Transforming Women’s Healthcare and Reducing Insurance Costs with MARCH Health  

Executive Summary  

Endometriosis poses a massive economic burden in the U.S., estimated at $78-119 billion annually. Direct costs range from $1,109 to $12,118 per patient yearly, driven by diagnostics like laparoscopy, treatments like hormonal therapy, and surgeries. Indirect costs from absenteeism and presenteeism can reach $16,000 per employed patient. 

Comorbidities like infertility and mental health issues further escalate long-term costs. Insurers should prioritize early detection, comprehensive treatment, and patient-centric models like MARCH Health’s Onion-Layer approach. This model combines screening, AI symptom management, and optimal care utilization, potentially reducing unnecessary procedures by 20-30%, ER visits by 15-25%, and specialist consultations by 10-20%, driving significant cost savings. 

Introduction  

Endometriosis is a chronic gynecological condition affecting millions of women worldwide, leading to significant economic burdens on healthcare systems and insurance companies. This white paper aims to provide a comprehensive analysis of the direct and indirect costs associated with endometriosis, supported by data from various studies. By understanding these costs, insurance companies can better allocate resources and develop strategies to manage the economic impact of endometriosis. 

The State of Endometriosis Costs in the United States  

Women’s healthcare costs in the United States are substantial, with conditions like endometriosis imposing significant financial burdens. According to the systematic literature review by Ahmed M. Soliman et al., the direct and indirect costs associated with endometriosis in the United States are generally higher compared to other countries.  

Staggering Total Costs 

• The total economic burden of endometriosis in the U.S. is estimated to be as high as $78-119 billion annually. 

• The economic burden per patient ($9,754-$14,881) is 11-70% higher than for diabetes ($8,767 per patient). 

These costs manifest in various ways:  

Direct Costs 

A study on women with Medicaid insurance found that patients with endometriosis incur significantly higher healthcare costs compared to those without the condition: 

• 14.5% had an endometriosis-related hospital admission 

• 11.1% had an endometriosis-related emergency room visit 

• 45.6% had an endometriosis-related physician office visit 

The mean total healthcare costs for endometriosis patients were $13,670 during the 12-month post-diagnosis period, with the highest expenditures for: 

• Inpatient admissions ($5,785) 

• Outpatient services ($4,363) 

• Outpatient prescriptions ($2,096) 

A systematic review estimates total direct costs ranging from $1,109 per patient per year in Canada to $12,118 in the USA, highlighting the substantial direct cost burden in the U.S. 

While methodologies vary across studies, the evidence consistently shows that endometriosis imposes a disproportionately high economic burden in the United States compared to other countries, driven by significant direct healthcare costs and indirect costs from lost productivity and disability. 

Diagnostic Costs for Endometriosis 

Endometriosis typically requires diagnostic procedures such as pelvic examinations, ultrasound imaging, and laparoscopy to confirm the presence of the condition. The reimbursement for these procedures contributes to the overall medical expenditure incurred by insurance providers.  

Pelvic Examination 

A routine pelvic examination typically ranges from $100 to $250, depending on the healthcare provider and location. 

Laparoscopic Surgery 

• Laparoscopy (CPT codes: 49320-49329) is considered the gold standard for diagnosing endometriosis. 

• The procedure alone can range from $4,000 to $6,000, excluding additional hospital and anesthesia fees. 

Imaging Studies  

• Imaging Studies (CPT codes: 74000-76999): Ultrasound, CT scans, or MRI may be utilized. Ultrasound imaging for endometriosis diagnosis can cost between $200 and $500 per session.  

Visits (Physician office visit and OB/GYN visit) 

• Physician office visit costs for all-cause healthcare in endometriosis patients were $606, while physician office visit costs specifically related to endometriosis averaged $48. 

• OB/GYN visit costs for all-cause healthcare in endometriosis patients were $60, while OB/GYN visit costs specifically related to endometriosis averaged $19. 

Medical Therapy 

The management of endometriosis often requires various medical therapies, including hormonal treatments and pain management medications, contributing to the overall treatment costs borne by insurance providers. 

Hormonal Therapies 

Estrogen/progestin oral contraceptives, progestins, and gonadotropin-releasing hormone agonists are commonly prescribed. 

• Relevant CPT codes: J1050, J1055, J1056, J3490 

Pain Management 

Opioids and NSAIDs are used for pain relief in endometriosis patients. 

• Relevant CPT codes: J2270, J2275, J3490 

In a study on Medicaid patients: 

• Pharmacy costs for all-cause healthcare in endometriosis patients were $2,096 (SD = 6,173). 

• Pharmacy costs specifically related to endometriosis averaged $212 (SD = 941). 

Surgical Treatments 

Endometriosis often requires surgical interventions for treatment and diagnosis: 

• 65.8% of endometriosis patients underwent endometriosis-related surgery. 

• 40.2% had a hysterectomy (CPT codes: 58150-58294). 

• 31.5% underwent laparoscopy (CPT codes: 49320-49329). 

Surgical costs range from: 

• $4,852 for a diagnostic laparoscopy (CPT codes: 49320-49329) 

• $12,894 for an abdominal hysterectomy (CPT codes: 58150-58294) 

Indirect Costs  

Endometriosis is associated with substantial indirect costs, primarily driven by lost productivity due to absenteeism and presenteeism. These indirect costs can be equally or even more significant than the direct medical costs of managing the condition.  

Estimated Indirect Costs  

One study estimated the indirect costs, including days of work lost and reduced productivity, were almost $16,000 per patient per year for endometriosis patients in the U.S. The same study by Castelli-Haley et al. found that the average incremental indirect costs (absenteeism, short-term disability, long-term disability) for endometriosis patients were $2,132 per patient in the 12 months following diagnosis, compared to matched controls. 

Absenteeism and Presenteeism  

Endometriosis-related symptoms, such as pelvic pain, fatigue, and gastrointestinal issues, often lead to absenteeism from work or reduced productivity while at work (presenteeism).  

• Indirect costs due to productivity loss ranged from $3,314 per patient per year in Austria to $15,737 per patient per year in the USA. 

• On average, women with endometriosis miss 10.8 hours of work per week due to symptoms, leading to significant productivity losses for employers.  

• Absenteeism costs ranged from $1 per employed woman per week in Nigeria to $280 in Italy. 

• Across 10 countries, the average indirect cost from productivity loss was $9,911 per employed patient per year. 

• Presenteeism (reduced productivity at work) costs ranged from $4 per employed woman per week in Nigeria to $303 in the USA. 

Mental Health Costs  

Endometriosis is a chronic condition that can have a profound impact on an individual’s mental well-being. The physical symptoms, pain, and emotional distress associated with the disease can increase the risk of developing mental health conditions, such as depression and anxiety. Addressing these comorbidities adds another layer of expense to the overall healthcare costs related to endometriosis.  

• According to the World Endometriosis Research Foundation (WERF), approximately 60% of women with endometriosis experience symptoms of anxiety, and around 25% experience symptoms of depression.  

• A study in Northern Cyprus found that the odds of endometriosis cases reporting an anxiety diagnosis were 1.56 times higher than symptomatic controls and 1.95 times higher than asymptomatic controls.  

• Prevalence rates for depression and anxiety as high as 48% have been reported for women with endometriosis.  

• The review by Trilliant Health also highlighted that women with endometriosis displayed higher rates of anxiety and depression (1,539 per 10,000) compared to those without endometriosis (572 per 10,000). 

While mental health management costs are not provided in studies, we can estimate potential costs based on general mental health care expenses in the U.S: 

• Therapy sessions (CPT code: 90837-90834): The average cost of psychotherapy in the U.S. ranges from $100 to $200 per session, according to a 2019 report. In 2021, the average cost per therapy session was around $150. 

• Medications (CPT code: 99213): After a series of therapy appointments, a patient may be referred to a psychiatrist for medication management, further increasing the costs. 

• Hospitalizations (CPT code: 99221-99223): For those requiring inpatient treatment, the costs can be staggering. One individual shared their experience of a three-day inpatient stay costing nearly $20,000, with only $6,000 covered by insurance, leaving them responsible for over $12,000. 

• The high costs often stem from charges for emergency room visits, hospital stays, medication, and physician fees, which can quickly accumulate. 

Health insurance coverage for mental health services is often inadequate. Only about 55% of psychiatrists accept insurance, well below the average for all healthcare professionals. 

Many insurers provide little or no coverage for out-of-network care, forcing patients to pay out-of-pocket for mental health professionals in their area. 

Even with insurance, patients may face high deductibles, copays, and costs for prescription medications, especially newer drugs. 

Long-Term Impact  

The long-term impact of endometriosis on insurance companies extends beyond immediate medical and indirect costs. Chronic conditions like endometriosis may result in complications and comorbidities that require ongoing management and surveillance. These long-term implications include:  

Reproductive Health Services  

Endometriosis can adversely affect fertility, leading individuals to seek assisted reproductive technologies (ART) such as in vitro fertilization (IVF) or intrauterine insemination (IUI). 

• Endometriosis is a leading cause of infertility, affecting 30-50% of those with the condition. 

• The average cost of a single IVF cycle in the U.S. ranges from $12,000 to $15,000, excluding additional medications and services. 

• The direct medical costs of ART can be prohibitively expensive, representing a significant economic burden for patients. 

• Health insurance coverage for fertility treatments like IVF and IUI is often limited or excluded entirely in the U.S. When covered, it helps reduce the out-of-pocket costs borne by patients. 

• Some U.S. states like Arkansas, Maryland, and Rhode Island mandate insurance coverage up to lifetime limits of $15,000 – $100,000 for IVF. 

• For those with endometriosis requiring ART to conceive, lack of adequate insurance coverage adds to the long-term financial burden of managing their condition and pursuing fertility treatment. 

Comorbidities and Complications  

Women with endometriosis have a higher prevalence of comorbid conditions like ovarian cysts, uterine fibroids, pelvic inflammatory disease, interstitial cystitis, irritable bowel syndrome, constipation, and ovarian and endometrial cancers. 

Studies have shown that endometriosis patients have higher odds ratios for conditions like fibromyalgia, chronic fatigue syndrome, autoimmune diseases like lupus, and cardiovascular diseases compared to matched controls. 

Comorbidities associated with endometriosis necessitate additional medical care, testing, treatments, and healthcare resource utilization, driving up direct and indirect costs. 

Also, Patients with more comorbidities tend to experience higher diagnostic delays, leading to accrual of substantial disease burden and costs before diagnosis. Patients with long diagnostic delays (3-5 years) had 60% higher mean all-cause pre-diagnosis healthcare costs ($34,460) compared to those with short delays (≤1 year) ($21,489). 

Economic Burden in Other Regions 

The economic burden of endometriosis varies by region, reflecting differences in healthcare systems and economic conditions. 

Hungary 

Annual Health Insurance Expenditure: A nationwide study based on routinely collected real-world health insurance claims data estimates that the NHIFA spent EUR 1.91 million on endometriosis treatment in 2019. 

• Pharmaceuticals: 48.20%. 

• Acute Inpatient Care: 31.63%. 

• Outpatient Care: 6.25%. 

Sweden 

Mean Annual Cost per Woman: A study estimates the mean annual cost per woman with endometriosis to be EUR 8,768. 

• Direct Healthcare Costs (EUR 4,282): Including inpatient care, outpatient visits, emergency room visits, and surgical procedures (CPT codes: Various). 

• Indirect Costs (EUR 4,486): Absenteeism from work and reduced productivity while at work. 

Addressing the Economic Burden: Strategies for Insurance Companies 

To effectively mitigate the substantial economic impact of endometriosis, insurance companies should prioritize proactive measures that emphasize early intervention, comprehensive treatment approaches, and patient-centered care models. 

Promoting Early Detection and Intervention 

• Invest in initiatives that promote early detection and intervention for endometriosis 

• Provide coverage for screening tests and preventive services to encourage timely medical care 

• Early intervention can mitigate disease progression and reduce long-term healthcare costs 

Supporting Comprehensive Treatment Approaches 

• Emphasize coverage for comprehensive treatment approaches, including medications, surgery, and adjunctive therapies 

• Improved access to multidisciplinary care teams and specialized centers of excellence can optimize treatment outcomes 

• Comprehensive treatment can minimize the need for costly interventions in the future 

Prioritizing Patient-Centered Care Models 

• Tailor insurance coverage to prioritize patient-centered care models, such as MARCH Health’s Onion-Layer model 

• Holistic approaches like personalized health coaching, virtual consultations, and AI-driven symptom management can enhance patient satisfaction and adherence 

• Investing in patient-centered care can improve health outcomes and reduce long-term healthcare costs for endometriosis patients 

By implementing these strategies, insurance companies can proactively address the economic burden of endometriosis while improving the quality of care and overall well-being of individuals with this chronic condition. 

MARCH Health’s Innovative Solution  

MARCH Health’s Onion-Layer model offers a comprehensive solution to reduce the costs and burdens of endometriosis for both individuals and employers. This model comprises five layers of personalized care, each aimed at early detection, proactive management, and ongoing support:  

Early Detection and Intervention  

• Screening with Diagnostic Kits and Questionnaires 

• Utilizing non-invasive urinary analysis and blood test kits for early screening 

• Advanced algorithms identify symptoms and risk factors for early diagnosis and tailored treatment plans 

• Early detection and intervention may reduce the need for costly surgeries by 20-30% 

Proactive Symptom Management  

• AI-Developed Recommendations and Medical Support 

• AI-driven insights and personalized health management tools for effective symptom tracking 

• Medical Support Bot offers immediate assistance, reducing need for emergency care 

• Proactive symptom management could decrease emergency room visits and hospitalizations by 15-25% 

Optimal Resource Utilization  

• Health Coaching and OBGYN Meetings 

• Personalized interactions with health coaches and virtual OBGYN consultations 

• Ensures appropriate level of care, preventing unnecessary specialist consultations or treatments 

• Optimal resource utilization may reduce unnecessary specialist consultations and diagnostic tests by 10-20% 

Total Potential Cost Savings  

• Early detection and intervention: Assuming an average cost of $4,852 to $12,894 per surgical procedure, a 20-30% reduction could result in savings of $970 to $3,868 per patient. 

• Proactive symptom management: If each emergency room visit costs $1,500 and each hospitalization costs $10,000, a 15-25% reduction could lead to savings of $225 to $1,750 per patient annually. 

• Optimal resource utilization: Assuming an average cost of $500 per specialist consultation and $1,000 per diagnostic test, a 10-20% reduction could result in savings of $50 to $200 per patient per year. 

By combining early detection, proactive symptom management, and optimal resource utilization, MARCH Health’s solution offers the potential for significant cost savings in the management of endometriosis for insurance providers and employers. 

Conclusion  

MARCH Health’s comprehensive approach to endometriosis care not only improves health outcomes for individuals but also reduces the financial burden on insurance companies. By facilitating early detection, proactive symptom management, and optimal resource utilization, our solution minimizes healthcare costs associated with endometriosis while enhancing patient well-being and productivity. 

Through collaboration with insurers and employers, MARCH Health aims to transform the landscape of women’s healthcare and alleviate the economic burden of endometriosis on healthcare systems. Our innovative Onion-Layer model offers the potential for significant cost savings in the management of endometriosis, benefiting both patients and insurance providers. 

References  

1. Fuldeore, M., Yang, H., Du, E. X., Soliman, A. M., Wu, E. Q., & Winkel, C. (2015). Healthcare utilization and costs in women diagnosed with endometriosis before and after diagnosis: a longitudinal analysis of claims databases. Fertility and sterility, 103(1), 163–171. https://doi.org/10.1016/j.fertnstert.2014.10.011  

2. Simoens, S., Dunselman, G., Dirksen, C., Hummelshoj, L., Bokor, A., Brandes, I., Brodszky, V., Canis, M., Colombo, G. L., DeLeire, T., Falcone, T., Graham, B., Halis, G., Horne, A., Kanj, O., Kjer, J. J., Kristensen, J., Lebovic, D., Mueller, M., Vigano, P., … D’Hooghe, T. (2012). The burden of endometriosis: costs and quality of life of women with endometriosis and treated in referral centres. Human reproduction (Oxford, England), 27(5), 1292–1299. https://doi.org/10.1093/humrep/des073  

3. As-Sanie, S., Soliman, A. M., Evans, K., Erpelding, N., Lanier, R., & Katz, N. P. (2020). Healthcare utilization and cost burden among women with endometriosis by opioid prescription status in the first year after diagnosis: a retrospective claims database analysis. Journal of medical economics, 23(4), 371–377. https://doi.org/10.1080/13696998.2019.1707212  

4. Ellis, K., Munro, D., & Clarke, J. (2022). Endometriosis Is Undervalued: A Call to Action. Frontiers in global women’s health, 3, 902371. https://doi.org/10.3389/fgwh.2022.902371  

5. Armour, M., Lawson, K., Wood, A., Smith, C. A., & Abbott, J. (2019). The cost of illness and economic burden of endometriosis and chronic pelvic pain in Australia: A national online survey. PloS one, 14(10), e0223316. https://doi.org/10.1371/journal.pone.0223316  

6. Soliman, A. M., Surrey, E., Bonafede, M., Nelson, J. K., & Castelli-Haley, J. (2018). Real-World Evaluation of Direct and Indirect Economic Burden Among Endometriosis Patients in the United States. Advances in therapy, 35(3), 408–423. https://doi.org/10.1007/s12325-018-0667-3  

7. Soliman, A. M., Surrey, E. S., Bonafede, M., Nelson, J. K., Vora, J. B., & Agarwal, S. K. (2019). Health Care Utilization and Costs Associated with Endometriosis Among Women with Medicaid Insurance. Journal of managed care & specialty pharmacy, 25(5), 566–572. https://doi.org/10.18553/jmcp.2019.25.5.566  

10. Csákvári, T., Pónusz-Kovács, D., Kajos, L. F., Elmer, D., Pónusz, R., Kovács, B., Várnagy, Á., Kovács, K., Bódis, J., & Boncz, I. (2023). Prevalence and Annual Health Insurance Cost of Endometriosis in Hungary-A Nationwide Study Based on Routinely Collected, Real-World Health Insurance Claims Data. Healthcare (Basel, Switzerland), 11(10), 1448. https://doi.org/10.3390/healthcare11101448  

11. Missmer, S. A., Tu, F. F., Agarwal, S. K., Chapron, C., Soliman, A. M., Chiuve, S., Eichner, S., Flores-Caldera, I., Horne, A. W., Kimball, A. B., Laufer, M. R., Leyland, N., Singh, S. S., Taylor, H. S., & As-Sanie, S. (2021). Impact of Endometriosis on Life-Course Potential: A Narrative Review. International journal of general medicine, 14, 9–25. https://doi.org/10.2147/IJGM.S261139  

12. Swift, B., Taneri, B., Becker, C. M., Basarir, H., Naci, H., Missmer, S. A., Zondervan, K. T., & Rahmioglu, N. (2024). Prevalence, diagnostic delay and economic burden of endometriosis and its impact on quality of life: results from an Eastern Mediterranean population. European journal of public health, 34(2), 244–252. https://doi.org/10.1093/eurpub/ckad216  

13. Soliman, A. M., Yang, H., Du, E. X., Kelley, C., & Winkel, C. (2016). The direct and indirect costs associated with endometriosis: a systematic literature review. Human reproduction (Oxford, England), 31(4), 712–722. https://doi.org/10.1093/humrep/dev335 

14. Sunderam S, Kissin DM, Zhang Y, et al. Assisted Reproductive Technology Surveillance — United States, 2016. MMWR Surveill Summ 2019;68(No. SS-4):1–23. DOI: http://dx.doi.org/10.15585/mmwr.ss6804a1 

15. Eisenberg, V. H., Decter, D. H., Chodick, G., Shalev, V., & Weil, C. (2022). Burden of Endometriosis: Infertility, Comorbidities, and Healthcare Resource Utilization. Journal of clinical medicine, 11(4), 1133. https://doi.org/10.3390/jcm11041133 

16. Surrey, E., Soliman, A. M., Trenz, H., Blauer-Peterson, C., & Sluis, A. (2020). Impact of Endometriosis Diagnostic Delays on Healthcare Resource Utilization and Costs. Advances in therapy, 37(3), 1087–1099. https://doi.org/10.1007/s12325-019-01215-x