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Impact of insurance coverage on in vitro fertilization practice patterns: a complex relationship
FERTILITY AND STERILITY威 VOL. 80, NO. 1, JULY 2003 Copyright ©2003 American Society for Reproductive Medicine Published by Elsevier Inc. Printed on acid-free paper in U.S.A.
Impact of insurance coverage on in vitro fertilization practice patterns: a complex relationship William D. Schlaff, M.D. University of Colorado Health Sciences Center, Aurora, Colorado
In this issue, Reynolds et al. ask a practical question that has both intrigued and plagued physicians, insurers, and health policy planners for some time. It has long been speculated that insurance coverage for ART would reduce or eliminate the incentive for patients to request or accept an excessive number of embryos at the time of IVF. Thus, it was hoped that insurance coverage of IVF would reduce the burden of high-order multiple gestations and the necessity of performing the emotionally charged procedure of multifetal embryo reduction.
Received January 29, 2003; revised and accepted February 21, 2003. Reprint requests: William D. Schlaff, M.D., University of Colorado Health Sciences Center, Fitzsimons Campus, 1635 North Ursula Street, Mail Stop F701, Aurora, Colorado 80010 (FAX: 720848-1662; E-mail: [email protected]). 0015-0282/03/$30.00 doi:10.1016/S0015-0282(03) 00575-2
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On the basis of 1998 data from the Society for Assisted Reproductive Technologies and the Centers for Disease Control and Prevention, Reynolds et al. found a modest reduction in the proportion of high-order embryo transfers (three or more) in Massachusetts and Rhode Island (insured states) than in three noninsured states (Indiana, Michigan, and New Jersey) among women 35 years of age or younger. There was no difference in practice in Illinois (an insured state) compared to uninsured states. However, they observed a modest reduction in the actual rate of high-order multiple gestation (three or more gestational sacs seen on ultrasonography) only in Massachusetts compared with noninsured states. In this regard, Illinois did not differ from the noninsured states; the authors speculate that this may be because the total number of cycles covered by insurance is limited in Illinois but not in Massachusetts and Rhode Island. However, in all states, three or more embryos were transferred in most cases (66.4% of IVF cases in Massachusetts, 73.5% in Rhode Island, 83.6% in Illinois, and 81.6% in noninsurance states). These observations would lead us to conclude that insurance status affects the number of embryos transferred and the risk of high-order multiple gestation, but
we must further scrutinize our IVF practices to have a significant impact on this outcome. The study by Reynolds et al. highlights at least two important factors that must be considered in our analysis of this question. First, the authors note that existing data did not provide information on the rate of multifetal reduction. It is impossible to fully understand the proportion of high-order multiple pregnancies without knowing the frequency with which this procedure was performed. Second, and perhaps most important, the authors acknowledge the likely problem that patient samples may differ in insured versus uninsured states. In this study, only women 35 years of age or younger were considered. Yet, given this constraint, the average patient was older in the insured states of Massachusetts and Rhode Island compared to the uninsured states. The authors also observed that in Massachusetts, the implantation rate and number of embryos cryopreserved were lower and the spontaneous fetal reduction rate was higher. These observations suggest that patients in Massachusetts may well have had diminished ovarian reserve compared to patients of similar age in insured states and would lead to the predictable conclusion that women with a poor prognosis for IVF success may be more likely to pursue this treatment option when they have insurance coverage than when they are uninsured. If this is indeed true, these data suggest that the reduction in the proportion of high-order transfers in Massachusetts may reflect the patient sample rather than an active commitment to reduce the number of embryos transferred. We should applaud the authors for their quantitative analysis of the effect of insurance on IVF practice. At the same time, we should use this
information to better refine the questions we need to ask of ourselves. It appears to me that the proportion of high-order transfers is at best only modestly affected by the insurance status of patients. Although insured patients may elect to limit the number of embryos transferred, transfer of three or more embryos continues to be the rule and not the exception. The lowest proportion of three or more embryo transfers was 66.4% in Massachusetts, whereas the highest was 83.6% in Illinois. I believe this high proportion in part reflects our sincere wish to optimize pregnancy rates for our patients. At the same time, we must be sanguine about our incentives for transferring a large number of embryos. In my
FERTILITY & STERILITY威
opinion, the availability of published “success rates” has exacerbated already intense competition among infertility practices, and the data presented by Reynolds et al. suggest to me that the practice of high-order transfers may well be driven more by decisions we make as physicians rather than by decisions made by patients themselves. I wonder if this question could be addressed by comparing IVF practices in highly competitive markets with practices in more geographically isolated centers. I believe that Reynolds et al. have taught us a great deal with their study, and I hope that we can approach the next step of this analysis with introspection and candor.
31
Impact of insurance coverage on in vitro fertilization practice patterns: a complex relationship William D. Schlaff, M.D. University of Colorado Health Sciences Center, Aurora, Colorado
In this issue, Reynolds et al. ask a practical question that has both intrigued and plagued physicians, insurers, and health policy planners for some time. It has long been speculated that insurance coverage for ART would reduce or eliminate the incentive for patients to request or accept an excessive number of embryos at the time of IVF. Thus, it was hoped that insurance coverage of IVF would reduce the burden of high-order multiple gestations and the necessity of performing the emotionally charged procedure of multifetal embryo reduction.
Received January 29, 2003; revised and accepted February 21, 2003. Reprint requests: William D. Schlaff, M.D., University of Colorado Health Sciences Center, Fitzsimons Campus, 1635 North Ursula Street, Mail Stop F701, Aurora, Colorado 80010 (FAX: 720848-1662; E-mail: [email protected]). 0015-0282/03/$30.00 doi:10.1016/S0015-0282(03) 00575-2
30
On the basis of 1998 data from the Society for Assisted Reproductive Technologies and the Centers for Disease Control and Prevention, Reynolds et al. found a modest reduction in the proportion of high-order embryo transfers (three or more) in Massachusetts and Rhode Island (insured states) than in three noninsured states (Indiana, Michigan, and New Jersey) among women 35 years of age or younger. There was no difference in practice in Illinois (an insured state) compared to uninsured states. However, they observed a modest reduction in the actual rate of high-order multiple gestation (three or more gestational sacs seen on ultrasonography) only in Massachusetts compared with noninsured states. In this regard, Illinois did not differ from the noninsured states; the authors speculate that this may be because the total number of cycles covered by insurance is limited in Illinois but not in Massachusetts and Rhode Island. However, in all states, three or more embryos were transferred in most cases (66.4% of IVF cases in Massachusetts, 73.5% in Rhode Island, 83.6% in Illinois, and 81.6% in noninsurance states). These observations would lead us to conclude that insurance status affects the number of embryos transferred and the risk of high-order multiple gestation, but
we must further scrutinize our IVF practices to have a significant impact on this outcome. The study by Reynolds et al. highlights at least two important factors that must be considered in our analysis of this question. First, the authors note that existing data did not provide information on the rate of multifetal reduction. It is impossible to fully understand the proportion of high-order multiple pregnancies without knowing the frequency with which this procedure was performed. Second, and perhaps most important, the authors acknowledge the likely problem that patient samples may differ in insured versus uninsured states. In this study, only women 35 years of age or younger were considered. Yet, given this constraint, the average patient was older in the insured states of Massachusetts and Rhode Island compared to the uninsured states. The authors also observed that in Massachusetts, the implantation rate and number of embryos cryopreserved were lower and the spontaneous fetal reduction rate was higher. These observations suggest that patients in Massachusetts may well have had diminished ovarian reserve compared to patients of similar age in insured states and would lead to the predictable conclusion that women with a poor prognosis for IVF success may be more likely to pursue this treatment option when they have insurance coverage than when they are uninsured. If this is indeed true, these data suggest that the reduction in the proportion of high-order transfers in Massachusetts may reflect the patient sample rather than an active commitment to reduce the number of embryos transferred. We should applaud the authors for their quantitative analysis of the effect of insurance on IVF practice. At the same time, we should use this
information to better refine the questions we need to ask of ourselves. It appears to me that the proportion of high-order transfers is at best only modestly affected by the insurance status of patients. Although insured patients may elect to limit the number of embryos transferred, transfer of three or more embryos continues to be the rule and not the exception. The lowest proportion of three or more embryo transfers was 66.4% in Massachusetts, whereas the highest was 83.6% in Illinois. I believe this high proportion in part reflects our sincere wish to optimize pregnancy rates for our patients. At the same time, we must be sanguine about our incentives for transferring a large number of embryos. In my
FERTILITY & STERILITY威
opinion, the availability of published “success rates” has exacerbated already intense competition among infertility practices, and the data presented by Reynolds et al. suggest to me that the practice of high-order transfers may well be driven more by decisions we make as physicians rather than by decisions made by patients themselves. I wonder if this question could be addressed by comparing IVF practices in highly competitive markets with practices in more geographically isolated centers. I believe that Reynolds et al. have taught us a great deal with their study, and I hope that we can approach the next step of this analysis with introspection and candor.
31