Quality of Healthcare Access for Women Survey

Executive Summary

Female Reproductive Health Coverage

A national survey of benefits managers reveals that reproductive health coverage in many US companies is broad, but not deep. While common products such as oral contraception are almost universally covered, newer products are less likely to be available and benefits managers are relatively uninformed about advances in reproductive health. Moreover, benefits managers believe that their reproductive health coverage is excellent or good, yet there is a clear gap in coverage between new procedures and the traditional, more common procedures.

This lack of access makes it difficult for women to have the most effective reproductive health products and procedures available today. Garnering coverage for new procedures is complicated by the lack of employee requests for them and the overwhelming belief by benefits managers that insurers make the decisions about coverage, suggesting that any efforts to alter the scope of coverage requires putting pressure on insurance companies rather than employees or internal company management.

These results are based on a survey conducted by Greenberg Quinlan Rosner Research, Inc. of 250 benefits managers completed from April 15 to May 6, 2004 with a margin of error of +/- 6.3 percent. The respondents were from a diverse spectrum of companies with the size of the company ranging from just a few employees to a staff of over 5000. The average size of the company for managers interviewed was about 2300 employees, but the majority of companies range from 100 to 500 employees. The managers are also representative of a range of industries with 26 percent in the service industry, 18 percent in manufacturing and 11 percent in communications, transportation or electric and gas. Only companies that offer their employees health insurance were used for this survey.

Key Findings

Benefits managers believe their employees have good reproductive health care coverage. Seventy-three percent of benefits managers claim that the coverage their employees receive for reproductive health is either excellent or good. Only 18 percent say their company offers fair or poor coverage. Managers whose employees are covered by major insurance providers are more likely to believe their employees have excellent or good coverage (76 percent) than those companies that self insure employees (69 percent). Companies with more than a thousand employees (67 percent) are slightly less likely than companies with less than a thousand employees (74 percent) to believe the reproductive health coverage they offer is excellent or good.

Employees rarely make requests regarding reproductive healthcare services and products. Only 10 percent say that employees frequently or sometimes make requests for expanded reproductive health coverage. Fully 65 percent say that employees have not made any requests for more coverage. When employees do ask for more reproductive health coverage, fertility (35 percent) and contraceptives (20 percent) dominate their requests.

Insurance companies control access to care. About half of benefits managers (53 percent) say that insurers frequently or sometimes make recommendations about new reproductive health procedures, while both employee requests (45 percent frequently or sometimes) and the American Medical Association (22 percent frequently or sometimes) less frequently play a role in making recommendations for new procedures.

A majority of companies use a major insurance company to cover employees. Of those interviewed, 58 percent use a major insurance company for their coverage and 38 percent are self-insured, though almost everyone (83 percent) used a third party administrator. Fully 33 percent use Blue Cross/Blue Shield or an affiliate as either their insurance provider or third party administrator. Another 10 percent use United HealthCare.

Insurance decisions driven by cost – not quality or scope of service. Turnover of insurance companies is frequent. An astounding 89 percent of benefits managers have been with their current insurer for a year or less. Of these benefits managers, 58 percent say the reason they switched companies was because of cost. Broader coverage (16 percent) and better service (7 percent) are both secondary to the concern that the benefits mangers place on the cost of their health plan. However, these companies do not stick with their providers for long, with most firms reporting that they have been with their insurer for less than a year.

Insurance companies play the largest role in determining what procedures are covered, however, benefits managers in larger companies believe they have more say about what is covered. Forty-two percent of benefits managers name insurers as the sole decision makers in deciding what new reproductive health procedures are covered. Benefits managers admit they have a limited role in providing input for expanded coverage (12 percent) while 24 percent say the executive leadership of the company is the primary voice in coverage decisions. Fifteen percent say that it is a collaborative effort of all three groups. For companies with 300 hundred employees or less, 53 percent of benefits managers say that insurers are the prime decision makers in coverage. Only 29 percent of benefits managers for companies over 1000 employees defer to insurers and more often the executive leadership is the decision maker (36 percent).

Health coverage is extensive, but expensive for employees. Benefits managers report that 28 percent receive insurance coverage upon employment. A majority of companies (57 percent) offer coverage within the first month of employment and almost all (99 percent) offer coverage by the end of the first year of employment. Despite extending coverage early, only 12 percent of companies offer full coverage and more than a fifth (21 percent) pay over 150 dollars a month in premiums for single coverage. Over a quarter (26 percent) pay more than 400 dollars a month for family coverage. The high costs extend to prescription drugs, which are covered up-front by insurance companies (99 percent), but fully 65 percent pay over 20 dollars for name brand pharmaceuticals.

Scope of Coverage for Reproductive Health

Most companies cover contraceptives and screening procedures, but there is less knowledge and coverage for permanent contraceptive procedures, erectile dysfunction medications and fertility treatment. Almost all companies surveyed cover screening procedures (90 percent cover) and contraceptives for women (89 percent cover). Less than half of companies cover sterilization or permanent contraception (49 percent) or ED medications, while just over a third cover fertility procedures (39 percent). A little over a quarter of benefits managers do not know if their insurance covers sterilization or permanent contraception (27 percent) and erectile dysfunction (ED) medication (28 percent). Fertility treatments are the least likely to be covered (39 percent) and fully one-fifth do not know if they cover it at all.

Bigger companies cover more. Larger companies (1000 employees or more) have more coverage in their health plans. Broadly covered products like oral contraceptives are covered either partially or in full by 83 percent of large companies, while only 75 percent of smaller companies offer full coverage. Fifty-five percent of larger companies cover permanent contraceptives, compared to only 47 percent of smaller companies. Fertility procedures, which are covered by only 39 percent of benefits managers interviewed, are covered by 47 percent of large companies, but only 34 percent of small companies.

High level of coverage for contraceptives is driven by oral contraceptives. Contraceptives, in some form or another, are covered by 89 percent of companies. However, varying types of contraceptives yield different coverage levels. Oral contraceptives are the most broadly covered (81 percent either partial or full coverage) and the morning after pill is the least covered contraceptive product (18 percent). Other products like the patch (59 percent), NuvaRing or diaphragms (54 percent) and contraceptive injections (51 percent) all receive coverage from a majority of companies. Forty-two percent of companies cover IUD placement and the IUD device is covered by 40 percent, but removal is only covered by 35 percent.

Coverage for a newer permanent contraception procedure, hysteroscopic sterilization is least commonly covered. However, specific procedures do show a slightly higher level of coverage in some cases. Both tubal ligation and vasectomies are covered either partially or in full by 54 percent, while hysteroscopic sterilization (Essure) is covered by only 36 percent. Less than a quarter of benefits managers are unable to say whether or not they cover tubal ligation and vasectomies, while nearly 40 percent do not know if they cover hysteroscopic sterilization or Essure. When the knowledge gap is removed, coverage for Essure is more comprehensive, but still less than other permanent contraceptive procedures. A majority of companies cover Essure (59 percent) while 69 percent cover tubal ligation and 70 percent cover vasectomies. This disparity stems primarily from the lack of partial coverage for Essure. Forty-two percent fully cover both vasectomies and tubal ligation, while 40 percent fully cover Essure. However, only 19 percent say their employees have partial coverage for Essure, while 28 percent claim to have partial coverage for both tubal ligation and vasectomies.

Fertility procedures are the top request of employees, yet coverage of individual procedures is limited. While 16 percent of benefits managers report requests for invitro fertilization, only 28 percent of companies cover the procedure. Ovulation induction drugs and procedures, artificial insemination and uterine arterial embolization all have the same level of coverage (26 percent each). Only Myomectomies are covered by fewer than a quarter of companies (22 percent). All of the fertility procedures tested are covered by larger companies (1000 or more employees) at almost double the level of small companies (300 employees or less). However, it should be noted that smaller companies also have a lower response rate for fertility procedures. For example, only 24 percent of companies with over 1000 employees “do not know” about their coverage for invitro fertilization while 42 percent of companies with 300 employees or less do not know.

Coverage for Erectile Dysfunction medications is less common than contraceptive coverage. Forty-five percent of companies cover ED medications with only 21 percent providing full coverage. ED medications are relatively evenly covered across large companies (45 percent) and small companies (42 percent). The only real variance in coverage comes in the premiums that employees pay. Among employees who pay more than fifty dollars a month in premiums a majority (51 percent) offer coverage for ED medications, while only 45 percent of cheaper plans offer coverage.

Screening procedures receive both broad and deep coverage. Overall, 90 percent of benefits managers report coverage of screening procedures. Unlike contraceptives, this covers a wide range of preventative procedures. PAP smears and mammograms are covered by almost all of benefits mangers surveyed (95 percent each). Even advanced PAP smears (84 percent) and thin prep PAP smears (81 percent) are covered by most companies. Four out of five benefits managers also report coverage of breast utltrasounds. Prostate cancer blood test was the only procedure tested for men and is covered by 90 percent of companies. Among all screening procedures, only ductal lavage (38 percent) and HPV DNA reflex tests (35 percent) are covered by less than 80 percent of companies.

Patterns of Coverage

More traditional contraceptive methods receive broad coverage, but newer products are less likely to be covered. Of the contraceptives tested, oral contraceptives are most commonly covered (81 percent). However, newer contraceptives like the patch (59 percent) and the morning after pill (17 percent) have much lower rates of coverage.

Benefits managers lack knowledge of coverage on specific procedures and are less likely to know about recently developed procedures. Benefits managers have a varying degree of knowledge on reproductive procedures. They have knowledge of more widely used procedures such as mammograms (2 percent don’t know), PAP smears (3 percent don’t know), prostate cancer blood test (8 percent don’t know) and oral contraceptives (10 percent don’t know). On the other hand, newer procedures like HPV DNA reflex testing (45 percent don’t know), ductal lavage (45 percent don’t know), Plan B or Preven (44 percent don’t know) and Essure (38 percent don’t know) are less familiar with benefits managers.

New preventative measures have decent levels of coverage, but are low compared to more traditional procedures. PAP smears (95 percent) and mammograms (95 percent) are the most frequently covered of all procedures tested. Again, newer screening procedures such as ductal lavage (38 percent) and HPV DNA reflex (35 percent) received less coverage. This should not be completely attributed to the age of the procedures as many of these new procedures and products are more complex and expensive than their predecessors.

Companies with a higher concentration of African American employees have equal coverage to less diverse companies. Seventy percent of companies that have a higher average of African American employees (20 percent African American or higher) report excellent or good reproductive health coverage and 71 percent of average or lower (20 percent African American or less) companies report good coverage. Among commonly covered products such as oral contraceptives, 79 percent of higher concentrated black companies offer coverage and 83 percent of less concentrated black companies offer coverage. The pattern is consistent across the range of reproductive health products and procedures. For example, the morning after pill is covered by 16 percent of the higher concentrated African American companies and 21 percent of less concentrated black companies offer coverage. All of these differences are within the margin of error.

Knowledge and coverage of procedures do not show a gender gap. While we tested more female reproductive health procedures than male reproductive health procedures, there is no marked gender difference. If anything, there is a slight advantage in coverage for female reproductive procedures. Coverage for erectile dysfunction medications (45 percent) is less common than newer contraceptives, such as the patch (59 percent). Moreover, oral contraceptives are covered by 90 percent of companies and even diaphragms and NuvaRing are covered by 54 percent.

The lack of a gender gap is reinforced by coverage for screening procedures. A more accurate comparison of gender coverage may come from coverage of screening processes. Coverage for PAP smears (95 percent) and mammograms (95 percent) is slightly higher than coverage for prostate cancer blood tests (90 percent). Moreover, employees have access to these procedures at the same levels: prostate cancer blood test (81 percent answer one per year; 5 percent two or more) and a mammogram (88 percent answer one per year; 4 percent two or more).