Research Highlights Article

January 23, 2019

Expanding access vs. controlling costs

A new paper examines some of the factors that may drive patient choices to pursue expensive fertility treatments.

Chris Fleisher

New research examines how insurance coverage of IVF influences patient decisions.

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Americans are choosing to have children later in life, with many women waiting until their late-30s or 40s to become pregnant.

Medical advancements such as in vitro fertilization, or IVF, have made it easier to conceive later in life when many women are considered infertile. But the procedure does not come without risk. Patients face myriad considerations, including how aggressively to pursue treatment and how to pay for it. Insurance plans in many states do not cover IVF, leaving hopeful parents with bills that exceed $10,000 per treatment. In theory, the high cost may give patients an incentive to choose the most aggressive treatments so that it works on the first time.

A paper in the December issue of the American Economic Review considers how improved access to IVF affects patient decisions. If insurance covered the cost of treatment, would patients choose less aggressive — and lower cost —  treatments?

“To get to the heart of the policy questions, we really needed to understand what was motivating patients, what constraints they faced, and how they were reviewing the consequences of their actions,” co-author Brian McManus said in a Skype interview with the AEA.

McManus and co-authors Barton Hamilton, Emily Jungheim, and Juan Pantano collected detailed patient data from a fertility clinic in St. Louis — where Jungheim is a physician —  to study how alternative policies might affect patient decisions. The paper highlights important considerations for health care systems and demonstrates the potential for economic models to provide insights into patient choices and incentives. It also underscores the broader challenges of expanding access to care while reining in spending.

In vitro fertilization treatments are a combination of medicines and surgical procedures used to help fertilize an egg, which is then implanted in a woman’s uterus. Patients may choose to implant more than one embryo to increase their chances of a successful pregnancy. But that brings both higher costs and medical risks, including the possibility of having more than one child. The average cost of a singleton IVF pregnancy is estimated around $27,000, while twin and triplet births are well into six-figures.

The authors’ data spanned eight years from 2001 to 2009 and included patients from around the St. Louis metro area. It included patients from Missouri, where there was no insurance mandate to cover IVF treatments, and Illinois, where treatments were required to be covered. McManus and his co-authors wondered whether Illinois couples would choose the less risky path to implant only one embryo, knowing that if they were unsuccessful the cost of doing it again would be covered.

They then developed a model to test how two leading policy recommendations around IVF — requiring insurers to cover treatments and limiting the number of embryos that can be received  — affected couples’ decisions.

Patients really appear to value the opportunity to take multiple embryos for a few reasons. First they don’t want to fail treatment and failures would happen a lot more frequently without a cap. And second, patients like twins.

Brian McManus

Neither struck the optimal balance. According to the model, the insurance mandate would lead more couples to pursue IVF, but it wouldn’t change the aggressiveness of treatment. Patients would still choose to have more than one embryo. Meanwhile, the embryo cap would lower patient risk by reducing the potential of having twins or triplets, but that would also make IVF overall less attractive to patients. The authors predicted that couples would consider it an option.

“Patients really appear to value the opportunity to take multiple embryos for a few reasons,” McManus said. “First, they don’t want to fail treatment and failures would happen a lot more frequently without a cap. And second, patients like twins.”

If policymakers want to make IVF accessible without encouraging expensive treatments, they should consider a “top-up” approach that would make patients more sensitive to the costs, McManus said. Insurers would cover the first embryo, and then the patient covers the cost for any additional embryos.

The findings suggest that such a pricing policy could make both patients and insurers better off in states where IVF isn’t covered at all.

“In the end, it seemed to strike a nice balance between opening up patient access to treatment while also reducing some of the medically costly spillover effects,” McManus said.

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"Health Care Access, Costs, and Treatment Dynamics: Evidence from In Vitro Fertilization" appears in the January American Economic Review.