Planning on having a baby? For-profit healthcare in general, and private equity specifically, are moving into the arena of reproductive health, especially women’s health. And the results are … mixed.
While some experts say that in some areas – fertility treatment, for example – the success rates of for-profit and private-equity-owned companies are good, the trend is still young. And the effects of private equity on other parts of the healthcare system have been uninspiring, with increasing evidence that healthcare is worse and it costs more when in private equity’s hands.
For example, a recent study found that private-equity-owned hospitals had significantly more adverse events than other hospitals.
And some experts will say that even if the results are better – as measured, for example, in live births, in the area of fertility – as in other parts of the healthcare system, the for-profit and private equity playbook cannot comfortably reside next to patients’ best interests. After all, in much of healthcare, for-profit entities seeking to maximize the bottom line are known to deny treatments, pay less, and hire less-qualified clinicians.
A look at the specifics
Of course, for-profit healthcare is pretty much the basis of our entire U.S. healthcare system. Hospitals, once community-based, are now for-profits, or very profit-minded tax-exempt entities; insurance companies, once nonprofit mutuals, have increasingly reorganized themselves as for-profits, answering to Wall Street for their results.
Yes, there are nonprofit insurers and nonprofit hospitals, but many of them act like for-profits, paying executives high salaries, looking for growth, and socking away money in cash reserves. Look, for example, at New York Presbyterian, widely regarded as the highest-priced hospital system in the New York City area, and one that was excluded from the network of one powerful local union, the Service Employees International Union’s 32BJ local.
A subset of for-profit healthcare is the growing private equity sector. The private equity firms are privately held, and therefore their financials are not visible, as are the financials of for-profit and publicly traded firms.
The private equity companies in healthcare use the same playbook they do in other industries: Buy a company or roll up several companies into a bigger company. Cut costs and consolidate services. Finance with investments from those looking for quick and robust returns. Refinance with strategies like dividend recapitalization, issuing new debt, and sell assets like real estate to increase payouts to owners. In the standard playbook, these events take place in rapid succession, leading the acquirer to an exit in 3-7 years – either as a sale, a public offering (IPO) or other liquidity event. (See this nursing home acquisition, or this hospital and emergency department staffing bankruptcy.)
A recent report, for example, says that private equity firm Apollo Global Management acquired two major American hospital systems and in the process degraded services, hurt workers and put patients at grave risk. The report, by the Private Equity Stakeholder Project and the American Federation of Teachers, documents Apollo’s consolidation of ownership of 220 hospitals in 36 states, adding that “The hospitals have experienced cuts to services, layoffs, poor quality ratings, and regulatory investigations.”
The factor of getting out fast with as much money as possible leads to business practices that often leave the company in question in a much worse financial position. A for-profit mindset (minus the private equity aspect) tends to more of a long-term horizon. To be sure, the nonprofit world is not immune to profit-seeking; nonprofits, of course, don’t pay taxes, but they are also concerned with the bottom line.
In general, according to a 2023 paper in the BMJ, “Across the outcome measures, PE ownership was most consistently associated with increases in costs to patients or payers. Additionally, PE ownership was associated with mixed to harmful impacts on quality. … Health outcomes showed both beneficial and harmful results, as did costs to operators, but the volume of studies for these outcomes was too low for conclusive interpretation. In some instances, PE ownership was associated with reduced nurse staffing levels or a shift towards lower nursing skill mix. No consistently beneficial impacts of PE ownership were identified.” The paper, “Evaluating trends in private equity ownership and impacts on health outcomes, costs, and quality: systematic review,“ was authored by Joseph Dov Bruch at the University of Chicago and his co-authors, Alexander Borsa, Geronimo Bejarano and Moriah Ellen.
Investment in fertility
So where are private equity companies investing in the world of women’s health or reproductive health? Mostly in fertility companies, and not the broader gynecology-women’s health companies, experts told us.
One person familiar with the market, speaking on condition of anonymity, wrote in an email that he thought “there is a lot more penetration of PE in fertility (I think most of the market share, >50%, belongs to 5 fertility clinic chains that are PE backed — US Fertility, CCRM, Pinnacle, etc) …
“I’m not sure how penetrated PE is in gyn but my gut is that it is probably ~20%,” he added. “There is one large PE ob hospitalist group that I’m aware of (OBHG). And there are a few large ‘women’s health’ chains (Unified Women’s Health and Axia are two that come to mind).”
Another academic said that estimate sounds right, but noted that no one is really keeping a census of who is strictly private equity, who is for-profit but not private equity — so the numbers are squishy.
Bruch, at the University of Chicago, said he thought PE was about 30% of the fertility market and 5% of the OB GYN market. With almost 30% of assisted reproductive cycles taking place in private equity-affiliated practices, he said, there is clear evidence of “emerging interest in women’s health by private equity firms.”
The highest penetration is on the coasts, he said: New York, Maryland, Washington, California, and also some southern regions. Florida has a lot, there’s a little in Texas, but much less in the Midwest, he added.
Also in fertility, some of the big names, like Kindbody, are venture-backed but not P.E. Progyny, a manager of fertility benefits, is also venture-backed but not private equity-backed.
Results for chain patients
And what are the results? In many parts of the healthcare industry, for-profit ownership means patients might not benefit. But interestingly, in the fertility industry, chain ownership increases success rates, specifically in in-vitro fertilization (IVF), according to a paper by Ambar La Forgia and Julia Bodner “Getting Down to Business: Chain Ownership and Fertility Clinic Performance” (August 2023).
Despite the anticipated result that chain ownership could spoil outcomes, the two found, “Our results show that after a fertility chain acquires a clinic, IVF cycles increase by 28.2%, IVF transfers increase by 21.4%, and the live birth rate increases by 13.6%.“
Live births are the success metric in IVF, the authors noted. (Read on for the distinction between for-profit and private-equity setups.)
“Qualitative data obtained from press releases, marketing materials, and interviews suggest chains help clinics achieve growth by providing financial and managerial resources, such as revenue cycle management and marketing services,” the authors wrote.
“These materials also suggest that chains help improve quality by implementing best practices, protocols, and training and facilitating knowledge sharing between clinics through research consortiums and complex case review meetings. … These resource and knowledge transfers drive performance improvements rather than alternative mechanisms such as patient selection.”
There are other subtleties, the authors write: “We find that acquired clinics are twice as likely as non-chain clinics to advertise money-back guarantees or multiple-cycle discounts. Such marketing efforts may contribute to market expansion since patients likely view these offers as increasing IVF affordability.”
The role of private equity
“As another strategy to illustrate the role of resource transfers, we study how private equity (PE) investment into fertility chains impacts outcomes. At different points during the sample period, eight out of eleven chains receive PE funding, allowing us to separately identify the effect of chain ownership with and without PE funding. Consistent with PE firms easing financial constraints, we find the largest increases in clinic volume occur when a fertility chain receives PE funding.”
This differs from other markets, the authors wrote. “Most chains are owned by a for- profit corporation, but not all corporate-owned firms are chains,” they wrote. “The positive impact of chain ownership on fertility clinic quality differs considerably from the predominantly negative or null effects on quality found in the recent healthcare literature.”
In other areas of healthcare, including nursing homes, dialysis and hospitals, neutral to negative effects on patients have accompanied private equity investments. But the fertility market differs, th authors say: Nursing home, dialysis clinics and hospital markets are concentrated, which may limit incentives to invest in quality. “By contrast, fertility clinics and other retail health settings are still relatively fragmented,“ the authors write.
Other factors also distinguish fertility medicine from non-fertility medicine, they add. Medicare plays a large role in the non-fertility marketplace, the authors say, making it hard for people to trace the money and also making incentives differ for providers.
In fertility, by contrast, “the ‘free market’ features of fertility clinics better resemble the consumer-centric model of the retail and service sectors. Such features include price and quality transparency, minimal government intervention, and reliance on consumer choice and self-paying patients.” Fertility clinic report cards play a role, they said, leading “consumers to alter their choice of clinics.”
Because insurers quite often have a limited role in fertility as compared to other aspects of healthcare, they write, chains may do more competitive pricing to gain market share from individual patients. “Using hand-collected data, we find that chain clinics are twice as likely to advertise fertility discounts and money-back guarantees, which may be interpreted as a signal of affordability by patients,” the paper adds.
Another factor in improving quality: “Fertility chains also create internal processes to facilitate knowledge sharing and establish best practices within the chain. Many chains create committees with physicians across clinics who meet regularly to discuss clinical research and patient cases and, in some instances, conduct their own research and clinical trials,” and, when possible, incorporate improvements into chain-wide practices.
What does fertility treatment look like?
There are many elements. First, usually, there’s a workup: How long have you been trying? What causes might there be for failure to conceive? Are you LGBTQ? Have you tried without assisted reproductive technology? What were the results? What physical tests are needed? Is there a hormonal imbalance,? Is there a clear physical barrier (lack of ovaries, low ovarian reserve, male-factor infertility)?
What is the best course of treatment? Intrauterine insemination (IUI), in vitro fertilization (IVF), donor egg, surrogacy?
The process is expensive in any case, and it’s hard to generalize because there are many different factors. LaForgia and Bodner write: “The cumulative cost of IVF is estimated to be between $40,000 and $60,000 because the average patient undergoes multiple IVF cycles (Fertility IQ 2022). These costs are either financed privately by patients or subsidized by insurance companies. However, even with some coverage, patients pay for the majority of services out of pocket.”
The market is not that huge, but it’s growing, with delayed childbearing, increases in reproduction challenges, single-parent families, LGBTQ parents and other factors. “By the end of the century, it is estimated that 3% of the world’s population will have been born via IVF (Faddy, Gosden, and Gosden 2018). This growth is mostly driven by heterosexual couples delaying childbirth and more same-sex couples choosing to have biological children,” La Forgia and Bodner write.
More procedures, more money
Fertility treatments can seem mysterious and even chaotic, since patients rarely have a lot of knowledge and expertise. This is also emotionally laden, and patients (or as we like to call them, people) feel that they have to take doctor’s orders.
Do we need to use low-dose naltrexone? Human growth hormone? DHEA? What screening tests are mandatory and which can we skip? What about preimplantation genetic testing?
Related: Those medications are terribly expensive. How can we save money on medications? This post of ours is slightly dated, but it gives some ideas.
One study about the different add-ons to the fertility process found that a number of them have little or no supporting evidence.
The 2019 paper titled “Clinical adjuncts in in vitro fertilization: a growing list” in the journal Fertility and Sterility, by Mohan S. Kamath, Mariano Mascarenhas, Sebastian Franik, Emily Liu and Sesh Kamal Sunkara, said: “A growing list of clinical adjuncts are being used during in vitro fertilization (IVF) treatment. Most of these IVF add-ons (such as growth hormone, aspirin, heparin, dehydroepiandrostenedione, testosterone, male and female antioxidants, and screening hysteroscopy) are being introduced into routine clinical practice in a hurried manner without any clear evidence of benefit in most cases. These add-ons make the IVF more complicated and increase the overall cost for the treatment, which is borne by the couples and health care providers. Our current review found no high-quality evidence to support the use of these IVF add-ons in routine practice.“
They examined the evidence, and found that all of these interventions had “amber: small body of evidence or conflicting evidence which means further research required and technique not recommended for routine use; red: no evidence to show it is effective and safe.”
They concluded: “In their continuous quest to maximize successes, clinicians resort to interventions with firm beliefs. However, it is imperative that any perceived benefits should be backed by robust evidence.”
Until such evidence is available, use of clinical adjuncts in routine clinical practice should be avoided, the authors wrote: “Apart from the added costs incurred by the patients or the health provider, there could also be detrimental, unquantified side effects.” (Note: We do not give medical advice.)
Bruch said his work suggests something similar: “We did some cross sectional work, finding that private equity-affiliated practices tend to have more add-on services, suggesting the possibility but certainly not definitively, that there may be services that are unnecessary or not medically or clinically useful at these practices, or at least that they could be more revenue-generating.”
Financialization of fertility
The availability of assisted reproductive technology to the wealthy and not the poor is not a new topic. Lucy van de Wiel, a scholar of reproductive technology at the University of Cambridge, wrote in a 2019 paper in the journal “New Genetics and Society,” titled “The speculative turn in IVF: egg freezing and the financialization of fertility.”
“Of course, from its very inception, fertility treatment has been closely aligned with capital accumulation and privatized healthcare,” Van de Wiel wrote. “In the UK, where the first IVF baby was born and the first IVF clinic was founded in 1980 by the clinicians responsible for Louise Brown’s birth, the emergence of this new medical sector coincided with Margaret Thatcher’s rise to power.
“Marilyn Strathern has described the ‘enterprising up’ of IVF in this context and Sarah Franklin has analyzed IVF in relation to the ‘enterprise culture’ of Thatcherism. Gay Becker documented the embeddedness of IVF experiences in the ethos of the American Dream.”
Private equity and quality
Private equity does not always have positive effects on healthcare. Bruch was one of the co-authors on a recent study finding that “Private equity acquisition of hospitals, on average, was associated with increased hospital-acquired adverse events despite a likely lower-risk pool of admitted Medicare beneficiaries, suggesting poorer quality of inpatient care.”
The study, “Changes in Hospital Adverse Events and Patient Outcomes Associated With Private Equity Acquisition,” by Bruch, Zirui Song and Sneha Kannan, was published in December 2023 in JAMA Network.
It concluded: “In a difference-in-differences examination of 662,095 hospitalizations at 51 private equity-acquired hospitals and 4,160,720 hospitalizations at 259 matched control hospitals using 100% Medicare Part A claims data, private equity acquisition was associated with a 25.4% increase in hospital-acquired conditions, which was driven by falls and central line-associated bloodstream infections.
“Medicare beneficiaries at private equity hospitals were modestly younger, less likely to have dual eligibility for Medicare and Medicaid, and transferred more to other acute care hospitals relative to control, likely reflecting a lower-risk population of admitted beneficiaries. This potentially explained a small relative reduction for in-hospital mortality that dissipated by 30 days after hospital discharge.”
A hard look at the data
La Forgia said she began looking at OB GYN practices that were being acquired, initially, as she thought, by hospitals. But it turned out that they were being acquired by management organizations, particularly in Florida, where she was concentrating research.
“The ones that I was studying were not private equity-backed, but then during my sample, like a couple years down the line, they all got acquired by private equity,” she said. “I studied it before the private equity events really had an impact on any outcomes.
“But there’s reason to believe that there’s not severe differences between the goals potentially of a private and for-profit management company and the private equity firm. That’s where this whole area gets complicated –a lot of times people call something private equity that’s not private equity. Private equity is a very tiny, tiny part of the total acquisition space in health care, except for infertility and fertility. There, it is super dominant.”
The appeal of private equity is clear, she said – especially when it’s a practice management affiliation that seems to relieve the doctor of pesky things like taxes, compliance, paperwork, and other things separate from the practice of medicine.
“It’s an amazing value proposition for a doctor who did not go into medicine to learn to run a business and to take on all of that stress,” she said. “So you can see exactly why physicians would want to sell their practice, especially when we talk about the burnout crisis. Of course, then the issue comes when there are directives and you are unhappy. And now you’re kind of stuck in this contract. And the only way to get out is to buy yourself out or to move to a different state, often because of non-compete clauses” which might say that a doctor cannot practice within 100 miles of the place they started.
There are different types of arrangements, she said: “An affiliation where there is some sort of long-term contract for management services, but in other situations, you are partially selling your practice – and there are ownership rights that the management company has.”
Report cards
In other cases, she said, the outcomes seemed positive. In one, they provided report cards to doctors comparing their performance to other doctors in their network – not telling them to do something, “but once you start comparing people to other people, that might change their behavior in good or bad ways.”
“One of the management companies I studied really wanted to go after Value Based Payment contracts, which has been popular in obstetrics, where essentially, they’re like, the better you do on your quality outcomes, the better your payment, particularly when it comes to the C-section rate. So if you can reduce your unnecessary C-section rate, you’re gonna actually make more money than if you do more C-sections.
“This management company really wanted to get those types of contracts, because they thought this is where the future of healthcare is going. They took all these efforts to reduce the C-section rate. And so I saw after acquisition of a practice, there was like a 21% reduction in the low-risk C-section rate. So huge improvements in that outcome, as well as some other outcomes — like maternal morbidity went down, for example. And they got those contracts with these values.
“That’s a really happy story. But that company got acquired by a private equity firm, and now expanded the model nationwide, and I haven’t looked at the data So I don’t know whether the same kind of values and practices still exist today.”
A different path
“Two of the other companies I followed had a completely different model,” she said. “They did not care about value-based contracting. They just wanted to really expand in size, and negotiate higher prices with insurance companies. And those insurance companies were getting so mad and even dropped some of them from their networks. And in those companies, C-section rates went up by around 8 to 10%, for low risk women who should not be getting C-sections. And that was associated with worse maternal outcomes.“
La Forgia said she tries to examine nuance. For example, some researchers are sure that private equity is bad. But what does the data show?
“I end up finding that there are massive improvements in quality when a fertility clinic gets acquired by a chain. However, the chain is not necessarily private equity, There are some publicly traded chains or privately owned chains that do not have private equity. And I do a decomposition between quality outcomes for when a clinic had private equity and not private equity. Whatever quality enhancement is happening is happening when the clinic becomes part of the chain, but not when the chain gets private equity funding. When the chain gets private equity funding, it helps expand access by increasing volume, which suggests that P.E. is working as you would think it would work, towards expansion. But it’s not being invested into quality improvement – that’s happening at the chain level.”
“The whole special insight of my paper when it comes to fertility clinics is fertility does not operate in any way like the rest of the healthcare system. It’s the opposite of a nursing home. There are no Medicare patients, there is no almost no insurance. It’s completely almost paid out of pocket. So you can’t negotiate with insurers for higher prices.
“It’s also very fragmented. You can’t really consolidate a bunch of clinics in a single area. Most of these companies are just acquiring practices, like one in L.A., one in Chicago, one in Austin, one in New York. So there might be consolidation. But it’s national, it’s not geographically local.
Transparent quality outcomes
“One of the most important things: fertility outcomes are very salient. If you’re getting fertility services, you want to have a live baby. That’s the goal. Those outcomes are published by the C.D.C. for every clinic in the United States since 1992. Any patient can go online and look at the quality outcomes for every clinic. Because that quality is so transparent, there’s so much more emphasis on consumer choice. You’re not stuck within your insurance network, or within any any other kind of geographic bounds.
“Often people who use IVF have a lot of means to do so. And so they are willing to travel for the best care. That’s just the opposite of nursing homes. So I argue that that’s why there’s so much more incentive for these corporate owners to want to increase quality than in other areas of healthcare.
“It’s simultaneously one of the more regulated and least regulated industries in the country,” she said, noting that Congress mandated the fertility clinic report cards because in 1992, Congress was very concerned that patients were being “bamboozled” into believing that IVF would be effective, and “that these clinics were selling false hope.”
While success rates have increased, these outcomes are still being published, she said. “But even though they have increased dramatically, it’s still not that high. Like if you’re under the age of 35, and you undergo three cycles, you have like an 80% chance of having a baby, which is great. Once you’re closer to 40, that falls to like 5%.”
She said research is needed to explicate the differences. “I want to look at what happens when physician practices get acquired by a hospital versus an insurer versus private equity versus management versus another physician practice. Like, are there differences in outcomes across each of those different ownership types? I think that would be very interesting.”
A side note: In fertility, she said, it’s not easy to identify what is P.E. and what is not. In another paper, about anesthesiology consolidation, with Cornell co-authors, she said: “One is we are able to disaggregate between private equity and just a normal management company. And we find that a management company alone, with no private equity, increases prices by 12%. But once there’s private equity funding, prices went up by 26%. And we hypothesize that that’s because private equity focused a lot more on local market concentration, which then the F.T.C. suit basically proved our hypothesis by going after this very concentrated, private-equity backed anesthesia group.”
What else should we know about private equity? She said that her research shows that anesthesiologists and dentists in general complain about PE ownership, and that nursing homes are known to be in dire straits after P.E. acquisitions. But in fertility, OB GYN and dermatology, the clinicians seem less unhappy.
Separate from fertility treatment, other aspects of women’s health and reproductive health are also seeing an increase in for-profit and private equity involvement.
In related fields, including neonatology, maternal-fetal medicine including genetic testing, for-profit entities and private equity are making inroads, but the vast majority of P.E. investing is in fertility, probably because there is so much money to be made.
Rising prices, less access
Another aspect is the rising costs of assisted reproduction in general, Bruch noted.
“Fertility is an interesting case study, because it’s so under-regulated, and because not all insurers reimburse for it,” he said. “Not all states require insurers to reimburse it. There’s a lot of new technologies.”
High costs to patients raise questions, he said: “There is a sizable inequality aspect going on here. The more you think about it, the more kind of grotesque it is — it’s only certain people who can have access to offspring.” More people are seeking to use these services, he said, and encountering “the financial barriers inherent in them.”
“I do think the rise of financial firms being the owners of these companies will ensure that these become stratified by income and wealth — like if they continue not to be accessible to Medicaid recipients, or they continue to require a sizable amount of money, or only certain companies provide insurance for these services.
Health inequity
“It really does mean reproductive health care becomes limited to the wealthy, or at least to the middle class, the high middle class. There is a major concern about how this surge of financial investment in reproductive health care ushers in a new wave of unequal and racialized health inequity.”
He added: “It’s not just that financial firms are entering this market, but what does that mean on a larger level of how we think about reproduction, and the way that reproduction in this country is financed? Who has access to it? And who gets to say, who has access and who owns basically our reproductive health care services? Because to me, that is almost more important than asking what are the short-term effects of private equity going into a sector.”
Beyond that, he pointed out, egg-freezing creates a market not just for the present, but also for the future: He’s interested in “the sociology of the financialization of fertility, and how financial firms have been able to basically create a market for future reproduction — it’s no longer about the needs of solving current infertility, but about future needs, and creating the market for that future.”
Men’s health
The fertility business often focuses on women, but of course male factor infertility is a substantive issue, and several companies have started up to address that.
One company, Legacy, offers at-home semen analysis and sperm freezing. Another, Posterity Health, a Denver company, recently raised $7.5 million. Its site says “The company provides an extensive portfolio of technology-enabled male fertility services, including at-home diagnostics, virtual visits and in-person consults focused on improving a man’s fertility status. The company seeks to educate, engage, and treat men, shifting the burden of conceiving from solely the woman and creating a unifying experience for the couple.”
Legacy is “hosting a ‘sexy sperm party’ for influencers, journalists, investors and others in a midtown Manhattan bar … for a talk about declining sperm counts,” Axios reported in. a story titled “Tech firms court growing demand for male fertility services.”
“Calling it an ‘SOS’ or ‘Save Our Sperm’ party, the marketing is intentionally cheeky to get attention,” Axios reported, quoting the CEO as saying “the message is serious: getting men to see semen as a ‘check engine light’ for their health.”
Dadi, an at-home sperm testing company, was acquired in 2022 by Ro, the online health giant. Dadi’s test kits, a proprietary technology, are supposed to resist temperature extremes and breakage. They sell for $199 each.
Of course, there’s AI: Mojo Fertility “created a new piece of AI-based technology that can count sperm with 95% accuracy and compute sperm count, sperm motility and the integrity of the sperm’s DNA, “ Ernst and Young reported, describing the brand development and marketing of the technology.
More at-home sperm analysis
Another company, Yo, took its expertise in sperm analysis in a lab setting, and made a home test. The company says: “While an at-home semen analysis is not a replacement for a full laboratory test, it is a first step to learn where you stand and work on lifestyle-based fertility improvements. … An at-home solution also provides an immediate and proactive option to test male fertility at the beginning of the pregnancy journey instead of waiting 1 year for an infertility diagnosis. YO reports a screening of the most important semen analysis parameter = Motile Sperm Concentration (MSC), but other sperm characteristics are important for conception.”
It’s hard to believe that enough men are looking for sperm analysis to keep this many companies afloat; maybe that’s why private equity seems not to be rushing into the men’s health fertility sector.
It has long been known that men have a very different relationship to healthcare than women do, as we wrote in this blog post “Women, men and healthcare costs: Speaking different languages.” Women make or influence 80 to 90 percent of healthcare decisions in the U.S., and that is clearly a big factor in fertility – women tend to drive the decisions much more than men do.
For more about men and healthcare, here’s Neel Shah, an obstetrician, writing about healthcare, men and paternity.
What clinicians should know
If you’re a clinician and thinking about working for a bigger private equity-funded firm, or selling to such a firm, Bruch said there are some things you might want to consider.
What should clinicians know?
“This concern is happening across medicine, and clinicians are all kind of grappling with it. The concern for young physicians is they’re not the one selling the practice. So they will not reap the reward. The initial cash infusion for selling to private equity — that, their more senior colleagues will receive.
“And while in the past, younger clinicians may have expected to gain more ownership of the practice during their tenure, they won’t have that opportunity. They’ll increasingly become employed by these private equity-owned groups. So there’s a concern for the junior physician, that they may lose out on those types of ownership privileges, or a future where they will have those ownership privileges.
“There’s also this concern about is this good for patients? Increasingly, the evidence is more concerning. And there, while it certainly is mixed, it does tend to lean negative — poor quality measures, higher costs, sometimes even higher mortality. Also, higher charges, higher amounts of medical debt. So there is major concern that these acquisitions may harm patients. And I think clinicians need to weigh that when they think about selling their practice.
“Ultimately, though, there are real financial imperatives that physicians are facing, if they don’t see real alternatives to selling their practice. I mean, they may not have such a choice. Now, I mean, of course, they have a choice, but maybe it won’t be the most financially lucrative choice. So I think, if I were a clinician, I would stay up to date. Let’s. say if I’m a dermatologist, I’m thinking of selling my practice. What is the literature on private equity in dermatology today? it’s generally concerning. So that might be something I would want to keep in mind.
“I would want to look at the private equity owner and see what is their reputation? Do I lose full ownership? Do I still get to maintain some semblance of clinical authority and administrative authority in the practice? What are the long term ambitions of this firm? Are they going to sell this in a couple of years? Is this going to become part of a larger chain of private equity-owned dermatology practices? Am I concerned about the possibility that my practice may become increasingly run by advanced practice providers? What does that look like – not physicians but physician’s associates? Those are some of the questions I would think about if I was a clinician.”
Lightly regulated
It’s not often discussed, but the industry seems to be well-regulated, but in many ways is lightly regulated. This has come up recently in episodes of “errors” as you can see in this Google search of news reports on the topic with failures of freezing systems, lost eggs and embryos, ruined embryos and the like. This search is far from exhaustive; the incidents are reported sporadically and as a series of one-offs. But there may be clear danger signals at some clinics.
“Most of the time, experts say, errors and accidents go unreported in the burgeoning fertility industry, which is largely self-policed,” Lenny Bernstein and Yeganeh Torbati wrote recently for The Washington Post (gift link). “It is not mandated to report errant episodes to the government, the public, any professional organization or even patients — despite a code of ethics that explicitly says practitioners should promptly tell patients about lost or destroyed genetic material.”
“‘In other areas of health care, states require hospitals to monitor and report major avoidable errors, things like mismatched blood transfusions or surgery on the wrong body part,’ said Dov Fox, a law professor and director of the Center for Health Law Policy and Bioethics at the University of San Diego, who studies the fertility industry. ‘They call these ‘never events’ because these are things that just shouldn’t happen. No agency or authority tracks or polices what might be called ‘reproductive never events.’”
“States license clinics and professional groups govern practitioners. But the inspection and accreditation of labs are handled mostly by private, voluntary organizations that consider that information the property of clinics. Many inspectors are the directors of labs themselves, a fraternity of scientists who review one another’s work, looking for systemic problems, not lost reproductive material, according to the College of American Pathologists.”
Paying for assisted reproduction
For patients, the fertility market is complicated, to say the least. It’s wrenching emotionally and beyond expensive. (Disclosure: I speak from experience.)
Insurance coverage varies greatly from company to company and state to state. For example, New Jersey recently passed a law mandating that health insurance coverage for infertility apply to everyone, regardless of sexual orientation, meaning that LGBTQ people are eligible. Company policies are often out of step with state regulations. In many cases, a diagnosis of infertility is required – effectively ruling out same-sex couples. Some companies that previously covered infertility treatment for people who had vasectomies and tubal ligations, for example, apparently changed their policies at the turn of the year.
How can you find out what you need to know? Seeking advice on online forums and message boards is one way people are coping – what companies offer insurance, and what are the benefits and limitations? What states have what laws?
In investigating the actual course of treatment, some patients trade information via the national support group Resolve, while others visit Facebook or Reddit groups.
Some of the most informative I have seen at this writing, in general terms, are the subreddit r/Infertility, and the Facebook group Paying for IVF
On Facebook, many groups have a name including “IVF” or “Fertility.” “TTC” for” trying to conceive” is another search term. There are special groups for Amazon employees, for example: Amazon Infertility Journey on Facebook. We understand that Amazon uses Progyny, which is considered a Cadillac of fertility insurance. Progyny fertility insurance offers something called “smart cycles” – apparently with Amazon you get one, but if it doesn’t result in a live birth it unlocks a second.
There’s a Facebook group called Progyny IVF Jobs. Reddit also has sub-groups. Search for infertility with a modifier like LGBTQ, single parents, WFH (work from home), Amazon, eBay, federal employees.
Other communities on Reddit and Facebook relate to PCOS (polycystic ovary syndrome), surrogacy, miscarriage, endometriosis, male infertility, “stilltrying,” “queerception,” and practically any other topic you might choose. We have not joined these Facebook communities, since we as journalists are not honestly able to say we are eligible to be members of these communities, but people who are eligible can join and see the conversation – and many Reddit communities are open and can be read by non-members.
Many of the contributions are from people who are sharing information about companies that have IVF as part of their benefits. T-Mobile, Amazon, Wayfair, PayPal, eBay, Ikea, Sherwin Williams, Cigna. Citibank, Lowe’s, Microsoft, Credit Suisse and the federal government come up a lot. Some companies reportedly have IVF coverage for part-time employees, reportedly Target and Starbucks, but the landscape seems to change frequently and even be dependent on the particular role of the job. Also a self-standing Starbucks has different benefits from a Starbucks in a hospital or in a retail store. Eligibility varies; for some companies it’s the first day of employment, but for others there is a waiting period.
The companies’ offerings seem to change fairly frequently, and for a prospective employee, it’s difficult to suss out in advance what your benefits will be: Asking up front during the hiring process about fertility benefits is regarded as a sure way to not get hired.
To help in this situation, the Facebook group Paying for IVF has a spreadsheet of companies with benefits. The Reddit subreddit r/infertility also has a spreadsheet detailing what companies are offering insurance coverage, as well as basic references on procedures, medication costs and the like.
As with any online information, this should be considered directional and not medical advice — and not definitive, because a company might change its policies before the Facebook spreadsheet catches up.
The discussions about price frequently seem to mention CNY Fertility, which markets itself as “Making priceless affordable,” and has up-front packaging including a relatively low initial price for the industry, and also a payment plan calculator with add-ons for different things like donor egg, donor sperm, reciprocal IVF, genetic testing and so on. With the relatively low prices, some of the commenters are enthusiastic, while others say the patient experience can be challenging – yet the patient experience in IVF is always challenging. CNY has locations in New York (including Syracuse, Rochester, Albany and Buffalo), and also Atlanta, Philadelphia, Colorado Springs and Sarasota, Fla. – which is inconvenient if you live elsewhere, but they seem to get a lot of travel-in traffic and to be set up for people who are not local residents. CNY also reportedly offers in-house financing, as do many clinics.
The advice on joining a company to get fertility benefits goes so granular as to say when you can start and activate your plan, and then when to quit to pay COBRA. Some commenters note that this practice is somewhat controversial, because the companies don’t really want to be perceived as, and used for, a supplier of fertility benefits – commenters have noticed that some companies have changed their policies for fertility eligibility to avoid this type of employee turnover.
There’s a huge amount of information available on TikTok, too, including a demonstration of the pre-implantation procedures (sperm assessment under the microscope) and a video of an egg retrieval, among other things.
Insider tips
These online groups have data from real people on the ground. It is complicated and it seems to change a lot – for example, one company may start IVF insurance on Jan. 1 and one might discontinue.
Changes in law and policy also surface on these online groups. For example, the Department of Veterans Affairs recently announced that it would expand access to fertility treatments to same-sex couples, single veterans and people planning to use donor gametes.
It does seem that the online groups are fairly well equipped to inform and answer questions.
Taking a loan: Consumer loan rates for IVF can be very high, and dependent of course on your credit. Places like BetterMed and Future Family offer specialized plans, but they may not be an improvement on your bank or credit union rates — and these communities know the inside information. (“xxx is a scam!”)
The conversations involve things like “Amazon offers day 1 fertility coverage to full time regular employees through Progyny. People work 1 day, quit and elect COBRA; keeping your current coverage at a much higher cost for 18 months or until the benefit runs out.”
“Don’t apply for a seasonal job at Amazon or Wayfair – only the fulltime jobs offer IVF benefits.”
“You will have to do at least the first 4 days … Cause you’re still tech in training the first 4 days. And the insurance doesn’t kick in for at least 1 weeks cause they only put it in to the insurance on Tuesday and Thursdays and then it takes the insurance a min to put it in on their side. So plan for the first week at least to play it safe.”
“Also I think they are also picking up on people only working 1 day and then quitting.”
“Also, someone said their cobra was 900 bucks a month so at that point you might as well go to CNY bc in like 4 to 5 months of saving 900 bucks a month you’d have your cycle covered.
About CNY: “”I paid almost 13k. That includes their price for the retrieval and transfer. I was a traveling patient so the 13k includes travel expenses and out of state monitoring as well as meds.”
”I just finished a cycle, I would say in total I paid around $6000-$7000. I had little to no travel expenses because I live close enough that I was able to drive and I stayed with family while doing my retrieval and transfer.
“I did finance and the process was VERY easy. Just filled out the paperwork and paid the 50% requirement through the portal and that was it.”
“We are cash pay & have gone through 3 retrievals & fresh transfers at CNY. We are also travel patients who did local monitoring. Depending on the meds I was on, our total costs were between $7,500 – $9,000 per cycle”
“We have done 2 ivf cycles with CNY sarasota. Our 2nd was successful. Total, each cycle ended up around $8,000…. We paid half up front and financed the rest over two years. I pay around $250 monthly for each cycle. … I live about 2 hours away. The first cycle I drove back and forth for monitoring and the 2nd I monitored locally.”
Where did you get your meds?
“I traveled to Mexico (Tijuana) to pick up the medicine. Pharmacy’s name is Fertifarma. I spent about 2K for the meds I needed for 1 egg retrieval. I did meds for about 11 days, I think.”
“I have heard good RX. I got my Progest*** meds from Amazon pharmacy and they were 1/4 of the cost of freedom pharmacy”
Our original story about buying fertility medications has been frequently updated; it talks about buying overseas, patient assistance programs, and how companies try to get you to buy medications from them instead of from someone else.
Scholarships
What are your chances for getting a scholarship or grant? What’s the inside story on these offerings? This Resolve list is not exhaustive, but it’s at least a start. Here’s a version from Parents magazine. Here is a list from Progyny. Note that none of these are guaranteed, but they’re a good starting place and fine directionally: For example, cancer patients may get aid from Livestrong, some grants may be regional, and there may be other sources.
Going abroad: For a lot of people, this is out of the question. But the message boards have a number of options. For instance, the Tijuana, Mexico, area seems to have several options, and there are online groups discussing the ins and outs of this path.
Pro tip: There was recently a scandal about HIV infections in a Mexico cosmetic surgery clinic, and stem-cell treatments in Mexico too. We do not give medical advice, except to say: Be careful.
The Facebook groups and Reddit message boards will also offer current information about people’s experiences domestically and overseas – what to expect, what you’ll pay, how long you’ll stay, what the surrogate or donor experience is.
This is information that is not available – to my knowledge – anywhere else but on these Facebook groups and message boards. It does take a little while to orient yourself. For example, r/IVF has a lot of information about clinics abroad. The r/Infertility subreddit is, as you would expect, bigger than r/IVF. Both have a lot about “IVF Abroad.” but the r/IVFAbroad Subreddit doesn’t have that many members.
The Society for Assisted Reproductive Technology has a lot of resources on its site, including this patient’s guide. It also has success rates per clinic.
The C.D.C. has success rates here.
What you can do
La Forgia said private equity and for-profit are not necessarily all bad. But bigger seems to be better than smaller
“I would personally want to go to a clinic that does extreme high volume of care and has the resources to provide me fast, efficient quality care,” she said, emphasizing that this is a personal preference. “Given my dataset, that seems to be the chain. It doesn’t have to be private equity. But the ones that are part of a national chain is where I would go.”
Bruch said: “For fertility care, I think some questions that one might want to look at is ‘what are the financing options? Are these typical financing arrangements? Is there a potential for predatory financing?'”
He also noted that some practices are introducing binding arbitration as part of their contract, which may mean that in the event of questions, patients have less leverage.
“Patients should ask about arbitration agreements,” he said. ‘They should ask about the financing of their treatment. And they should ask about ownership. Who owns their fertility practice? Is this a physician-owned practice? Is this owned by the hospital? Is this owned by a financial firm? Is this a large venture capital backed? A private equity practice?”
The C.D.C. has success rates here. You can also investigate the success rates per clinic via the SART site. I pointed out that a lot of the data in healthcare is squishy or manipulated, but La Forgia said this data is pretty reliable.
Specific groups
Check the Facebook groups mentioned above (Paying for IVF, Amazon Infertility Journey etc.) and the subreddits (try starting with https://www.reddit.com/r/infertility/, https://www.reddit.com/r/InfertilitySucks/). If you’re LGBTQ, or a PCOS person, you’ll find more specific information on the more specific Facebook groups and subreddits. For example, there are several CNY fertility groups on Facebook, several Shady Grove fertility groups, and so on.
Remembryo collects various kinds of data on costs and process. The prices seem to be crowdsourced and not necessarily current, so valuable as directional but not gospel truth. (At this point, I see 2020 and 2021 prices.). There’s also information on current IVF research by the founder, a former embryologist.
Some companies cover fertility assistance as part of a benefits package. The lists on the Facebook and Reddit groups will also have some information, probably more current. As with anything online, you need to check yourself: If the company is listed here as having fertility assistance, what does that mean?
Some people pursue treatment abroad because it is so expensive in the United States. Reports from others who have followed this path maybe of the most assistance. Here’s a no-longer-fresh Reddit thread on this topic.
Clinics
A good place to find the names of clinics and their stats is at the C.D.C listing of success rates here.
This chart of chains from 2018, some with P.E. investment and some without, is drawn from the study by La Forgia and Bodner. It is very informative on their characteristics in the context of the study. But it is not an exhaustive — it omits, for example, CNY and many others.
