A pretty strong case against consumer directed care

I’m normally a proponent of unleashing American consumers’ well-honed shopping skills in the health care industry, but I’m having difficulty reconciling that with a front page article in today’s Wall Street Journal (Multiple Births Persist as Doctors Buck Guidelines.) In vitro fertilization is the ultimate consumer directed procedure. Patients generally pay out of pocket and there is excellent, publicly available information about the quality of clinics, including pregnancy rates and percentage of births that are singletons, twins, and triplets and above.

And still, patients are making bad decisions that can have devastating medical, social, and financial consequences. In particular, patients push to have multiple embryos implanted, which leads to multiple births. Having triplets or quads sounds exciting, but the babies tend to be sick or disabled leading to hundreds of thousands of dollars or more of neonatal intensive care costs, and additional costs down the road. Even healthy triplets and quads place a major strain on family finances and marriages. Finally, the practice of “reduction,” i.e., aborting one or more fetuses has the potential to undermine support for abortion in general.

Some clinics achieve high pregnancy rates and a low rate of higher order multiples simultaneously, but on the whole patients don’t seem to be seeking them out. Maybe it would make more sense for managed care companies to cover fertility treatments the way they cover other procedures. They could direct patients to clinics that combine high pregnancy rates with low multiple birth rates and also save on the neonatal intensive care that they are paying for now anyway. Perhaps consumers don’t deserve to make these decisions.

October 7, 2005

21 thoughts on “A pretty strong case against consumer directed care”

  1. I’m a semi-professional infertility patient (3 artificial insemination attempts, plus 4 IVF attempts), and am very active in RESOLVE (the national infertility organization) and in a number of online communities for infertile woman. All told, I correspond regularly with hundreds of infertile women. And I have to say that this article does not at all present the typical “state of the union” regarding IVF treatment in the United States in 2005.

    As the article noted, the latest data they have is from 2002. Things have changed quite a bit since then. These days, most reputable US clinics will TRANSFER (“implant” is the wrong terminology – how I WISH we could guarantee implantation!) only 1 or 2 embryos for women under 37-38 years, and only 3 for women older than that.

    The one exception might be if there is a proven history of _multiple_ prior failed IVF attempts. It used to be more common to put all available embryos back in this case, but now it is more common to do PGD (pre-implantation genetic diagnosis) or blastocyst culture to determine which embryos are the best 2 or 3 to put back. Both are new procedures that have only become commonly available in the last 2 years. Blastocyst culture does not cost incrementally more, and PGD costs about $2K per cycle, compared to total IVF cycle costs of about $10-$15K.

    These days, a more likely cause of multiples is not from IVF, because the number of eggs that are fertilized and then put back into the womb is strictly controlled. If one just takes infertility drugs (injectibles, pills) and then has either an artificial insemination done or does it the “natural way”, then the number of eggs produced and fertilized is uncontrolled.

    Contrary to your statement “having triplets or quads sounds exciting,” _none_ of the hundreds of women I know undertaking infertility treatment wants triplets or more (although many want twins). I think your statement is a bit dismissing and assumes that patients don’t know what they’re doing. On the contrary, IVF patients are usually highly educated about their condition and understand the prematurity and health problems inherent in multiples. They are spending over $10K on treatment and have likely struggled for several years with a major medical condition, trying everything first.

    And finally, more complete medical coverage for infertility is definitely a solution to this problem. Although people claim that IVF is an expensive procedure, from a total-cost point of view it is far less than having out-patient surgery done to correct reproductive abnormalities and is usually far less risky. Patients are left optimizing THEIR side of the cost equation, which leads them to choose an insurance covered surgerical repair to their reproductive organs instead of an uncovered IVF, even though IVF is usually more successful, less risky, and less expensive from the total-cost point of view. It also leads patients to push for higher order transfers of embryos.

    I do agree with the article’s assertion that some clinics try to manipulate their published success rates by cherry-picking the best patients and outright rejected patients with failed prior cycles, poor response to medications, age >40, etc… In my experience, the clinics with these criteria tend to be the worst ones and the least connected to the latest thinking in the field.

    Sorry for taking over your blog with such a long comment.

  2. David,

    I can’t link to the article, so I’ll take some educated guesses as to why consumers make choices they do. I suspect couples choose centers that are relatively close to where they live. Secondarily, they may choose places with high success rates. The risk of premies and multiples is known, but this consideration is trumped by the desire to get pregnant, period.

    I doubt that embryo “reduction” might weaken support for induced abortion. The zeitgeist does not favor a serious consideration of “when life begins” and under what circumstances that life should be ended. Dire predictions from certain quarters concerning Supreme Court nominees notwithstanding, induced abortion is widely accepted in the U.S., and it’s here to stay.

    Finally, I have not seen head-to-head cost comparisons, but I suspect that adoption is cheaper than IVF, though the former is not cheap by any means.

    One of the many tragedies and unintended consequences of the emergence of reproductive technologies has been the virtual disappearance of adoption of American babies.

  3. .
    I have to take issue with Susan’s assertion that more complete medical coverage for infertility is definitely a solution to this problem.

    There is no justification for this. On the contrary, IVF is purely a matter of choice; by her logic, adoption should be a covered medical expense. Mandating such benefits — and a mandate is what it would take to make this happen — simply adds more cost to the health insurance premium equation.

    IVF, like breast enhancement/reduction surgery, or male hair transplants, is not a candidate for effective risk management.

    And yes, I am explicitly stating that breast enhancement, male baldness cures, and IVF are of a piece. That is, there is no medical necessity inherent in any of them.

    And further yes, my wife and I experienced some problems with conception before we were blessed with our two lovely daughters. It never occurred to us that this would necessitate asking for assistance from our insurance.

    This is a lifestyle choice, not a medically necessary procedure.

  4. Actually, adoption is usually more expensive than a single IVF cycle.

    A typical IVF cycle costs $10K-$15K depending on how much medication you need. The costs for adoption can vary wildly, but are typically $15K-$25K for both domestic and international. With the cost being the same, many people opt for International adoption because there is only a small chance of the adoption falling through at the last minute, where here in the US birthmothers can change their mind after the baby is born, and after the adoptive couple already paid all her expenses and been through the emotional wringer.

    I’m not sure what is meant by Anonymous’s comment regarding the “disappearance of adoption of American babies.” Virtually every healthy newborn baby born in the US is adopted within months, regardless of race. At any time there are three times as many couples seeking to adopt as babies available for adoption.

    And as far as hgstern’s comments, well gotta say I heartily disagree. First, infertility is a condition, and 90% of the time a specific medical cause can be identified.

    Second, having children is a major life activity, not a “lifestyle” choice akin to plastic surgery or hair replacement. The medical inability to have them has been proven to cause as much stress as losing one’s arm or leg. Sure, you can live without the arm or leg. But is it really a “life style” choice to want to seek medical treatment for a genuine medical problem? Do you _really_ equate your two lovely daughters with a pair of lovely breast implants? If so, I feel badly for them!

    The “savings” that hgstern wants from not covering including infertility in insurance coverage are false. To work around the lack of coverage, people opt for more expensive, less successful procedures that are covered (laparoscopies, varicocele repair, etc). Multiple gestations occur because it’s financially unrealistic for couples to transfer just one embryo, and each twin (and more) pregnancies costs a LOT more than covering several single-embryo infertility procedures.

  5. .
    I notice that Susan took the ad hominem route, rather than address the factual statement that there is no medical necessity to IVF, and therefore no reason to be a covered expense.

    I understand that you take this personally, but that has nothing to do with the irrefutable argument that it infertility is not — in and of itself — a medical condition that requires treatment, let alone reimbursement by a third party.

    Perhaps had I said “Viagra” instead of “breast implants” then Susan would understand that this is not a he/she argument.

    The bottom line is, there is no compelling argument for covering IVF under an insurance contract.

    Want more proof? The gummint doesn’t even recognize IVF as a legitimate (eligible) expense for reimbursement under FSA/HSA/HRA.

    I’m sorry if you’re offended, none is intended. It’s just that we keep hearing about how expensive insurance is, and at the same time we need to cover this procedure or that, but there is no risk management analysis applied, nor even common sense.

  6. The bottom line is, there is no compelling argument for covering IVF under an insurance contract.

    With an insurance contract, the US Treasury pays part of the cost. With direct payment, you pay all. This is due to the US federal income tax deduction given for money laundered through an insurance company. The difference is particularly large if two cycles are paid for in different tax years, and can amount to several thousand dollars.

  7. I guess it all comes down to what types of medical conditions you believe are “medical necessities.”

    I think we all agree that life-threatening illnesses are medical necessities. But what about things that are not life-threatening but prohibit “major life activities”? I would argue that medical treatment to help someone see, walk, run, hear, care for one’s self, have sexual relationships and, yes, reproduce are medical necessities. All these things are defined as “major life activities” under the Americans with Disabilities Act and by the US Supreme Court. To me, that seems to have a bit more weight than the lack of

    Stepping away from the plastic surgery analogies (which I did not regard as sexist, because infertilty affects both men and women), let’s take an example that is a lot more inconsequential than having an anomaly in your reproductive organs that prevents you from bearing children: let’s take knee surgery. You play sports, twist your knee and require surgery on your knee ligaments. Now, you won’t die if you don’t have the surgery, but you might limp around for the rest of your life. Most people, myself included, would say ABSOLUTELY that insurance should cover the surgery. Where do you stand on this?

    Because I’ll tell you what, I personally would take a permanent limp over never ever having children any day of the week.

    And finally, you are incorrect in that the IRS _does_ indeed allow you to deduct IVF costs as medical expenses on your taxes and under FSA plans. Please see IRS publication 502. Looks like this bit of “proof” is actually on my side!

  8. Maybe not being able to walk isn’t a medical condition that requires treatment or reimbursement either.
    Being able to have children is a natural and fundamental part of being human and living life. Maybe hgstern will gain this insight one day. But I’m afraid he’ll have to go through a lot of suffering for that.

    (And yes, we do take this personally)

  9. I 100% think Susan is right in all that she is saying. And you better believe that I take this personally. – Sophie

  10. .
    Susan: In regard to the FSA/HSA/HRA issue, I stand corrected. I had pulled that up last evening, and was looking specifically for a heading of “IVF” or “In Vitro” (stupid pdf won’t let me do a real search, so I was relying on eyesight alone), and completely missed “Fertility Treatments” as eligible expenses.

    My apologies.

    I stand behind everything else, however. And, ladies, the ad hominems do nothing to further your cause. This is not a medically necessary procedure. It is a life-enhancement, perhaps, but there is no medical prrof (or even allegation) that having children is a basic medical function.

    David, I certainly didn’t intend to hijack the thread, or cause acrimony on your blog, so I’ll step away now.

  11. Hey, no one hijacked the thread – I came to read the link from Grand Rounds and found a very interesting debate in the comments! Is there no middle ground? Perhaps insurance covers one or two attempts and patients are responsible for the rest. BTW, infertility has never been an issue for me, but my sister-in-law had twins via IVF on her first try….

  12. An excellent point, Kim. I actually have good infertility insurance coverage; it covers three lifetime IVF attempts. This coverage let me chose the alternative with the least medical risk: single-embryo transfers. If I had to pay for it myself, I might have pushed for transferring two. (My clinic would not allow me to transfer three unless I had multiple failed prior attempts.) The “three tries” limit also encouraged me to cancel my cycles that were not turning out well, prior to the egg retrieval procedure.

    I think 3 attempts is sufficient coverage. If IVF is going to work for you, it probably will within that many attempts. And many people don’t have the emotional energy to go through more than 2 or 3 attempts anyway. A cycle limit would actually free most unsuccessful women to move on to other options (as I am doing now).

  13. “Virtually every healthy newborn baby born in the US is adopted within months”

    Makes one wonder why the qualification given to this statement . . . “healthy” newborn.

    “With an insurance contract, the US Treasury pays part of the cost. With direct payment, you pay all. This is due to the US federal income tax deduction given for money laundered through an insurance company.”

    Don’t forget to bring in the grassy knoll conspirators . . .

    Now back to the primary subject matter, I do agree with hgstern that IVF (or any other “medically enhanced” method of fertilization is not a medical necessity. Those who are “pro” on this issue are apparently having difficulty in separating the medical condition from the underlying desire for the procedure(s).

    Consider a port wine stain. This is certainly a medical condition but (except in rare cases) is not something that MUST be corrected to enhance the life of the individual. Corrective procedures are considered cosmetic and thus denied by most (if not all) insurance contracts.

    The same is true for fertility treatments. While some employer contracts do provide for such coverage, that is a conscious choice made by the employer to offer a richer than normal contract.

  14. I was interested in hearing hgstern’s response to the knee surgery analogy. (And I didn’t understand the “Viagra” one; I thought Viagra was covered under many insurance plans.)

  15. Wow! I should check David’s blog more often (our internet is down at work, and yesterday was a holiday – sorry excuses I know)

    In any case, does anybody care to answer the question at hand, which is “why do consumers ignore outcomes data?”

    I suggested above that the passions surrounding this issue (see thread above for abundant evidence) cloud judgment. That’s a shame. Do I suspect correctly that our blogger agrees?

  16. Anon:

    I didn’t respond to your knee surgery analogy because it wasn’t relevant: procedures to repair knee injuries are, by definition, medically necessary, while IVF is not. So it was a false analogy.

    And my point about viagra was that that I don’t believe that it is medically necessary, either. The fact that some (many?) plans cover it doesn’t make it so.

  17. I realize I’m coming a bit late to this post and many of you may have moved on. I’d like to firmly disagree with the idea that IVF cannot be considered medically necessary.

    The disease I have is called endometriosis. It’s a common though peculiar auto-immune problem (doctors believe)resulting from cyclical menstrual bleeding flowing up out of the uterus into the abdomen. I crudely call it uterine backwash. It plays a significant role in my infertility by creating a hostile intrabdominal environment. Defensive white blood cells attack the backflow of tissue causing painful inflammation on implant sites and in my case a orange sized blood filled cyst which hemorrhaghed for some time. Pictures taken during my laproscopic procedure showed a rust textured stain down the length of my fallopian tube and uterine wall. This blood was being routinely attacked at each menstrual cycle. Typically this reaction prevents a healthy egg from surviving the entrance to the fallopian tube and hence proper fertilization. Other entirely common symptoms are extemely painful cycles. I am typically disabled for four days a month, I have lost consciousness because of the intensity of cramps. I take narcotics which abuse my stomach, I routinely vomit during my period. Urination is painful due to the proximity of the auto-immune attack to the bladder as well as bowel movements.

    Pregnancy is recommended by my gynecologist as the best management and likely only cure. Medical management of endometriosis is also possible through months long injections of the drug Lupron, putting me into a premature menopause. This would obviously eliminate the option of a pregnancy and a long term cure.
    If I am unable to sustain a pregnancy via IVF, I will likely have to spend some quality time with syringes of lupron to regress my disease. It’s that or have the “you could lose a kidney” talk with my doctor.
    This is certainly harmful to life and to my ability to be a contributing member of society. Would you hire me knowing that I’m going to call in sick four days a month and be on narcotics two or three more days beyond that? I wouldn’t. Perhaps no one deserves to have children, but I should certainly deserve to avail myself of of minimally invasive technology that would solve my chronic pain difficulties, allowing me to live as a normal, non-disabled person.

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