The Bargain Baby-maker

GynCor attracted managed-care companies by convincing them that it was in their best interests to cover infertility treatments. “The smarter insurance carriers understand that even where there’s no official infertility coverage, they spend a ton of money on fertility services,” explains Gleicher. “You can say you’re doing tubal surgery to treat advanced tubal disease, or a laparoscopy for endometriosis, but everyone understands you’re really doing it for infertility. In effect, insurers are subsidizing highly inefficient care. The patient may have surgery simply because it’s covered but not have a more effective treatment, such as IVF, because it’s not covered.”
This strategy proved remarkably successful in Chicago, where GynCor swallowed up five major infertility practices. “Physicians were initially skeptical and resistant, but many competitors came to the conclusion that it was smarter to join us than fight us,” Gleicher says. Since Illinois law requires most companies to cover infertility services, several large insurers decided that contracting exclusively with GynCor’s Center for Human Reproduction (CHR) could indeed save them money.

In a cost-cutting strategy, doctors perform many surgeries, including egg retrievals and embryo transfers, in the office rather than in the hospital. At most larger CHR centers, about 20 percent of revenue comes from IVF, versus about one third at New York University. The remainder of CHR’s revenue comes from ovulation induction, the use of medications to stimulate the ovaries to release multiple eggs.

At Columbia, Sauer says, he’s trying to further streamline care by reducing the number of pricey blood tests performed during IVF cycles. In a typical IVF procedure at the nation’s top academic centers, a woman has her blood taken seven to ten times during the month to measure levels of such hormones as estradiol and follicle-stimulating hormone, which tell doctors when to harvest eggs. At Columbia, in contrast, the average woman gets three to four blood tests in a cycle. Sauer argues, “There is no objective evidence that you need these tests, you need them daily, and you need all of them in the conglomerate.”
“You can see the patient on day three and go back and see her again on day nine or ten,” agrees Cornell’s Zev Rosenwaks. “For 90 percent of the patients, you get away with it in the sense that they’ll do fine. But what about the 5 or 10 percent that might have a problem because you overstimulated them? This can lead to an extremely rare but potentially dangerous fluid imbalance causing the liver, kidneys, and heart to fail. I don’t think that’s right. I would rather do 100 times the work on 100 people to avoid complications.”
Rosenwaks and other reproductive endocrinologists also question whether practices dependent on managed care can deliver top-notch services. But physicians associated with GynCor say that while doctors have to account for their spending, no one from the business side tells them how to practice medicine. “This is something GynCor is very firm about,” says Dr. Vishvanath Karande of CHR-Chicago. “If I have a patient I think needs in vitro fertilization, I don’t have to justify it to GynCor.”

But Sauer admits he’s had some “heated discussions” with Gleicher about GynCor’s fairly prescriptive management style. “I tend to spend a lot of time in my initial consults, up to an hour and a half,” he says. “As a result, there’s a two-to-three-month wait to see me. Norbert’s told me he’d like to see my wait time down to two weeks.” Sauer says the only way to do that is to cut his consults down to 45 minutes.

If Chicago is any example, he may end up spending even less time with patients. “In the egg-donor program, I only saw my doctor at the beginning and for the embryo transfer,” says a nonetheless satisfied 47-year-old CHR patient who is pregnant with triplets. “The nurse was the person who called me every day to talk to me about my medication. She kept me on top of how things were going with the donor and told me when to make my next appointment.”
Last year, after receiving complaints that patients’ calls weren’t being returned, Gleicher implemented a new phone system that embodies the new wave in health care: Now patients call specially designated voice-mail boxes where instructions are left for them on how much medication to take that night. The plan is innovative and efficient -- but not exactly the human touch that couples undergoing the emotional roller coaster of fertility treatments might crave.

So far, these complaints don’t appear to apply to Columbia. A 27-year-old trader whose wife is about to give birth to triplets says the couple likes Columbia precisely because of the attentive care. Their doctor, Steve Lindheim, is “compassionate and understanding,” says the husband.

Perhaps even more important to Columbia patients is whether the program will deliver babies at rates equal or superior to its competitors’. Gleicher says it will: “Data from our Chicago affiliates, with large numbers of transfers similar to Cornell’s, suggests you can get rates very comparable to theirs without doing big workups.”

But a look at the latest published success rates, for assisted reproductive technologies performed in 1995, shows a 17.6 percent live-birth rate per transfer for women under age 35 at CHR-Chicago, versus a national average of 30.6 percent, according to a report by the Centers for Disease Control. Cornell, New York University, and Saint Barnabas, meanwhile, had rates of 54.2 percent, 49.0 percent, and 59.5 percent, respectively.

Sauer’s record is less clear. Asked whether it’s fair to say that his rates have traditionally been lower than his competitors’, he responds, “Yes, it’s fair, but complete the sentence: Who does Mark treat? I just saw a 47-year-old woman who wanted to do IVF with her own eggs. Even though there’s a less than one percent chance that it would work, she really wanted to do this. I treat the poor responders the other programs turn away. That’s the reason our rates are what they are.”
Dr. Richard Scott, director of assisted reproduction at Saint Barnabas Medical Center, responds: “When rates are so much lower, what can you say? ‘My patients are more difficult?’ Programs that get paid x dollars per patient because of managed care and run on volume will cycle everybody. I have very strong ethical concerns about that. If you know a patient’s chance of conceiving is extremely low, it’s not fair to the patient. It holds out false hope.”
A look at egg-donation rates may give a clearer picture of Columbia’s capabilities, because its donors are healthy young women with, presumably, good-quality eggs. According to Sauer, Columbia patients who conceived with donor eggs in 1997 have about a 42 percent pregnancy and delivery rate, not far from NYU’s 48 percent rate.

“There are a lot of reasons to choose an IVF program, such as cost and how they treat you,” Sauer says, a bit testily. “You’re still a person. There shouldn’t be a dismissal of you if you don’t meet strict criteria. I’m not going to be beholden to the holy rate.”
Some of his patients agree. “Before I tried IVF, people suggested I look into Cornell because it had higher success rates. I decided, because of my young age and the fact that I’d had a good experience at Columbia so far, that I didn’t want to make a change based just on success rates,” says 27-year-old Marisa Fyodorov, whose first attempt at IVF was a success. “I felt confident with my doctor’s experience.”
It’s just the response that Sauer hopes to hear. “We are looking to be a major player in New York City,” he says. “We’re here to play hardball.”
Full article: http://nymag.com/nymetro/health/features/2163/index1.html

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Category: infertility, IVF