Friday, October 14, 2005

Medical Necessity vs IVF

In our backyard, we have a woodpile from which we feed our fireplace during those notoriously harsh Ohio winters. This summer, a clan of bees decided to make their home therein, a fact of which I became acutely aware when I went to retrieve some wood for our outdoor firepit. Apparently, bees do not like to have their natural habitat disturbed, and I was treated to a stinging demonstration of their displeasure.
I mention this anecdote because, while commenting on an excellent post over at the Health Business Blog, I have managed to set off a swarm of indignant women: another commenter, Susan opined that In Vitro Fertilization (IVF) should be a covered medical expense, and others soon joined the chorus.
I demurred, thus setting off the swarm.
Because I am an insurance critter, I tend to see these things through the simple lens of “risk.” Risk is defined as “the chance or possibility of loss,”and insurance is all about managing risk. I am of the opinion that lifestyle choices such as IVF do not fall under the aegis of risk management. Now, in my own defense, being of the Y chromosome crowd, I am perhaps less sensitive to this issue than XX’ers [ed: is that even a word?]. Nevertheless, I stand by my analysis.
It may be helpful to define what constitutes “medical necessity,” at least insofar as IVF, or Viagra, or baldness cures are concerned. For example, I readily admit that I am close to actually mainlining Rogaine these days, but it does not seem to me reasonable that my insurance policy should reimburse me for that. After all, no one has ever died or became acutely ill by becoming bald. Likewise, search as I have, I can find no evidence that anyone ever became seriously ill, let alone died, because they were unable to easily conceive.
So, what then constitutes medical necessity? Well, according to the standard industry definition, “medical necessity refers to treatment which is required to treat or care for symptoms of an illness or injury or to diagnose an illness or condition that is harmful to life or health.” Thus, we see that IVF fails to meet the threshold of “medical necessity,” ergo it should not be covered by insurance.
But Prof, you may ask, what about all those other “lifestyle” treatments and medications that insurance covers, like Viagra, or “the pill,” or even hair transplants?
There are actually two answers here. The first is that some med’s and procedures are covered because of competitive pressure (Viagra), or collective bargaining (“the pill”). And some, such as hair transplants, are covered by brute force of the gummint. That is, coverage for such treatments has been mandated by various state and/or federal legislatures, and thus became part of the contract, as well as 17% (or more) of the cost of your medical insurance.
So, when an IVF advocate demands coverage for that regimen, she is saying that she believes that you and I should help pay for her to conceive a baby (or babies). There are only two ways that this is going to happen:
An insurance carrier (or some insurance carriers) will determine that this is an under served market, and offer it as an optional benefit. Of course, this presupposes that there is a huge groundswell of folks who want and/or need IVF treatments, and are willing to pay extra for that coverage, and that other insureds don’t mind the premium increase to cover them.
More likely, though, she means that she wants IVF to be a mandated benefit, and thus advocates that the government should force you and me to help pay for her to conceive a baby (or babies). I may well have had my own plans for that money, but will now have to re-budget because those dollars have been forcibly taken from me, and given to her. Somehow, that doesn’t seem quite fair.
Now, I suspect that none (or very few) of those who advocate coverage for IVF really want to take my money from me, nor would they explicitly agitate for that. But that is precisely what they are advocating, whether or not they realize it. Their argument seems to be that they somehow deserve to have children, and I am standing in their way because I am reluctant to help them pay for that wonderful privilege. By this logic, of course, the costs of adoption should then be a covered medical expense as well. Again, I must pull out my lens, squint carefully through it, and declare that neither of these rises to the level of medical necessity, and wishing that it were so isn’t going to change that diagnosis.
It will be interesting to see how those who favor IVF coverage will address this post.
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