CHR maintains contractual provider contracts only with two insurance companies, Oxford/United and Aetna. Patients often ask us why CHR does not accept insurances from other carriers. The simple answer is that we cannot afford to do so! Let us explain why.
By intent, CHR in many different ways is not your usual fertility center! CHR differs from other centers in many different ways, from philosophy of practice, over the way CHR conducts clinical practice to our strong commitment to research. Here, we, however, want to discuss why, in contrast to so many other fertility centers, CHR does not practice what we call “assembly-line medicine.”
The reason is not that we believe that practicing regimented, single protocol-driven “assembly-line medicine” is necessarily bad or inferior medicine. To the contrary, after the state of Illinois passed one of the first insurance mandates for infertility services in the nation, CHR in its original location in Chicago, then being the first fertility center in the nation to sign large-scale exclusive provider contracts with practically all major insurance carriers in the city, likely invented the concept of “assembly line medicine.” Based on numbers of IVF cycles, CHR in those years (the 1990s) was, indeed, likely the largest IVF program in the nation and we, therefore, understand “assembly-line” infertility practice very well.
Once insurance companies were mandated to include infertility coverage (including IVF) into their insurance plans, they, of course, wanted to minimize their costs. The obvious solution was to transfer cost-risks to fertility centers. Reimbursement rates for infertility services from insurance companies, therefore, from the beginning were marginal and, over time, even further deteriorated. Though IVF centers over the years produced steadily improving IVF outcomes (except for the last few years), reimbursement rates for IVF services did not even keep up with inflation.
High volume IVF programs, consequently, must run a very tight ship administratively as well as clinically if they want to remain economically viable. Well-executed “assembly-line medicine” is, therefore, the only way to practice medicine if an infertility center largely depends on reimbursements by insurance companies. We, indeed, have great admiration for colleagues who do this well and, in doing so, successfully serve large numbers of infertility patients.
Circumstances in New York City were, however, different from those in Chicago when CHR for the first time in the late 1990s established a presence in the city. In contrast to Illinois, New York state did not have an insurance mandate for fertility services and very few insurance companies considered infertility a covered benefit. IVF coverage was, indeed, practically non-existent. The number of IVF centers was comparatively small, and IVF practice in NYC, therefore, was almost exclusively private. As a consequence, the services IVF centers provided were much more personal than in Chicago.
Over ensuing years, competition in the market place forced insurance companies, however, to increasingly add fertility benefits, often including IVF, to their coverage. Like most fertility centers in the city, CHR signed on to all newly offered contract relationships. Some carriers (including the State of New York, which started offering a restricted IVF grant program) were highly selective in contracting with centers, and CHR in those years, likely, offered more third-party coverage agreements in the city than most other IVF centers.
As offered insurance coverage increased, the demand for IVF cycles increased in parallel; and as demand for IVF increased, many new IVF centers were established. In other words, similar contracting dynamics started evolving with insurance carriers in NYC as CHR had witnessed before in Chicago: With more provider clinics competing for patients, insurance companies were able to further reduce reimbursement rates.
CHR’s Founder and Medical Director, Norbert Gleicher, MD, who previously in Chicago had pioneered the concept of large-scale insurance contracting and, therefore, of “assembly line” infertility services, at that point decided that the time had come to go the opposite way.
Though financial considerations were obviously of importance, they were not decisive in reaching this crossroad. What led Dr. Gleicher to take CHR into a new direction was his recognition that for a large majority of infertile patients “assembly-style medicine” offered very adequate services at unbeatable low costs. He, however, also foresaw that, as this market continued to expand, increasing numbers of more complex patients would fall through the cracks of an “assembly line” system that was not meant and able to satisfactorily individualize treatments for more complex patients.
Dr. Gleicher, therefore, already in the early 2000s in many ways foresaw the evolution of personalized medicine and concierge services, both nowadays widely appreciated medical practice formats. He also foresaw that IVF centers would see rapidly increasing numbers of older infertility patients, who would require distinctively different treatments from a majority of younger women. All pointed toward the need for a new kind of IVF center that did not cater to the large majority of infertility patients who could satisfactorily and cost-effectively be taken care of by “assembly-line medicine” but concentrated on those patients who were falling through the cracks of such a system.
Requiring more manpower and effort, concentrating on such a new treatment paradigm of individualized care, however, had to be costlier. Under such a model, CHR, therefore, had to be able to attract better service reimbursement fees than most insurance companies offered. Around 2002, CHR, therefore, cancelled most of its insurance relationships, (maintaining only the two that at least came closest to covering the center’s costs of providing care). Ever since, CHR, likely, has been New York City’s only fertility center that offers this form of highly individualized infertility care to every patient.
Because this decision coincided with the rapid development of the Internet, it had unanticipated consequences: CHR started not only to attract patients from New York City and its surrounding home-base who had fallen through the cracks elsewhere, but from the rest of the country and Canada. And, as the word about CHR’s services and outcomes spread via the Internet’s chat rooms, patients from all over the world started seeking treatments at CHR. Today we, therefore, without exaggerations can describe CHR as the fertility center the world comes to when wanting to conceive after prior failures. Over half of CHR’s new patients now reside outside of the larger New York City area.
We hope that here presented lengthy explanation offers a better understanding why CHR only maintains two insurance relationships. CHR, at the same time, is very conscious of the high costs patients incur in pursuing fertility treatments, and is constantly trying to keep them to a minimum wherever and whenever we can. CHR’s fee structure, therefore, is highly competitive with those of other fertility centers. We are just not willing to offer third party insurers much higher discounts than we are willing and able to offer our cash paying patients (see also below).
Our concerns about treatment costs are also expressed by CHR’s almost obsessive efforts to convince colleagues to stop using useless and, at times, even potentially harmful add-ons to IVF. We have extensively reported on these efforts in these pages, and that CHR investigators have in recent months been receiving increasing support in the medical literature for their positions.
An excellent example has been CHR’s strong opposition to preimplantation genetic screening (PGS), now also called preimplantation genetic testing for aneuploidy (PGT-A), which we consider a complete waste of money and effort. One of the reasons why this procedure has gained so much prominence in some IVF centers are the additional fees paid by patients for PGS/PGT-A, which are split between IVF centers and PGS laboratories and, therefore, generate significant added IVF cycle income. Because PGS/PGT-A is usually not covered by insurance, even insured patients, therefore, must pay for PGS/PGT-A out of pocket, thereby supplementing poor cycle reimbursements from insurance companies. Some IVF centers, indeed, have become financially dependent on these additional PGS/PGT-A fees and, otherwise, would be unprofitable. A good number of centers, therefore, now practically mandate PGS/PGT-A if patients want to undergo IVF.
As noted above, CHR’s skepticism about PGS/PGT-A is increasingly shared. Among a number of recent publications, we especially recommend a paper by Richard Paulson, MD, Professor at the University of Southern California at Los Angeles (USCLA), coincidentally also this year’s President of ASRM, which appeared in the August issue of Fertility & Sterility (2017;108(2):228-230). In it he explains in exquisite detail why PGS/PGT-A results in so many false-positive diagnoses. Also noteworthy is a second, still confidential draft of a position statement on the procedure from ASRM currently in circulation, which is greatly improved over the first draft of the document and, sometimes even verbatim, reflects verbiage used by CHR investigators in their earlier publications on the subject.
Because we have so much concern for our patients’ pocketbooks, we, of course, fully understand and respect patients who utilize their insurance coverage rather than pay out of pocket for infertility services. Conversations with patients who have such insurance coverage through companies CHR has no contractual agreements with, are always difficult. While it is CHR policy to offer a detailed recommendation letter to every patient, which they then can pass on to any colleague they may receive treatments from under their insurance coverage, we and they know that most IVF centers will not change their treatment protocols just because they received such a recommendation letter from a CHR physician.
And we cannot blame our colleagues for that because we, here at CHR, would also not change how we treat patients, just because we receive such a letter. At the same time, we, however, always wonder how much better we could have done for many of our patients had they only come earlier for treatment to CHR.
We, therefore, encourage patients who have insurance coverage that CHR accepts (Oxford/United and Aetna) and those who do not have any third-party insurance for fertility at all to consider at least a formal infertility second opinion from a CHR physician at already early stages in their fertility treatment history, even if it means a long-distance consultation by telephone or via Skype. If CHR does so well in women who overwhelmingly have failed multiple IVF cycles at often multiple IVF centers before presenting to CHR, we could do even better a year or two earlier. Moreover, nothing is more cost-effective than quick pregnancy!
For patients with no insurance coverage for fertility treatments, please also remember that CHR offers:
- Income-associated discounts;
- Discounts for military personal on active duty;
- CHR also offers a 4-cycle IVF package for poor prognosis patients, which saves approximately half of full cycle costs for 4 IVF cycles.
Please contact us online or call our center at 212-994-4400 for further detail about CHR’s discount programs.
This is a part of the September 2017 CHR VOICE.