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Evaluating Infertility Treatment Financing Plans
The text below is from RESOLVE, the national infertility support group. Their Web site is: http://www.resolve.org/ .


Questions to Ask about Medical Treatment Package Plans
by Diane N. Clapp, BSN, RN
Medical Information Director, National RESOLVE

MANY CONSUMERS lack adequate health care insurance for infertility treatments, particularly for the assisted reproductive technologies (ART). As a result, some clinics have begun offering financing mechanisms that promise a specified number of ART cycles for a fixed fee, often with a "guarantee" that some portion of the fee win be refunded if treatment is unsuccessful. Such plans are sometimes referred to as "outcome based fee schedule plans," "shared risk plans," "money-back guarantees" or "treatment package plans."

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Medical treatment package plans may provide benefits to consumers because (depending on the number of ART cycles utilized), such plans may lower the cost per cycle as compared to conventional payment plans. In addition, the promise of "money back" in the event treatments are unsuccessful may provide consumers with the financial resources to pursue other family-building options, such as adoption.

Several concerns have been raised about these package plans, however. For example, some clinics may accept only patients whose diagnoses suggest a high probability of successful treatment. And patients who are successful in their first cycle of treatment will pay more than if they used conventional payment plans. Moreover, because the clinic is simultaneously serving as a medical provider, and bearing financial risk much as an insurer does, a potential conflict of interest may exist. There are concerns that this dual role may create incentives to change standard treatment protocols or, for example, to transfer a greater number of embryos than would otherwise be recommended, thereby increasing the likelihood of multiple gestation.

Concerns about the outcome-based nature of package treatment plans led the American Medical Association to issue a policy statement in June. 1996 stating that "basing payment on medical outcomes is unethical and in violation of the AMA's existing code of medical ethics." This position is a matter of debate within the infertility community. The Society for Assisted Reproductive Technology (SART) Executive Council approved a public statement paper on the topic of outcome based fee schedule plans. In their statement, SART states, "In this time of managed care, ILMO, PPO and other discounted fee schedules, it would appear to be untimely to assign any ethical stigma to any fee arrangements as long as complete disclosure has been accomplished." SART's statement also includes "At the same time, the SART Executive Council continues to have serious concerns about the potential of practices exploiting a very vulnerable patient population by: misleading advertising, severely limiting the access of patients to an outcome-based fee (OBF) cycle by overly restrictive criteria (e.g. age, FSH), requiring expensive and/or unnecessary testing prior to accepting a patient into an OBF program, premature or inappropriate use of ART in patients who would be better served by less invasive and less expensive treatment and inappropriate use of ART techniques such as excessive embryos transferred or excessive ovarian hyperstimulation in an attempt to increase pregnancy rates at the expense of patient safety." The SART paper also stressed the need for these "fee schedule plans" to provide answers to consumers questions.

Within the broader infertility community, there are also concerns about how these financial plans may affect efforts to achieve comprehensive insurance coverage for all people who experience infertility. Infertility is a recognized disease that should be treated the same as other diseases for insurance purposes. Package plans differentiate infertility from other medical diseases and conditions, as no other treatment comes with a "money-back guarantee."

If you are considering purchasing in a medical treatment package plan that offers a specified number of cycles of the assisted reproductive technologies for a set charge, you may want to consider the following questions when evaluating a medical program.

INFORMATION ABOUT PROGRAM SERVICES AND SUCCESS RATES

  • Does tm program have written information describing what is included in the package plan?
  • Does the clinic report its ART success rates to The Society for Assisted Reproductive Technology (SART), a division of the American Society for Reproductive Medicine?
  • Does the clinic/program audit success rates for shared risk programs separately from the rest of the practice?
  • Does the clinic have multiple sites? If so, are success rates for each site reported?
  • Under the terms of the agreement or contract, what is the actual determinant of "success"? How does the clinic describe "success"? Is it a clinical pregnancy, or live birth? For example, if you miscarry, is a refund made?
  • If you are making a large down-payment for a guaranteed number of cycles, how much, if any, money is refundable if you become pregnant after one cycle? Is your "down-payment" placed in escrow for possible return to you or are "package" payments co-mingled with general clinic funds?
  • Does the program have any policy in the event that ovarian stimulation does not result in a sufficient number or quality of oocytes or if the cycle is canceled?
  • A few clinics offering treatment plans require that the couple have one of the treatments used to treat possible immunologic response that may affect implantation. These treatments may include aspirin, Heparin or intravenous immunoglobulin therapy. These treatments are considered experimental. You may want to get a second opinion before you proceed with treatment. Is this cost included in the package?


INFORMATION ABOUT SCREENING

  • What testing is required to be accepted into the program? Are the costs for screening tests included?
  • Is there an age restriction for package plan patients?
  • Are patients who have particular medical situations such as elevated FSH levels, DES exposed uterine problems, etc., not eligible for the package?
  • Is it necessary to send your medical records prior to treatment for acceptance into the program?
INFORMATION ABOUT TREATMENT CYCLE
  • Will there be any differences in your treatment versus the standard fee-for-service patient?
  • Is there a waiting list to start a treatment cycle?
  • Is all medication monitoring done on-site or can you use a local clinic to monitor the initial phases of a treatment cycle?
  • Are there restrictions on how many cycles you can do in a set period of time and are you have to take rest cycles? If so, for how long?
  • Does the program have guidelines regarding the number of oocytes or pre-embryos transferred? Are there any requirements with regard to fetal reduction?
INFORMATION ABOUT COSTS
  • What, if any, arrangements can be made to use your health insurance? Can you get an itemized bill to submit for insurance purposes?
  • Is the cost of fertility drugs included in the package price? If not, what can you expect w pay for these drugs?
  • Does the package fee include intracytoplasmic sperm injection (ICSI), assisted hatching and co-culture if needed?
  • Does the package include fees for cryopreservation and a thaw cycle?
  • If donor sperm is needed, is the cost included in the package?
  • If donor egg is used, is the cost included in the package?
  • What happens if you decide after one cycle not to continue with the program? Is there a refund?
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