a baby regardless of what the cost is or the number of cycles, these are good programs sometimes to look at. There's also a sort of a variation where, you know, there may not be a refund, but the practice may say, we'll give you up to, you know, two cycles or three cycles without a refund, but we'll give you a discount on those if you choose to pay for them all up front. And you have to kind of look at sort of the cost benefit of that, because again, once you become pregnant and take home a baby, you don't get to get that money back if you didn't, you know, if you wouldn't have spent that under a fee for service arrangement.

So it's something to really talk to the practice about it and think about. Right. And sometimes there's restrictions on the shared risk programs where sometimes certain patients aren't eligible.

And so obviously, you know, again, the practice will help, but the patients need to understand if that program is even an option for them. And sometimes practices don't even have that as a option in their practice. What have you seen in terms of options for assistance, financial assistance, meaning loans, grants, financing? What are options out there for patients? Yeah, there certainly are loan programs that are available, and we've seen that most patients, you know, if needed, can, you know, can get a loan if they need to, usually through the practice is the best way to do it.

So if you're getting a financial, like, you mean the practice gives them a loan? Or do you mean that there's a financial company that the practice is working with that they'll direct the patient to? Yeah, it's a great question. It's typically a third party institution that provides loans, but the practice is often the one that will take care of some of the application, and the third party will often pay the practice directly. So it's kind of a three-way agreement, but it is a third party.

And what you find with those loans, you know, the patient sort of determines how much they need from a loan, and then they apply for that under a typical sort of loan application. And those loans, you know, are certainly less than a credit card loan. So it's way better to, you know, utilize a loan like this than it would be your credit card, but they're still fairly high interest.

You know, they can be in the 8%, 9% range. So you just have to kind of plan for that if that's what you want to do. Yeah.

Yeah, I think that, oh, let me just say, I think what I've seen is there's several financing companies that are, like, maybe only do infertility financing. And sometimes you can put just the cycle. Sometimes you can add your medication, so you can take out different amounts.

And yeah, and then they determine the, you know, interest level based on maybe your credit score and that kind of thing. That's a good point. You know, if you are a patient and your credit score, you know, isn't as great as it could be, and you have co-signers that are available, maybe parents or something like that, we've utilized co-signers on these loans as well to get a better interest rate.

So that's something to look at. And I always tell patients too, I don't know your thoughts on this, you know, you know, they can also, it doesn't have to be the company in the office. You know, if they have a local bank that they, you know, want to use, I mean, you know, it doesn't have to be a specific type of loan from the office.

It can be really a loan from anything if that's what they, if that's what they think is right for them. Certainly home equity loans, you can potentially access those at a lower rate. So if you have a banking relationship, I would look into those options as well.

Yeah. There are some grants I've seen and some patients have applied for grants in the past. I think they're definitely few and far between, but sometimes patients will find different organizations online that they can apply to grants as well for infertility cycles or treatments.

We've seen that. I think to your point, they are few and far between. A lot of the grants that I've seen are part of a promotional situation for a practice or an awareness campaign or something like that.

So they're actually pretty rare with the exception of most practices for fertility preservation. So for cancer patients, we'll have some sort of program that would help. And also you can apply for free medications under those programs as well.

So if you happen to be one of those patients that are going through this group for true medical reasons like cancer, then the grant situation is much different and that needs to be something that should be looked into and the practice should be able to help you with that for sure. I was also wondering about any sort of, I don't know, tax breaks because it's medical treatment, or sometimes patients ask if they can use their HSA or their FSA. Do you have any thoughts on those topics? A good question.

If a patient has an HSA, HRA, FSA, any of those alphabet soup type of situations, typically fertility treatments would fall under that. So you could use those funds pretty much across the board as far as I know if you have those available to you. The tax break is an interesting thought as well.

The way the federal law works is if someone spends more than 10% of their gross income in any given year on any type of medical expense, then they can itemize and deduct that from their taxes, which can be a big break. So if you think about a patient who spends $12,000 or $15,000 on a single IVF cycle and then adds that to all of their other medical expenses for the year, and this would include premiums for their insurance. So the premiums that you pay through your employer, you can add that as well.

And if you can get up to 10% of your gross income, which with IVF cycles you may be able to do that, then you can deduct that from your taxes and that would be a big break. So definitely look into that option. That's good to know.

Okay. And then the other thing I just wanted to talk about is sometimes we have patients who are doing infertility treatments and they're involving either, maybe they're doing IVF because they need to do genetic testing of embryos because they're looking for a specific disease, or maybe they're using an egg donor, but their insurance covers some parts of the process, but not the whole thing because they're using an egg donor. Have you seen patients get partial insurance coverage if they have a sort of a different type of treatment cycle? Yeah, absolutely.

And that gets back to our original conversation of if you have insurance, you really have to understand what's coming. It's pretty common to see exclusions, especially around donor services. So donor egg services, the donor sperm, we've seen coverage where anything that is done with the patient itself is covered, but anything outside of the patient, such as the donor gametes aren't covered.

And so you have sort of this split situation and often those will involve authorization processes as well. So definitely work with the practice on that, but can't expect, in some situations, exclusions based on donor services or third-party services. You know, it's interesting, the ASRM has a relatively new diagnosis of infertility, and now it includes that you can be diagnosed with infertility if you can't have a child with your partner.

And so I think a lot about our same-sex couples who are told, well, you can't access your infertility benefits because you don't have infertility, because you've never tried with someone of the opposite sex. And I have been encouraging some of our women using donor sperm to go back to their employers and say, here's our new diagnosis of infertility. I have infertility because I can't conceive with my wife, and therefore I want to access my infertility benefits.

And I think it's worked at least in one situation. So I think, and that's something you mentioned too, is that if you really, a patient can sometimes go to their employer or go to their human resources person and say, you know, this is something that I want to be able to access just like anybody else, or this is something that's important to the employees that work here, and we want to have coverage. Advocacy is a big deal, right? And you hit it on the head.

You need to go to your employer because they're the ones ultimately that are providing the benefit, and they can add those benefits if they so desire. And most employers want to take care of their people. They just may not know that the need is out there or that the desire is out there.

If they find out about it, then they can do something about it. We've certainly seen that, as I mentioned before, in the tech industry. A lot of these services are now covered by the tech industry, and you can even maybe provide some examples to your employer of what other employers are doing and that they should be keeping up with the Joneses, so to speak.

Right, and so I think as we kind of are getting to the end of our conversation here, I just wanted to ask if you had any other thoughts about, you know, how patients can talk to their providers about treatment and feel comfortable doing that, and potentially more important, how can the providers and the offices do a better job of making it comfortable for the patients? Yeah, it's a good question, and I think the reality is the sooner you can address the subject of finances in this journey, the better. And even if a patient isn't initially interested in going the IVF route, still talking about finances and what may occur down the road is really important. And if there are resources at the practice, for the patients to know, for us to tell them that, you know, it's very commonplace that all patients have to deal with this, and we certainly want to help them have a family, and a big part of that is the financial piece.

So there should be no embarrassment, no stigma. This is just the reality, and we as a team should be able to figure it out. And the earlier we can get working on that part of the journey, as well as the clinical part, I think it's better.

I think that's a great way to summarize all the things we spoke about today. Thank you so much. Again, this is Brad Senstra, and he is the Executive Director at Seattle Reproductive Medicine, and I want to thank him for helping us understand all the financial implications of infertility treatment and IVF treatment.

And again, my name is Brooke Rossi, and thank you so much for joining us for this SART podcast episode. Dr. Rossi, it's been a pleasure. Thank you.

Thank you. Thank you for listening to SART Fertility Experts, your resource for information on IVF. If you found this podcast useful, please like us on your favorite social media platform and tell your friends about us.

For more family-building resources, visit www.sart.org slash patient dash information or www.reproductivefacts.org. The information and opinions expressed in this podcast do not necessarily reflect those of ASRM and SART. These podcasts are provided as a source of general information and are not a substitute for consultation with a physician. Welcome to SART Fertility Experts, a podcast that brings you discussions on important topics for people trying to build a family.