The Daily News

LFCA Latest Issue: Friday, September 25, 2009.

Latest Post on BlogHer: Parenting after Infertility.

My Status: Fed Josh's almonds to the squirrels. They needed them very badly.

Tuesday, July 08, 2008

Barren Advice: Twelve

This is the twelfth installment of Barren Advice. You can ask questions that are fertility or non-fertility related.

Barren Advice is posted each Tuesday. If you have your own question for Barren Advice, click here to learn how to submit. Please weigh in with your own thoughts in the comment section and indicate which question you're addressing if there are multiple questions in the post.

Dear Mel:

My husband and I are in the early stages of preparing for IVF treatment. We are doing the tests required by the fertility clinic. I have been searching everywhere for information about the payment process, specifically regarding paying for multiple cycles. When I spoke with the clinic's billing office, they stated that you do not get a refund if you become pregnant on the first cycle, even if you paid for 2-3 cycles. At this particular clinic, it costs $6,900 for the first cycle and about $11,000 if you pay for 2 cycles. So, you save money if it takes you 2 cycles to get pregnant but you lose a big chunk of money if you get pregnant on one. This doesn't include medication costs of course.

Is this standard procedure for most clinics? I understand that you are happy just to get pregnant but it seems like they are taking advantage of desperate people. I can understand if they don't refund you the entire amount but what is the reasoning for not refunding any money at all? Do you know of anyone who has successfully fought back against this policy?


Shared risk is a great plan for those without insurance coverage with the emphasis on the word "shared." You are sharing the risk with the clinic; meaning, if you don't get pregnant, they ate a lot of the cost and if you do get pregnant, you may have eaten an extra portion of the cost. But the risk is shared by both parties.

With a single payment plan, the risk isn't shared at all. It's solely on you. Therefore, if you get pregnant, great--it will cost $6900. And if you don't get pregnant, we're sorry--but it will cost you $6900. And it sounds from the question that you'd like the risk to be solely on them. And it would be nice if they were willing to work with that, but since you have the option to apply for the program or the option to pay per cycle, it isn't really feasible for the person requesting the service to also have the service pay them to use them essentially. In other words, you need them. They don't need you (though they do need customers and they have set up these plans in order to make IVF more accessible to a larger population. Though, "more" is an relative word when you're talking about thousands of dollars).

Here's the thing with shared risk: because the clinic is deciding who qualifies for the plan, they are not taking anyone they see outright as a risk. Because that isn't in their best interests and they are a business and not an altruistic organization. Which sucks to think about because they are doctors, but you can't think of them in the same way you think of your local emergency room staff. It is simply a different kind of medical service. So if you qualify for the plan, it means they think that you have a greater chance of getting pregnant in one IVF cycle than you do taking two or more cycles to get pregnant.

You can do what you wish with that information.

Some people see if they qualify for shared risk and then decide that they'd rather take the gamble and pay per cycle. If they get pregnant on the first try, they saved a lot of money. If they get pregnant on the second try, they lost a little bit of money. But if they get pregnant on the third try, they lost a lot of money.

Here are the pros and cons to a shared risk plan and who should or shouldn't use the plan if they qualify:

  • If you are worried about the financial side of things and would rather know a flat end price than pay little bits at a time, never knowing fully how much you'll spend in the end.
  • If you have a lot of stress in your relationship about financial matters and want to argue about cost one time.
  • If you want to remove some of the stress inherent in a cycle.
  • If you want to have options to try different protocols.
  • If you have unexplained infertility or no clear diagnosis.
  • If you are doing it to save money (because you might or you might not and you'll be right pissed if you lose money and this was your reason for entering into the plan).
  • If you think you will get pregnant in one try.
  • If you have a clear diagnosis with a clear solution.
See which list you fall in and what you should do. I have seen both sides of this fence: one friend entered into shared risk because she thought she would save money. She got pregnant on the first try and is still bitter to this day that she paid more for IVF than she would have if she had paid per cycle. She really didn't enter into shared risk for the right reasons. I also have a friend who just left a shared risk program having a large portion of her money returned because they couldn't get her pregnant. She is obviously thankful that she is getting a portion of her money back because if she hadn't done shared risk, she would have paid for numerous fresh cycles and had nothing for it in the end. She can now apply that money to a different path to parenthood.

And that's the beauty of how these programs work. The plans are not actually for paying for IVF. They are simply insurance for when things don't go according to plan. And you need to decide whether or not you need insurance simply because it is offered.

No really, the beauty of a blog advice column is that you get to weigh in with your two cents too. Let the questioner know if you support the advice, add to the response, or dispute it completely. I would love people to add their feelings if they used (or didn't use) a shared risk plan.

Leave a comment in the reaction box below--only keep in mind that conflicting advice is embraced and rudeness is not. Want to ask your own question? Click here to see what you need to send in order to be included in a future Tuesday's installment of Barren Advice


LJ said...

Fresh cycle refund gal here, and I think you hit the nail on the head.
It's like gambling. In the end, we decided to do shared risk because we WERE unknown diagnosis, and didn't know if it would take us one try or all six. In the end, we figured the risk of overpaying for one cycle would be far less traumatic than only paying for one cycle and needing more. I know plenty of gals who got pregnant on the first try, but for me, shared risk was clearly the right plan.

Jamie said...

I think shared risk is the way to go. It took me 5 cycles to achieve a pregnancy -- and this is after being an "ideal" candidate. I was only 24 at the time, had a clear issue (no fallopian tubes), and still, it took 5 cycles. You just never know. I'd rather pay more and only need one cycle than pay a ton for more and more cycles.

DD said...

Watch for verbiage: is it "pregnant" or "live birth" that they consider the cycle successful.

You definitely would want to go with "live birth" since a pregnancy could be considered anything that results in a beta of over 5 but ends in a chemical pregnancy days later.

Yes, it's a gamble, but consider yourself very lucky you have the option. Both clinics in my state do not do "shared risks" cycles, therefore every fresh IVF cycle we did was out of pocket 100% and we did three with no "guarantees" whatsoever.

Samantha said...

I did the shared risk plan at my clinic, which was a 3 IVF-cycle plan, with some of your money back, should I not get pregnant by the end. It also threw in as many FETs as you needed. I did not get pregnant through that plan, so financially, I did make out with not having to pay a lot, which is good. That said, however, I feel like shared risk can be a gimmicky trick to capture patients into a specific clinic and also creates some perverse incentives.

I ended up feeling stuck with a clinic where I didn't like how they handled their patients and where the doctor was inflexible about drug protocols, even when it became clear that his particular choice wasn't working for me. His whole philosophy of "more is better" I think just gave me a bunch of crappy eggs and OHSS. Plus, with the FETs thrown in for free, he froze my three-day embryos in straws of 5, and then when four survived the thaw, proceeded to transfer all four back, which also freaked me out. (Selective reduction is not covered as part of shared risk). Both my husband and I felt very trapped and exhausted, but pushed to move forward with the treatment because there was a time limit during which the treatment should be completed if you were to get a refund. I probably would not do that again, if I had the choice, even with the financial incentive, mostly because of the patient-clinic mismatch.

So, questions I would want answers to before doing a shared risk cycle:
1. Do I really like my doctor, clinic and how they treat me?
2. Are they treating my specific problem, or is it just jumping on the IVF treadmill?
3. Do I know how I am going to react to the IVF cycle? Can I physically and emotionally handle multiple cycles that I'm going to tie myself into before I do so?

It's hard to know what IVF will be like before you do it. You may want to try a single cycle, and then if that doesn't work, try the shared risk if you feel comfortable with your clinic and doing additional cycles (of course, some clinics might then deny eligibility, but it could be worth discussing with them).

Ellen K. said...

Our clinic did not have its own shared risk program, but instead offered a third-party "insurance" program. The list of exclusions was quite lengthy. Seeing as how we were not committed to doing more than 2 cycles, we decided to gamble and pay out of pocket for each, with no "guarantees." I would not have chosen a clinic based on shared risk availability alone, for the reasons that Samantha cited. I also had very strong feelings against transferring more than 2 embryos, and the shared-risk clinics in our area were clearly not in harmony with my beliefs, based on their SART data.

Mama said...

We did not qualify for shared risk at our clinic (I didn't have regular cycles, which was a precondition of participating-- it actually seemed almost impossible to me for anyone to qualify!) but in retrospect, I'm a big proponent of the programs for one major reason: if the worst case scenario is that you overpaid for a cycle of IVF, but you have a baby (or babies!) in the end, then that's a small price to pay. I'd much rather be in that situation then where we were: out of lots of money for single cycles with nothing to show for it. Of course, in a perfect world you'd pay for one cycle and get pregnant (AND have a baby) on that cycle, but in all honesty, chances are not in favor of that outcome so I personally would have gone with the shared risk and been OK with the fact that I overpaid for one cycle.

FWIW, our RE told us that shared risk programs are actually just marketing gimmicks for clinics to get people in the door. Once they're in, and have gone through all of the preliminary steps (consultation, bloodwork, etc.), few people are going to leave to go to another clinic EVEN IF they are told they do not qualify for the program. So basically it's a way to bring a lot of people in through the front doors. It made me sick to my stomach to think about the medical profession behaving like a for-profit business, but as Mel stated, that's reality.

Good luck whatever you choose!

Star said...

I hope this isn't a dumb comment, but it seems like what the questioner's clinic is doing is different from (and worse than) the traditional shared-risk program that I am familiar with, in which you pay a flat fee for a certain number of tries and get some or all of the money back at the end if you don't have a take-home baby at the end of the process. This clinic is giving a discount for the second cycle if you pay for two at once, but then won't refund the money you paid for the second cycle if you get pregnant on the first try. The former program is somewhat ethically dicey for the reasons some PP have stated, but gives enough to the consumer to just pass the smell test. Maybe the difference is more perceived than real, but the latter seems more unfair to me and would definitely put me off that clinic.

Alex said...

To add to Samantha's questions, I'd also want to know --

4. How long do I have to finish the cycles? Can I take breaks?

5. How much control do I have over the decisions made? Can I limit the number of embryos put back?

And yes, I agree with Star that this sounds like a pretty "bare bones" shared risk plan. The pricing both of a single and of two cycles also sounds cheap to me, by US standards. Whether that's a good or a bad thing probably depends on your situation, but it's something to be aware of.

Bea said...

I would take issue with one thing only in your reply: no infertility patient really has a clear diagnosis with an obvious solution. It only seems so at the outset. Don't start making me name examples of people who "just" needed to get sperm to meet egg and they'd be fine, and then, twelve cycles later... Conversely, a high proportion of those I know of with unexplained infertility seem to have fallen pg on their first cycle.

I think if the clinic is willing to take you, that's probably as much as your prognosis comes into it. Either they'll take you or they won't. I wouldn't use it as a factor any further than that.