Democratizing IVF: Building The Profit And Loss Case

From Democratizing IVF: Using Science, Medicine, And Engineering (And Venture Capital) To Help Build Families.

So lets stop worrying for now whether or not infertility is a disease and instead turn our energy into showing that making it accessible and affordable is good business.

I’ve had this conversation many, many times. The first question is always the same:

How do you convince the small group of reproductive endocrinologists (RE’s), the fertility docs who are the primary gatekeepers to IVF in the United States, to lower prices and see more patients? How do you motivate someone already working long hours providing an ever-improving service and making a very good living to work longer hours for less pay?

The short answer is you don’t.

Instead, you make it easier for someone to fill the void left by millions of extremely motivated patients to gain access to treatment. The industry incumbents, not only doctors but also their scientist, embryologist and nursing colleagues, all play an indispensable role in the evolution of the industry; that evolution, however, can start and proceed without them for a long time, and open up the marketplace to varying degrees with only their incremental participation. Indeed, the process of democratizing IVF is well underway, with three others important groups building a foundation for a much larger, inclusive industry.

But before discussing how the complementary forces of patient advocacy, rational insurance expansion and entrepreneurship are already working effectively to transform the industry, lets dispel another of the myths of IVF: that RE’s are our opponents in making IVF more accessible and inclusive.

More accessible IVF means more IVF, but it also means better IVF, and no one wants to build a practice by doing hundreds of low quality cycles and charging for each one. The largest, fastest-growing, most successful IVF programs are those that have the highest percentages of successful cycles. This performance translates into low dollars per baby and time to baby calculations (I know that sounds crass, and boils the transcendence of parenthood down to the dry language of industrial quality control, but so be it), the two metrics that best align with patient priorities.

Industry leaders have earned their leadership positions by. working on the “better” part of the more, better, cheaper formula for IVF democratization. Healthy birth rates for each embryo transferred continue to climb, and now approach seventy percent in top programs. Each year there are more healthy babies and fewer multiple pregnancies, meaning more term pregnancies, less pre-eclampsia, lower rates of gestational diabetes and maternal morbidity and mortality. Severe ovarian hyperstimulation syndrome (OHSS), a once common and serious complication of fertility drugs, now preventable with modifications of the IVF procedure itself.

RE’s, embryologists, nurses, and other patient-facing professionals are our allies in democratizing IVF; however, with their traditional focus on outcome improvement, patient experience and quality control, its unrealistic to expect them to take the lead in expanding throughput when they are working close to capacity already. Leadership in that aspect of democratizing IVF falls to three other groups: advocates, payers and entrepreneurs.

In a perfect world, making it easy for others to build a healthy family would be top priority for all of us. Family planning, prenatal care, parental leave and access to fertility treatment would be reflex priorities — political “given” that we take for granted, knowing that paying upfront more than compensates us community-wide by preventing the downstream complications, both in terms of dollars and needless suffering. In our less than perfect world, we have advocates to remind us, again and again and again, of both the fiscal rationale and pursuit of happiness aspects of supportive parenthood policies.

If you think that this sounds fanciful and a bit wishy/hopey, I invite you to spend an advocacy day with the nonprofit army of a group like RESOLVE, the national infertility advocacy organization, as they travel to Washington or a state capital to negotiate for infertility coverage for wounded veterans, or for state mandates for infertility insurance coverage, or to remove restrictions on surrogacy or to fight attempts to drag IVF into pro-choice/pro-life legislation. Then look at the results from past efforts: HR 5325, the 2016 Veterans’ Administration IVF bill, nineteen state laws mandating insurance coverage for infertility, thirteen for IVF coverage and ten for fertility preservation.

RESOLVE and other advocates effectively work on the more part of the effort to democratize IVF whole RE’s, embryologists and their front-line, patient-facing work on the better part of the formula. Let’s look at our other two groups.

Next up is the insurance industry — usually seen as the enemy, but in reality an ally in waiting. The drive for greater insurance coverage for IVF is usually framed in terms of convincing or forcing insurance companies to provide IVF coverage, an argument that implicitly assumes that the insurance industry would otherwise avoid doing so. But we’ve argued back in chapter 1 that insurance companies, in many ways the most rational of businesses, are happy to insure just about anything if they have reliable enough numbers to plug into their actuarial formulas and write policies that fit their very conservative risk management rules. Insurance companies’ primary job is to survive. Like commercial banks, they take in lots of money and use that to make lots more, all made possible by convincing customers and clients that no matter what they are not going out of business. And they do the math to make sure that’s true.

So how do we enlist the insurance industry to help us democratize IVF? Well we’re not going to get very far by telling them to relax their standards, to underwrite policies based on inadequate data — to just this once ignore their actuarial tables and come up with something that threatens their solvency (or puts millions of other policy holders at risk of massive increases in their premium costs) when the claims for IVF treatment end up much higher than anticipated.

But.

If we play the insurance game by insurance industry rules, the most important one being Thou Shall Embrace Actuarial Tables, and we generate sufficiently precise numbers that make infertility and IVF as easy to cover as flood damage and car accidents (neither of which are considered diseases — you see where I am going here), we then shift he debate from IVF coverage as societal obligation to IVF coverage as good business.

Can this work? It’s already happening. Over the past five years, employer-based fertility coverage has grown rapidly, particularly in high cost of employee acquisition and retention industries. Human Resources departments recognized the importance of IVF coverage; in some industries offering IVF coverage changed from a competitive advantage in recruitment to a competitive necessity. Specialty insurers now cover millions of people.

How does this effect the marketplace? If we assume a conservative 10% prevalence of infertility, every million people with coverage yields 100,000 potential patients. Approximately 300,000 IVF cycles are performed each year in the United States, with most patients cycling more than once. One company alone insures over three million people. Taken together, these numbers point to a huge new population of potential patients who can now afford to knock on the doors of IVF clinics, seeking — and being to afford — care.

Listing our assets in the effort to democratize IVF, then, we have:

1. a patient-facing industry of medical professionals with a four decade record of innovation and outcome improvement, motivated by patient satisfaction and quality control
2. an effective advocacy infrastructure working with government on state and federal policy and
3. cost and outcomes data that increasingly meet the needs of the insurance industry to expand coverage and access

Taken together, these three components suggest that the IVF industry may be much less resistant to change than is commonly assumed.

It also suggests that reproductive medicine as a whole, and IVF in particular, will be one of the highest growth sectors in all of healthcare.

Which brings us to our last catalyst for the democratization of IVF: entrepreneurs, and their counterparts in venture capital, technology, and investment banking.

The combination of front-line operators committed to innovation, effective advocates successfully lobbying government and affecting policy, and an increasingly engaged insurance industry whose needs for outcome certainty are now being satisfied together mean that the real work of democratizing IVF is ready to start. We’re ready to tackle the ultimate goal: to provide access to safe, highest probability of success treatment to all seven million people with infertility; millions of IVF cycles instead of three hundred thousand, millions of babies instead of seventy thousand.

IVF, meet scale. Scale, meet IVF. But before we let the engineers and venture capitalists loose lets consider the patient journey through a democratized IVF.

(Next: improving the patient experience as IVF grows)