The importance of clinical leadership when it comes to cost accounting and planning fertility services

FERTILITY AND STERILITY威 VOL. 73, NO. 6, JUNE 2000 Copyright ©2000 American Society for Reproductive Medicine Published by Elsevier Science Inc. Printed on acid-free paper in U.S.A.

The Importance of Clinical Leadership When It Comes to Cost Accounting and Planning Fertility Services To the Editor: The article by Stovall et al. (1) is one of the few meaningful presentations of data relative to the cost of infertility care to consumers. The approach is startlingly simple, straightforward, and open. Not surprisingly, so are its implications. This soundly done work fulfilled its purpose of providing information from prospective experiential data and concludes [1] that, under the circumstances evaluated, a comprehensive infertility benefit covering both diagnosis and an entire range of available treatments can be provided at a reasonable cost to employers and insurers—somewhat less than 0.8% of total group health care costs, and at a reasonable cost to the insured—for about $.70 per member per month; and [2] that costs for fertility treatments are significantly less when compared with other selected medical diagnoses. Although it was not part of their stated purpose, they demonstrated that a well-designed fertility benefit can be implemented, delivered, and tracked successfully if coding is openly, honestly, and rigorously applied with a defined cap on the dollar amount of services available. It is of interest to note that only about 5% of patients required ART (-? IVF/GIFT). Cost assessment can be a treacherous exercise, and the authors appropriately point out limitations to the accuracy of their data. Those factors that might result in an underestimation of direct economic costs include [1] the inability to monitor male fertility care at other facilities, [2] the inability to audit appropriate coding for fertility-related care at outside facilities, [3] failure to include patient copayments (though stated to be small), and [4] limitation of access to care for women 42 years of age and older without use of donor oocytes. Those factors that might result in the overestimation of costs include [1] a unique population with a high proportion of highly educated patients who are of reproductive age that would be more likely to seek fertility treatments, and [2] unlimited access to ART, including patients with prior sterilization. The authors’ diagnostic and therapeutic approach strengthens the broader applicability of this experience, which I suspect does not differ significantly from that of most reproductive endocrinologists in 1999. In fact, their ART success rates seem to be comparable to many published in the literature and, therefore, might reasonably be consid-

LETTERS TO THE EDITOR ered respectable benchmarks for acceptable quality of care (outcomes) at present. In calculating the costs of providing this care they acknowledge that costs often designated as indirect—such as lost wages associated with evaluation and treatment—were not included, but counterbalance this by not including the potential cost savings of early intervention in disease processes and those cost savings associated with increased productivity from improved physical and mental well being (both true of other illnesses as well). The costs of subsequent obstetrical care and complications thereof are not included, and outcomes are measured in terms of pregnancy rates per initiated cycle rather than live births. One might philosophically argue the correctness of these omissions, but they do not seem to meaningfully detract from the value of the information provided given its focus. However, an important facet not addressed by this study deserves comment. The study population was a self-insured, fee-for-service health care plan with Blue Cross/Blue Shield as the third party administrator (TPA). The actual payments made by the TPA for a general infertility code were used as a surrogate for “costs” in this study. This muddies the water a bit because “payments” made by the TPA do not necessarily equate to charges made for the services provided. Payments by the TPA represent their costs (less general office overhead, marketing, and administration) for the services provided. The average calculated per member per month cost of approximately $.80 per month (plus copays) represents cost to the patient for the services they receive. Neither of these, however, reflects the cost to health care professionals for services rendered. Those costs are a summation of the value of the value of their time plus charges to them for the goods and labor they require to provide these infertility services. This is no small point. One would assume that in the setting described in this article (irrespective of provider charges) the reimbursements received (copay plus TPA actual payments) covered the costs incurred by the providers in a satisfactory manner, because their system has been ongoing for almost a decade. These comments are not made to detract from the importance of the data in this article. On the contrary, its publication is almost certain to generate more interest in insurance coverage for the symptom of infertility, which is often indicative of a disease process altering the function of the reproductive system— usually identifiable but sometimes obscure. As these discussions evolve, decisions regarding acceptable reimbursement levels must take into account the 1263

cost of providing professional services, a focus about which most physicians have exhibited little interest. In the absence of charitable or government support, medical enterprises must make a profit in order to continue to exist to serve their patients. McFarlan (2) attributes the following sentiment to the first dean of the Harvard Business School: “the objective of any business is to deliver goods and services at a profit in a decent [emphasis added] way.” At the medicine/business interface we have to keep our eyes on “all sides” of the ball! Barry S. Verkauf, M.D. 2919 Swann Avenue Suite 305 Tampa, Florida December 15, 1999

References 1. Stovall DW, Allen ED, Sparks AET, Syrop CH, Saunders RG, VanVoohris BJ. The cost of infertility evaluation and therapy: findings of a self-insured university health care plan. Fertil Steril 1999;72:778 – 84. 2. McFarlan FW. Working on nonprofit boards, don’t assume the shoe fits. Harvard Business Review 1999;77:64 – 80.

PII S0015-0282(00)00508-2

Reply of the Author: We thank Dr. Verkauf for his interest and thoughtful comments about our paper. We agree with him completely that payments made by a third party administrator do not necessarily equal charges, and that both are surrogates for the cost of providing a service. In a large academic center, the costs of providing services are difficult to determine, which forced us to use payment for infertility services as our measure of “cost” in this paper. In addition, one of our purposes was to evaluate the cost of providing infertility care from the perspective of an insurance company because there has been great reluctance in covering infertility care by so many companies. As suggested by Dr. Verkauf, the reimbursements we have received for infertility care have covered the costs of providing care in our center as we have been able to work “at a profit in a decent way” for many years. We hope that Dr. Verkauf is correct that our work generates more interest in insurance coverage for infertility. Dale W. Stovall, M.D. Department of Obstetrics and Gynecology Medical College of Virginia Richmond, Virginia January 18, 2000 PII S0015-0282(00)00509-4

1264 Letters to the Editor

All That Chocolate—BUT Where Did It Come From? To the Editor: I read with confusion the article by Jain and Dalton regarding chocolate ovarian cysts (1). Part of my confusion relates to the authors’ opinion that all chocolate cysts are endometrioma cysts, and thus the terms can be used interchangeably. This is especially confusing in light of their later acknowledgment that not all chocolate cysts are endometrioma cysts. In support of this opinion, they claim a 97% sensitivity in diagnosis of endometriomas by visual means alone, ignoring other studies that have found sensitivities of only 0% (2) and 47% (3). Indeed, most of the chocolate cysts in Sampson’s study (3) were histologically proved not to be endometriosis, and generations of authors have made the same misinterpretation of this work that Jain and Dalton make. Interestingly, Sampson (3) cites a paper by Runge from the German literature of 1903 whereby serial sections of the ovary indicated that invagination of the ovarian surface led to the eventual formation of ovarian endometrioma cysts. Sampson was not the first to describe chocolate cysts, and Hughesdon (4) was not the first to use serial sectioning to postulate invagination of the ovarian cortex in the formation of endometrioma cysts. The authors repeat another common error in restating that the ovaries are the most common site of involvement by endometriosis. Modern computer database analysis has clearly refuted this (5). The authors depend too heavily on introductory physiology when they state that corpus luteum cysts will always regress after a subsequent menstrual flow, as I’m sure many gynecologists have eventually removed a persistent cyst that was histologically proved to be a corpus luteum. I know I have on several occasions. Is it possible that the authors have simply confirmed that corpus luteum cysts develop from follicles? A few questions need more detailed answers. During follow-up ultrasonography, when did the cyst walls become thickened? Could this simply be an appropriate reaction of the wall of a retained corpus luteum cyst to irritation by the bloody fluid? The authors indicate that in 4 of their 12 patients, chocolate cysts were confined histologically. Does this mean that endometrioma cysts were confirmed? Finally, it seems unusual that during a 9-year interval only 12 patients with an eventual laparoscopic diagnosis of ovarian chocolate cysts had undergone serial ultrasounds. David B. Redwine, M.D. Bend, Oregon December 1, 1999

References 1. Jain S, Dalton ME. Chocolate cysts from ovarian follicles. Fertil Steril 1999;72:852– 6.

Vol. 73, No. 6, June 2000