Arkansas law often blocks coverage of infertility treatments for many couples

by Kim Souza (ksouza@talkbusiness.net) 656 views 

Having a baby is one of life’s greatest joys, but one in seven couples trying to conceive will be diagnosed as infertile, according to the National Women’s Health Resource Center. That means after a year of trying to conceive there is still no viable pregnancy.

What those couples are likely to find is if they chose to seek medical intervention, it will come at their own expense. A hefty expense.

While Arkansas is one of 15 states to legislate mandated coverage for infertility in 2013, health professionals said the law has a $15,000 lifetime cap for in vitro fertilization which likely only covers one treatment. There are also a number of loopholes in the law that exempts self-insured companies from providing the in vitro benefit. Many of the state’s largest employers – including Wal-Mart Stores, Tyson Foods, J.B. Hunt Transport, Murphy Oil –  are self-insured.

Dr. Michael Clouatre of Creekside Center for Women in Northwest Arkansas said it’s rare to see his patient’s insurance cover even the basic treatments. Coverage also rarely covers tests which can be used to determine if there is a medical condition requiring laparoscopic surgery such as blocked fallopian tubes or some other obstruction.

In his 20 years of practice he has seen around five to six cases a year. He said given the high number of women professionals in Northwest Arkansas who postpone child birth, many seek a diagnosis in their mid to late 30s.

Clouatre is not a fertility specialist, but as an obstetrics and gynecological physician he does work with patients seeking basic services when they can’t successfully get pregnant after a year. He said when there isn’t a medical problem 60% of couples will conceive within six months without medical assistance.

“Most of the time patients are paying for the services completely out of pocket and there are times when couples simply cannot afford tests and treatments offered locally, (or) much less more expensive treatments at fertility clinics in Tulsa or Little Rock,” he said.

DIAGNOSIS AND TREATMENT
Clouatre said the first step with a possible problem is to do a complete family history. He said 40% of the time the problem involves the male. Many times he said women are not regularly ovulating and that is something consumers can check themselves with over-the-counter tests similar to pregnancy tests. Clouatre said the cost for the ovulation strip tests could run a patient $20 to $40 a month. He said the next step is to prescribe Clomid which will induce ovulation, starting on a small dose to try and regulate the cycles.

“A few years ago Walmart put the generic for Clomid on its $9 prescription list which was a huge help to couples without script cards. The drug was expensive for women not that long ago,” he said. “Over a three-month period of using Clomid and timing intercourse some couples will conceive.”

If more intervention is needed Clouatre said there are diagnostic tests to examine the fallopian tubes for obstruction, but those tests are not covered by most insurance plans. The primary test known as HSG can range in cost between $800 and $3,000 depending on markets. The national average for that test is $1,259.

Clouatre said the test doesn’t always reveal a problem that is believed to be present because of its limitations. In those cases he said exploratory outpatient surgery which is done and laparoscopically is the best way to check the quality of the tubes and check for endometriosis. He said because it’s related to infertility, insurance most times will not cover that expense. Outpatient surgery can range from $5,000 to $15,000 on average.

Clouatre said seeking treatment locally is cheaper than in larger markets, but the cost is still out of reach for too many couples. He said patients can go as far as intrauterine insemination which can be done in the doctor’s office using the husband’s sperm or donor sperm if necessary. He said this procedure allows him to place sterile sperm through the cervix to the top of uterus near the fallopian tubes.

“The harsh environment of the vagina can kill off a large number of sperm and bypassing the vagina and cervix gives the male sperm the best chance to reach an egg,” he said.

Beyond that, Clouatre said he refers his patients to the Tulsa Fertility Center. In vitro fertilization there is about $12,000 for one round. He said if the patient doesn’t get pregnant after one cycle they must pay for round two which is somewhat less but still pricey. In a year’s time he said a patient could feasibly do four cycles of in vitro and the cost would be as much as $40,000, none of which is covered by insurance in most cases.

PLUGGING GAPS
When asked what he would like to be done to fill the gaps in coverage, Clouatre said it would likely have to legislated and the loopholes plugged because it’s doubtful a company will offer it otherwise – at least they haven’t thus far.

American Express made news in December when it began offering insured employees up to $35,000 for infertility treatments including advanced reproductive technology procedures through its health plan. The company also tossed in $35,000 of coverage for adoption and surrogacy events. American Express Human Resource Officer Kevin Cox said employees wanted and asked for the expanded coverage and in trying to retain and attract the talent it needs this was the right move to make because the market is moving in this direction.

Last year professional services firm EY (Ernst & Young) added a $25,000 benefit for infertility, surrogacy, adoption and egg-freezing. Intel also quadrupled its fertility benefit for its U.S. employees last year raising it to $40,000 on treatments and services and $20,000 on fertility drugs.

Clouatre said the corporate moves are commendable, but the trend has not reached Arkansas market sand likely won’t as long as state law exempts the largest employers.

GEOGRAPHIC CHALLENGES
While Northwest Arkansas offers a wide range of healthcare services it’s also important to note patients seeking in vitro fertilization must still travel to Tulsa, Little Rock or some other larger market for those services because there is not a fertility specialist in any of the three local health care systems. Clouatre said traveling outside the local market for care is not only expensive but also a time commitment.

A recent study by scientists at University of Pittsburgh and University of Michigan looked at the number of fertility clinics in the nation compared to population. They found that almost 25 million women of reproductive age in the U.S. don’t live near fertility clinics.

They also noted that 18.2 million women between the ages of 20 and 49 live in metropolitan areas that have no fertility clinics, and an additional 6.8 million women live in areas that only have one clinic and therefore don’t have a choice of provider. However, the remaining 38.1 million — or 60% of the population — live in regions with multiple fertility clinics, which gives them a choice of providers.

“Infertility is by itself a difficult issue for couples to face emotionally and financially,” study co-author Dr. John Harris, of Pitt’s School of Medicine, said in a statement. “Based on geography, many couples who are trying to start families may have only one clinic nearby where they seek these services, and many women with infertility do not have any nearby access to these services at all, adding additional anxiety during an already stressful time of life.”

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