Why Insurance Coverage Fails To Close The Access Gap To Artificial Reproductive Technology Andrew Fisher, BSE, MS4 February 10, 2014 Submitted here for consideration for the Perelman School of Medicine Research Paper Prize Competition
INTRODUCTION THE BURDEN AND COST OF INFERTILITY Infertility is a very common and distressing problem for reproductive- age couples. Between 1990 and 2001, the number of assisted reproductive technology (ART) cycles performed per 1000 women of reproductive age increased from 0.68 to 2.36, and the rate of births doubled from 14% to 29%; these rises were most dramatic in states mandating complete coverage (1). Yet, of the 7.9 million reproductive- age women with infertility issues, only 1.2 million obtained a fertility- related medical appointment in 2002 (2). Individuals who did not access ART center care are predominately from lower socioeconomic classes or of African American race. Cost presents a significant barrier to many couples; each IVF cycle ranges from an out- of- pocket cost of between $7,000 and $11,000 (or $38,000 to $85,000 per live infant conceived) (3, 4, 5). Fortunately, empirical studies have shown that state- mandated insurance coverage for ART can enhance ART utilization; ART centers in the few states that provide complete coverage perform 2.8 times more IVF cycles per 1000 women of reproductive age (6). Independent of state- based coverage, utilization of ART services is increasing nationally. Both demand for and utilization of ART services continue to grow; however, data will be presented which suggests that improving ART coverage through state- based insurance mandates will only improve access to a marginal degree. This essay aims to elucidate some of the additional socioeconomic, racial, and geographic factors that impact access to ART treatments. WHY MANDATED COVERAGE WILL NOT CLOSE THE GAP Even if mandated coverage were to be adopted in every state, a gap will persist between the demand for ART services and the utilization rates that result. For example, in
Europe where mandated insurance coverage or full public reimbursement is more common, the gap between insurance coverage and access remains (7). Belgium sees much lower utilization rates in low- income and low- education groups despite both the provision of full public reimbursement and policies that enforce cost- reduction on the part of the ART center and physicians (8). Several studies have demonstrated the positive correlation between IVF availability and mandated coverage as well as the positive correlation between IVF utilization and availability (9, 10, 11). Unfortunately, the actual impact may be finite (for example, a decrease in consumer costs by 1 percentage point of disposable income may increase utilization by 3.2%) (12). Equally importantly, the racial and ethnic distribution of the population, its per capita income, and the geographic variation of centers in relation to the density of populations who require their services impact ART utilization rates (13-29). THE DETERMINANT OF SOCIOECONOMIC STATUS Even when cost and insurance coverage are controlled for, there still exist socioeconomic and ethnic factors that are identified as determinants of ones ability to utilize ART at the international level (13). In one study which examined the impact of legislation that restricted Australian Medicare payouts for fertility treatment (thereby increasing out- of- pocket costs) there was a significant reduction of fresh ART cycles in the first 15 months (14); when stratified by socioeconomic status (SES), the greatest reduction in ART utilization was seen among the higher SES quintiles due to higher pre- existing utilization rates among this group (higher SES quintiles claimed twice as many fresh ART cycles as the lowest SES quintile in 2009) (15). If Medicare payouts instead increase rather than decrease, once can deduce that ART utilization may increase more for higher SES
groups than for lower SES groups. IVF availability correlates positively not only with mandated insurance coverage, but also with both percentage of single persons and median income independently. IVF utilization correlates positively with not only availability but also percentage urbanization and percentage of highly educated older individuals (16, 17). Thus, there exists more to the impact of SES on ART utilization that cannot be completely explained by ability to pay. THE DETERMINANT OF RACE Of all individuals accessing ART, only 16.16% are non- Caucasian non- Hispanic (18). Accordingly, another patient- specific determinant that must be considered is race. Black women received only 6.5% of IVF cycles between 2004 and 2006 (up from 4.5% in 1999) (19), but they compose 7.8% of married, reproductive- age women (20, 21). The data seem to suggest that black women are underrepresented among those receiving fertility care, which is only more unfortunate due to the worse pregnancy outcomes characteristic of this population. Black women are reported to have lower pregnancy and higher miscarriage rates than white women who are able to access ART, and black women tend to struggle with fertility problems longer before they present for fertility care (22). For those women who are successful in accessing ART, they may not be seen at centers that offer the same quality of ART. In 2008 it was shown that black women tended to access ART centers that perform fewer cycles per year and report lower pregnancy rates than the centers accessed by white women (23). These data suggest that the inequity for black women with a greater medical need for higher- level fertility care is deepened by the inaccessibility of equally skilled centers for this population. As a result, while the prevalence of infertility is slowly
dropping among white women, it is rising among blacks (24, 25). The cause for this observation is likely multifactorial, with only part of the equation relating to cost. THE DETERMINANT OF GEOGRAPHY The geographic distribution of ART centers is not designed to follow the proportion of populations who need them. One may speculate that individuals with little disposable income living in urban centers may depend more heavily on public transportation, or may face additional circumstances (such as limited time- off from work) that prevent them from travelling far for healthcare appointments. Thus, it is important to consider the relationship between the geographical location of ART centers and the populations whom they aim to treat. When the number and location of ART centers were studied in relation to the level of mandated coverage, it was demonstrated that, despite the equal rates of reproductive age women in every state, as many as six states were under- or poorly- served by ART centers (<36% of men and women of reproductive age live within sixty minutes of an ART center) (26). Five states were over- served (>95% of the reproductive- age population lives within 60- minutes of an ART center), all of which had mandated coverage (27). The number of ART centers is higher in states with some amount of ART coverage, but considering that one state (Montana) had mandated coverage yet no ART centers (28), the relationship is not directly causal. In fact, 48% of all ART procedures are performed in just six states (mostly in the Northeast), and the majority of the 484 total ART clinics in the United States are located in the eastern United States in or near major cities (29). Until the geographic gaps in ART center- need are filled, individuals struggling with infertility will face inequitable difficulty in receiving fertility care despite any improvement in insurance coverage or affordability of the procedures.
CONCLUSION While improving insurance coverage for ART for individuals with a reduced ability to pay is necessary in creating a more equitable system for ART delivery, it is far from sufficient to close the gap between it and the populations who need fertility care. Although much of the data that this essay s conclusions are drawn from are retrospective or cross- sectional, it is apparent that socioeconomic status, race, and geographic placement of ART centers are all determinants of access whose causal relationships need to be examined further if a more just distribution of fertility care is to be achieved.
References 1 Henne MB, Bundorf MK. Insurance mandates and trends in infertility treatments. Fertil Steril. 2008;89(1):66-73. 2 Chandra A, Martinez GM, Mosher WD, Abma JC, Jones J. Fertility, family planning, and reproductive health of U.S. women: Data from the 2002 national survey of family growth. Vital Health Stat 23. 2005;(25)(25):1-160 3 Collins JA, Bustillo M, Visscher RD, Lawrence LD. An estimate of the cost of in vitro fertilization services in the United States in 1995. Fertil Steril. 1995;64(3):538-545. 4 Collins J. Cost- effectiveness of in vitro fertilization. Semin Reprod Med. 2001;19(3):279-289. 5 Collins J. An international survey of the health economics of IVF and ICSI. Hum Reprod Update. 2002;8(3):265-277. 6 Jain T, Harlow BL, Hornstein MD. Insurance coverage and outcomes of in vitro fertilization. N Engl J Med. 2002;347(9):661-666. 7 ESHRE Task Force on Ethics and Law, Pennings G, de Wert G, et al. ESHRE task force on ethics and law 14: Equity of access to assisted reproductive technology. Hum Reprod. 2008;23(4):772-774. 8 Ibid. 9 Hammoud AO, Gibson M, Stanford J, White G, Carrell DT, Peterson M. In vitro fertilization availability and utilization in the united states: A study of demographic, social, and economic factors. Fertil Steril. 2009;91(5):1630-1635. 10 Henne MB, Bundorf MK. 2008. 11 Chambers GM, Hoang VP, Sullivan EA, et al. The impact of consumer affordability on access to assisted reproductive technologies and embryo transfer practices: An international analysis. Fertil Steril. 2013. 12 Ibid. 13 Lunenfeld B, Van Steirteghem A, Bertarelli Foundation. Infertility in the third millennium: Implications for the individual, family and society: Condensed meeting report from the bertarelli foundation's second global conference. Hum Reprod Update. 2004;10(4):317-326. 14 Chambers GM, Hoang VP, Zhu R, Illingworth PJ. A reduction in public funding for fertility treatment- - an econometric analysis of access to treatment and savings to government. BMC Health Serv Res. 2012;12:142-6963- 12-142. 15 Chambers GM, Hoang VP, Illingworth PJ. Socioeconomic disparities in access to ART treatment and the differential impact of a policy that increased consumer costs. Hum Reprod. 2013;28(11):3111-3117. 16 Bitler MP, Schmidt L. Utilization of infertility treatments: The effects of insurance mandates. Demography. 2012;49(1):125-149. 17 Hammoud AO. Et al. 2009. 18 Henne MB, Bundorf MK. 2008. 19 Seifer DB, Zackula R, Grainger DA, Society for Assisted Reproductive Technology Writing Group Report. Trends of racial disparities in assisted reproductive technology outcomes in black women compared with white women: Society for assisted reproductive technology 1999 and 2000 vs. 2004-2006. Fertil Steril. 2010;93(2):626-635. 20 McKinnon J. The black population: 2000. census brief. August 2001. 21 Greico EM. The white population: 2000. census brief.. August 2001. 22 Seifer DB, Frazier LM, Grainger DA. Disparity in assisted reproductive technologies outcomes in black women compared with white women. Fertil Steril. 2008;90(5):1701-1710. 23 Ibid. 24 Stephen EH, Chandra A. Declining estimates of infertility in the united states: 1982-2002. Fertil Steril. 2006;86(3):516-523. 25 Chandra A, Martinez GM, Mosher WD, Abma JC, Jones J. Fertility, family planning, and reproductive health of U.S. women: Data from the 2002 national survey of family growth. Vital Health Stat 23. 2005;(25)(25):1-160. 26 Nangia AK, Likosky DS, Wang D. Access to assisted reproductive technology centers in the united states. Fertil Steril. 2010;93(3):745-761. 27 Ibid. 28 Ibid. 29 Sunderam S, Kissin DM, Flowers L, et al. Assisted reproductive technology surveillance- - united states, 2009. MMWR Surveill Summ. 2012;61(7):1-23.