How Times Have Changed

I still remember the day that my Dad came home the hospital completely outraged over the actions of one of the other surgeons practicing at Quincy City Hospital (where my Dad had served as Chief of Surgery and President of the Medical Staff at various times over his 30 year career). Wow, I figured the guy must have done something really bad as even my Mom was shaking her head and lamenting how far the medical profession had fallen. The crime that the physician in question had committed? He had taken out a display ad for his practice in the Yellow Pages!

I have never really spoken to my Dad about advertising in IVF, but he has seen the ads in the Boston Globe (not mine, of course, as I am in Washington DC), noted them in the inflight magazine for American Airlines and heard them on the radio in Boston. This is a competitive field and since much of the treatments are out of pocket decisions can be driven by financial considerations. Hence the development of the “Financial Guarantee” or “Shared Risk” programs.

I have mixed feelings about these programs and I really don’t want to sound like the cashiers at Best Buy: “Are you ABSOLUTELY sure that you don’t want to buy the Extended Warrantee on that DVD palyer…Tsk, Tsk.” So what do I tell patients? I tell them 2 things:

1) No good IVF program is losing money on their Money Back Programs because the candidates are either the patients with the best prognosis for IVF success OR the patient must agree to use an egg donor if they fail to stim well or have poor quality embryos with repeated IVF attempts.

2) The only patients who have gotten mad at me are the ones who could have done a money back program but elected not too. They tell me “Dr. Gordon, if I knew that I wasn’t going to get pregnant the 1st time then I would have done the guarantee program.” Heck, if I knew who was and wasn’t going to get pregnant I wouldn’t have to work anymore and I could retire to my seaside mansion nextdoor to all the insurance company CEOs.

So go ahead and peruse the “Question of the Day” and if you leave a comment by midnight tonight we will throw in the Ginsu Knife set for FREE.

19. How expensive are infertility treatments?

Some insurance plans may cover the cost of fertility treatments. In those patients without insurance coverage, the cost of fertility treatments varies widely depending on the specific treatment utilized. For example, a cycle of ultrasound monitoring without the use of fertility medications, culminating with intrauterine insemination (IUI), may cost $1300 to $1500 in many clinics. Compare this with the cost of IVF with intracytoplasmic sperm injection, freezing of extra embryos, and assisted embryo hatching, for which the price tag can total $14,000 to $16,000, which must then be added to the cost of injectable fertility medications ($2000 to $4000). The use of donor-egg IVF, although extremely successful, is also very expensive, because the donor must be reimbursed for her time and effort as part of the treatment and also because of the extreme screening tests mandated by the FDA. The price for donor-egg IVF typically ranges between $25,000 and $30,000, depending on the clinic.

In most cases, the more expensive, more invasive fertility treatments usually result in the highest pregnancy rates. Couples are advised to carefully consider the proposed course of treatment and the costs that may be involved. Many IVF centers in the United States offer “money back” (refund) programs. A couple accepted into such a program pays a premium that covers several fresh IVF cycles as well as frozen embryo transfers (FET). If they fail to conceive or are deemed to no longer be appropriate candidates for treatment, then all or a percentage of their initial payment is refunded.

These programs have remained somewhat controversial but can allow couples to pursue other options if IVF proves unsuccessful. According to the ASRM Ethics Committee Statement of June 2006: The controversy surrounding such programs relates in part to the concern that such arrangements “appear to violate long-standing ethical prohibitions against paying contingency fees in medicine. This concern is based on Opinion 6.01 of the AMA Code of Medical Ethics, which states, “a physician’s fee should not be made contingent on the successful outcome of a medical treatment.” Furthermore, the Committee Statement (which can be found on the ASRM website at http://www.asrm.org/Media/Ethics/ethicsmain.html) concludes, “the risk-sharing form of payment for IVF is an option that might be ethically offered to patients without health insurance coverage for IVF if certain conditions that protect patient interests are met.

These conditions are that the criterion of success is clearly specified, that patients are fully informed of the financial costs and advantages and disadvantages of such programs, that informed consent materials clearly inform patients of their chances of success if found eligible for the risk-sharing program, and that the program is not guaranteeing pregnancy and delivery. It should also be clear to patients that they will be paying a higher cost for IVF if they in fact succeed on the first or second cycle than if they had not chosen the risk-sharing program, and that, in any event, the costs of screening and drugs are not included. “The Committee was especially concerned about the incentives that risk-sharing programs create for providers to take actions that might harm patients in order to achieve success and avoid a refund. For risk-sharing programs to be ethical, it is imperative that patients be aware of this potential conflict of interest, and that risk-sharing programs not overstimulate patients to obtain a large supply of eggs or transfer more embryos than is safe for the patient, fetus, and prospective offspring. Patients should be fully informed of the risks of multifetal gestation for mother and fetus, and have had ample time to discuss and consider them prior to egg retrieval.”