-Originally published by Benefits and Pension Monitor magazine in their October 2020 issue (page 37)-

If you're reading this at time of publication, you’re probably sick of hearing words like ‘epidemic’. Before you scroll away, I need to talk to you about a very important Canadian epidemic that pre-dated COVID-19.

This epidemic is under the radar, and extremely stigmatized. It is the widespread medical condition which is impacting 1 in 6 couples of childbearing age, as defined as ages 18 to 43.

It's infertility - the struggle to add a child to the family through conception.

That could mean any form of conception on the spectrum, but Canadians increasingly are requiring medical and financial help to grow their families.

The help they are turning to can be as little as downloading a free app to monitor their cycle, or as invasive as spending tens of thousands of dollars on medical interventions. This may include hormonal blood tests (AMH), cycle monitoring, intrauterine insemination (IUI), in-vitro fertilization (IVF), surgery, or engaging a gestational carrier (‘surrogates’) to bring the child to life.

Before we go any further, let’s straighten something out: choosing to have a child through any means should not be considered a negative knock against the person. People have struggled with fertility issues since human beings existed, and we must maintain a non-judgemental approach when viewing this category of medical care.

It’s my opinion that all plan sponsors should be considering adding some form of support for fertility in their group benefits plan.

This doesn’t need to break the bank: there is a way to underwrite a reasonable amount of fertility expenses in group insurance plans, without increasing premiums. I’ll share the answer in a minute, but first, let’s look at all angles.

The Patients’ Perspective

From an employee’s perspective, if they’ve been trying to conceive for awhile with no success, and are now at the point of needing to seek medical help, please know that it’s been a very stressful process.

According to the Mayo Clinic, the rate of miscarriages, defined as the spontaneous loss of pregnancy before the 20th week, happen in about 10 to 20 percent of all pregnancies. Women who have gone through a miscarriage report that it’s one of the most stressful life events to take place, which is still highly stigmatized. Employers may not see it, but productivity during that time will plummet, and puts a person at risk of going on a sick leave.

Employees feel like they can’t tell HR, since it will flag that they may be off work for an extended period of time, potentially interfering with career advancement.

Going to a fertility clinic for cycle monitoring can involve having to go in every day for a few hours, five days per month. Employees generally need to find excuses to tell work as to why they’ve been late every day, and so often. They may eventually feel pressured to tell work, thereby exposing their private medical details, and putting the company at risk of abusing that privileged information.

At the same time, these employees are very loyal. They often can’t move jobs because they need flexibility. This holds back their careers but they’re willing to make that sacrifice to stay with an employer who provides leeway.

The employee may be under stress from the familial or societal stigma they face. To be clear, this is not an elective medical procedure or a ‘lifestyle choice’, and although age does contribute to declining fertility rates, age is not the sole reason for infertility.

For example, approximately 1% of all males suffer from azoospermia, defined as the absence of sperm. Regardless of how many times these people try to conceive, without a sperm donor, it will not succeed. Endometriosis is another medical condition that affects women of all ages and impacts fertility. Why would this medical condition not be taken as seriously as psoriasis or arthritis? No-one ever died of lack of sunglasses, but companies that have vision benefits may spend 10% of their health premiums towards prescription lenses. In fact, it’s mandated in 19 states in America that fertility treatments are covered in most health insurance plans.

Plan Sponsor Perspective

I’m an employer and am certainly always looking to reduce costs. That said, there is something to prioritizing fertility coverage to help me attract, retain and care for my employees:

1. My employees are my business. They are my competitive advantage and the life force of my company. I fundamentally care about their wellbeing and their health.
2. Retention - anecdotally, I have spoken to Canadians who say they are more loyal to businesses who helped them conceive their child. Retaining my top talent is a huge priority of mine.
3. Absenteeism and presenteeism - when people struggle to conceive, it creates a stressor that inevitably impacts the workplace.
4. Financial strain - whether or not the individual reports it to us at performance reviews, it will impact their required compensation. If they can’t find it from us, they may find it elsewhere, which may involve loans or family help, but may also involve looking for a better paying position.

Insurance Company / Claims Payer Perspective

Historically, some insurers have provided solid benefit plans with fertility coverage as a minimum that cannot be removed. However, large employers who are self-insured have a greater ability to curate their own plan design. While about one quarter of large benefit plans cover some form of fertility coverage (Conference Board Benefits Survey 2018), most small and medium sized businesses lack this coverage.

In fact, it has been possible for some carriers to allow the removal of this coverage. This typically happens immediately after a claim, which may be reflected on claims statements and increased premiums.

There isn’t a lot of logic to removing fertility coverage after a claim, since they are usually non-recurring items. According to the Trio Fertility Clinic in Toronto, the average person who participates in IVF may need 2 rounds before it’s successful. The good news is that some provinces in Canada cover the first round, but may not cover the drugs required.

At my company Beneplan, our underwriting department ran a report on its block and found that claims for fertility drugs typically are in the $5,000 to $10,000 range, once per lifetime, and may impact premiums by 3% to 5% if seen as a recurring claim. Non-recurring claims are removed from plan experience and do not impact premiums. We spoke to other carriers with whom we underwrite health benefits, and they also echoed the statistics we shared.

I’m willing to bet that insurers are happy to make it easier to include fertility coverage in the range of $5,000, $10,000 or $15,000 of coverage, once per lifetime per plan member. Contrary to public belief, insurance companies don’t necessarily profit the most when very few health claims are submitted. In a transaction-based fee structure, where the carrier is paid a percentage of claims or premiums, the more claims are submitted and paid with permission of the plan sponsor (employer), the greater are their transaction fees.

With national pharmacare looming, and a post-pandemic reality of depressed claims, I would venture to say that health benefits processors are already looking at how to expand the definition of a ‘health benefit’ while maintaining favourable tax status.

The Costs

In order to find an extra 3% to 5% savings on the health benefit without negatively impacting patient care, the most seamless solution is to do one of three things:

1. Implement a managed drug formulary - save 3% or more on health premiums

A ‘managed drug formulary’ is a fancy term for a curated list of drugs that prioritizes medicines that have the highest patient value for the more reasonable cost base. It de-prioritizes expensive drugs that have safe and effective therapeutic alternatives. Beneplan groups who implemented either The Reformulary with Co-operators or Green Shield Canada’s Conditional Formulary saved an average of 9% of drug spend per year, year over year (n= 1154 lives, 2015).

2. Switch from fully-insured to self-insured (ASO) - save 5% to 10% of fees

If an employer can bear the risk, they may be able to unlock surplus premiums within their benefit plan. Talk to your advisor if this model fits your risk tolerance.

3. Switch from a fully-insured to a partial refund plan - save 5% - 10% of premiums

More carriers are offering a refund of surplus benefit plans. Again, talk to your advisor if your carrier allows this without increasing risk.

Finally, aside from costs, it may be the right thing to do to help educate your workforce about their options. Companies like Lilia, Modern Fertility or Ava are helping employers teach people that they have choices and don’t need to jeopardize their career in order to start a family.

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Yafa Sakkejha is the CEO of Beneplan. For full disclosure, she is an angel investor in the startup Lilia.

You can connect with Yafa on linkedin at https://www.linkedin.com/in/yafasakkejha