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2005/15: Should restrictions be placed on Medicare funding for IVF procedures?
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What they said ...
'There is a sense in which it is an elective procedure and there has to be some limit, speaking hypothetically, on what the government is prepared to spend on things which are non-essential ...'
Mr Tony Abbott, federal Health Minister
'We paid more than $35,000 to have our children, and that does not include the government subsidy. We sacrificed and suffered immeasurably. It was worth every second of pain, but I would not wish this journey on any one. Please don't make it harder'
An IVF parent
The issue at a glance
On April 19, 2005, it was reported that a leaked Government document indicated that the federal Government planned to limit the availability of Medicare payments to couples using IVF.
The plan, which would save the government $7 million a year, was confirmed by a Health Department official after the document was leaked to Channel 9.
Under the plan, women under 42 years of age would be able to claim rebates on three IVF cycles a year, and those over 42 would be allowed three cycles altogether.
There are no limits on the number of IVF cycles presently available to women. Medicare subsidises about half the $8,000 cost of each IVF cycle.
Doctors and researchers involved in IFV as well as couples using the procedure immediately criticised the plan. It was defended by both the Treasurer, Mr Costello, and the Health Minister, Mr Abbott.
Mr Costello referred to the probable success of a procedure as being one of the bases that should determine whether it attracted Medicare funding. Mr Abbott suggested that the 'essential' or 'lifesaving' quality of a procedure should determine whether it was covered by Medicare.
Ultimately, the proposal was not incorporated in the May budget as some commentators had speculated. However, an expert review panel has been set up apparently to look at Medicare funding of IVF. Some critic fear this may be part of a more wide-ranging review of the operation of Medicare.
Background
(The following is a slightly edited version of information available on the Women's Health Queensland Wide Inc Internet site.)
Reproductive technology is the term used to describe the range of medical treatments available to assist couples to conceive. The majority of people seeking assisted conception technologies are infertile. Infertility means being unable to conceive a baby naturally after at least 12 months of regular, unprotected sexual intercourse. It affects approximately 15% of Australian couples of reproductive age. The causes can lie equally with a woman or a man and in 20% of couples infertility is unexplained or idiopathic.
Previously there were only two remedies available for infertile couples: remaining childless or adopting a baby. Whilst remaining childless is a legitimate choice made by a number of couples, many men and women experience a strong desire to have a child. The inability to have a child can be devastating and involve a lengthy process of loss and grief.
Since the late 1970s, significant scientific and medical advances in reproductive technology have changed the way women can have children, and even definitions of motherhood and fatherhood.
Reproductive technology, however, does have its drawbacks. The success rate is relatively low and the treatments can be both financially and emotionally draining. There are also ongoing debates about the ethical, moral and legal dimensions of reproductive technology.
Current reproductive technologies include:
*Artificial insemination (AI) - involves the woman having sperm from either her partner or a donor injected into her vagina, cervix, uterus or fallopian tubes.
*In Vitro Fertilisation (IVF) - means literally fertilisation in a glass. In a laboratory, sperm and eggs are put together in sterile dishes or tubes. After fertilisation occurs the embryo or embryos are transferred to the uterus. This treatment was first developed for women with serious damage to their fallopian tubes. There are several types of IVF, depending on whether the woman or man is the cause of the infertility and how severe it is.
*Gamete Intra-Fallopian Transfer (GIFT) - where the egg is removed via laparoscopy and immediately transferred to the fallopian tubes together with sperm so that fertilisation can occur naturally.
*Zygote Intra Fallopian Transfer (ZIFT) - the egg and sperm are fertilised outside the body (as with IVF) and the embryo (zygote) is transferred to the fallopian tubes.
*Intracytoplasmic Single Sperm Injection (ICSI) - involves the retrieval of sperm directly from the epididymis or the testes and injecting this single sperm into an egg in the laboratory. The embryo is then used in an IVF or ZIFT procedure.
*Surrogacy - involves a woman bearing a child for another woman/couple. Surrogacy is often separated into commercial (where the bearer of the child is paid for her services) and altruistic (where the bearer receives no payment).
In Australia, surrogacy is governed by state laws so there are variations in each state. In Queensland, both altruistic and paid surrogacy are illegal, while in some other states altruistic surrogacy is allowed.
IVF, GIFT and ZIFT usually involve chemically stimulating the ovaries to produce more eggs which are extracted by a procedure called a laparoscopy. Producing multiple eggs means that those which are not used for fertilisation can be frozen for future use by either the woman herself (Frozen Embryo Transfer) or donated to an infertile couple.
Short and long term health effects
The majority of reproductive technologies are complex treatments involving the use of drugs and surgery. More is known about the short term hazards than the long term effects to a woman's health. Complications in the short term include problems associated with overstimulated ovaries, the complications (albeit small) associated with a general anaesthetic and surgery, and an increased likelihood of a caesarean birth. There are risks to the baby as well. These include an increased likelihood of premature birth and/or multiple birth and the associated consequences of these outcomes (experiencing sickness after the birth, hospitalisation in the first year, impairment and disability).
Concerns have also been raised regarding a possible association between the use of fertility drugs and an increased risk of cancer of the reproductive organs. There is a need for long term studies that follow women who have taken fertility drugs for many years to determine if their cancer risk is increased. A recent review of the use of fertility drugs and ovarian cancer found fertility drugs did not increase a woman's risk of ovarian cancer but that specific biological causes of infertility may be contributing factor.
Access to reproductive technology: costs and sexual preference
Prior to November 2000, Medicare would only cover the cost of the first six IVF cycles. This limit has now been abolished allowing couples unlimited attempts. It is this facility which the federal Government is considering removing.
The issue of access to reproductive technologies has been the subject of ongoing debate. A single woman won a court case against the Victorian Infertility Treatment Act, which restricts fertility procedures to married women and women in heterosexual de facto relationships. This issue has stimulated community debate about who has the right to access fertility procedures, who makes a good parent and what are the rights of the child?
It has been argued that reproductive technologies should be restricted to heterosexual couples who are infertile and that a child should grow up with a mother and a father. Others have suggested that lesbians and single women should have equal rights to fertility procedures, irrespective of their circumstances and sexual preference.
Internet Information
On April 27 2005 the federal Health Minister, Tony Abbott, defended plans to reduce Medicare funding for IVF procedures on Radio National's AM.
A full transcript of the Minister's comments can be found at http://www.abc.net.au/am/content/2005/s1354194.htm
On April 27, 2005, the Australian Medical Association (AMA) issued a media release criticising the federal Government's apparent intention to reduce the availability of Medicare funding for IFV procedures.
The full text of this media release can be found at http://www.ama.com.au/web.nsf/doc/WEEN-6BTUTP
On April 27 2005 the Opposition Health Minister, Julia Gillard, gave a doorstop interview in which she criticised both the Government's apparent intention to reduce Medicare funding for IVF procedures and their cutting back of the Medicare safety net.
These comments can be found at http://www.alp.org.au/media/0405/dsihea270.php
On April 28, 2005, the Australian Democrats issued a media release criticising the federal Government's apparent intention to reduce the availability of Medicare funding for IFV procedures.
The full text of this media release can be found at http://www.democrats.org.au/news/?press_id=4536&display=1
On April 27 2005 The Daily Telegraph published an opinion piece by Anita Quigley titled, 'IVF babies should be treasured, not costed' criticising the federal Government's proposed changes to Medicare funding for IVF.
The full text of the comment can be found at http://dailytelegraph.news.com.au/story.jsp?sectionid=2606684&storyid=3027241
Monash University's Centre for Health Program Evaluation produced a report in February 1992 titled, 'The Economics of the IVF Program: a critical review'. This is quite a complex document but it provides valuable background to the current discussion.
The full text of the report can be found at http://www.buseco.monash.edu.au/centres/che/pubs/wp20.pdf
This is a pdf file that requires Adobe Acrobat Reader in order to be read.
In 2003 the City University, London, Economics Department, published a paper titled, 'Funding fertility: issues in the allocation and distribution of resources to
assisted reproduction technologies' by Nancy Devlin and David Parkin.
This also is quite a complicated background to the issue, however, it is a valuable discussion from a British perspective.
The full text of the paper can be found at http://www.city.ac.uk/economics/dps/staff/devlin/huf6_2supp_pS02.pdf
This is a pdf file and requires Adobe Acrobat Reader in order to be read
Women's Health Queensland Wide Inc's Internet page has a subsection given to a clear, detailed explanation of IVF procedures and some of the associated issues. This material forms the basis of the background notes supplied at the start of this issue outline.
The source of this information in an unedited form is http://www.womhealth.org.au/studentfactsheets/infertility.htm
Arguments in favour of restrictions being placed on Medicare funding for IVF procedures
1. Medicare funding should be directed toward IVF treatments most likely to be successful
The Treasurer, Mr Costello, has suggested that women over 42 should only have three cycles of Medicare-funded IVF treatment available to them. Mr Costello has stated, 'It is a question of ensuring that those treatments that the taxpayer pays for are treatments that have a decent chance of success.'
According to this line of argument, it is an unreasonable use of taxpayer funds to have them used to finance procedures which are unlikely to be successful.
The Treasurer has stated, 'Where the chances of success are very low - nobody is saying you can't do it - but where the chances are very low, the taxpayer ought to direct the funding to where the chances are higher.'
The implication appears to be that given a finite health budget and, by extension, finite expenditure on IFV procedures, it makes sense to concentrate expenditure on women most likely to successfully use the interventions.
Thus Mr Costello has argued, 'The chances are higher with younger women.'
2. By international standards Australian funding of IVF procedures is generous
Mr Costello has argued that by world standards, Australia's Medicare funding of IVF procedures is liberal. The same claim has been made by the federal Health Minister, Mr Tony Abbott, who has claimed, 'The federal government had been a generous supporter of women's access to IVF.'
Supporters of the federal Government's funding of IVF have noted that Australian couples seeking to become parents using IVF receive far greater financial support from the Government than is the case in many other countries. In Britain and New Zealand women are offered only one cycle of publicly funded treatment.
A 2002 British report titled, 'Funding fertility: issues in the allocation and distribution of resources to assisted reproduction technologies' noted, 'In the UK most National Health Service Trusts offer no more than a skeleton infertility service. Because of its expense and low success rate, fertility treatment usually ranks high on the list of "banned" procedures which some health authorities and Trusts have drawn up to assist in rationing services.'
A recent official British recommendation proposed that publicly funded IVF be restricted to a total of three cycles and limited to patients aged 23-39. This is both more generous than what is currently available to British users of IVF and far less generous than the restriction proposed by the federal Government.
Over 3,500 assisted reproduction treatments were carried out in New Zealand in 2002 (the latest figures available). Just half of those were funded from the public purse; the rest were paid for by would-be parents desperate for a healthy baby and willing to part with up to $9,000 for a single treatment cycle.
3. The proposed IVF restrictions would have had little impact on most couples using IVF
The Minister for Health, Mr Tony Abbott, has argued that the changes proposed to the Medicare funding of IVF treatments would have had very little impact on most couples using the procedures. Mr Abbott has claimed that 90 per cent of IVF recipients had three or fewer cycles in any one year.
The implication would appear to be either that most couples were successful after three or fewer cycles and perhaps those that were not needed time to physically and emotionally recoperate before seeking treatment again.
According to these figures the limitations the Government planned to place on IVF funding would have interferred with the treatment options of only about 10 percent of couples using IVF.
4. Fertility treatments are not essential medical procedures
The Federal Health Minister, Mr Tony Abbott, has claimed, 'There is a sense in which it is an elective procedure and there has to be some limit, speaking hypothetically, on what the government is prepared to spend on things which are non-essential ...
If non-essential treatment is funded endlessly, medical costs blow out endlessly and responsible governments have to try to ensure that we give good value to taxpayers as well as good value to patients.'
Mr Abbott further went on to explain that IVF procedures were not lifesaving and thus, by implication, it was legitimate to restrict the extent to which they were funded through Medicare.
Again, attempting to clarify where he placed IVF as a federal spending priority, Mr Abbott stated, 'It's very important, obviously, but it's not lifesaving treatment.'
5. The cost of fertility treatments to the Australian taxpayer is rising dramatically
There are currently no limits on the number of IVF cycles available to women, with Medicare subsidising about half of the $8,000 cost of each IVF cycle.
Department of Health and Ageing figures show the cost to Medicare of in vitro fertilisation (IVF) treatments rose by 57 per cent in 2004, with Medicare IVF benefits rising from $50 million in 2003 to $78.6 million last year, after the Medicare safety net was introduced.
Around 30 per cent of clinics were charging administrative and laboratory costs directly to patients before the introduction of the safety net last year. Now, 95 per cent of all clinics are charging those costs to Medicare direct. This, combined with a 14 per cent rise in the number of IVF cycles in 2004, accounted for the rising costs to the public purse.
It is estimated about $7 million a year would be saved by the Government under IVF changes which would limit women over 42 to three publicly funded treatments and younger women to three a year.
Arguments against restrictions being placed on Medicare funding for IVF procedures
1. It should not be up to Government to determine what are 'essential' or sufficiently 'successful' medical services
AMA Queensland President and IVF specialist Dr David Molloy has noted that it is the Medicare Act which defines fundable treatments as 'the relevant clinical services for clinical conditions'. However, Dr Molloy, argues the Health Minister has 'unilaterally reinterpreted the basis of Medicare as restricted to lifesaving procedures alone'.
Dr Molloy said Mr Abbott's reinterpretation of Medicare represented the most fundamental shift in the principle behind Medicare since it was instituted 30 years ago and the decision was made without consultation with doctors or the public.
'What is the next step?' Dr Molloy questioned. 'Restricting hip replacements for those over 80 years of age because they will only get a few years use out of the prosthetic.'
Critics of the success-based Medicare funding model proposed by both Mr Abbott and Mr Costello have argued that this is the thin edge of a highly unacceptable wedge. Daily Telegraph commentator, Anita Quigley, has asked, 'If Mr Abbott and Mr Costello want to limit public spending on treatments that are expensive, with low prospects of success, shouldn't they start with treatments for people with terminal diseases?'
IVF pioneer and Melbourne IVF chairman Dr John McBain has noted, 'There are many people who have surgery and chemotherapy where there is no prospect of a cure, but some prospect of improving the quality of life.' Under Mr Abbott's criterion, that Medicare-funded procedures be lifesaving, these treatments would presumably not qualify.
2. The proposal appears arbitrary and discriminatory
A 2002 report on assisted reproductive technology in Australia and New Zealand by the Australian Institute of Health and Welfare claims the average age of women undergoing treatment is 35.2 and the average age of men is 37.6. It describes women of reproductive age as 15 to 44. This clearly raises the question of why it is that some members of the Government have set 42 as the age at which women would move from being entitled to three Medicare-funded cycles of IVF treatment per year to three for the rest of their reproductive lifetimes.
In an article published in The Age on April 29, Sushi Das argued, 'It is generally accepted that a woman's fertility declines significantly after 37, but there is no explanation by the Government for its cut-off age at 42. This is an arbitrary figure.'
The failure rate for IVF is approximately 80% across all age groups. Das asks, 'But if the across-the-board failure rate is so high in all age groups, why is the Government ... focusing on the failure rate among the over-42s when it comes to deciding who can receive rebates and who cannot?'
There are also those who wish to know why some within the Government have decided to focus on patients accessing reproductive technologies and not other forms of medical assistance.
According to this line of argument, limiting the Medicare funding available to those who use IVF and to those over 42 in particular is simply discriminatory.
3. The amount of money the Government stands to save is relatively small
It has been claimed that the proposed restrictions on Medicare funding of IVF procedures would have saved the federal Government some $7 million each financial year.
Even if larger savings could be made they are unlikely to be much more substantial. The total cost of Medicare-funded IVF treatments in 2004 was some $79 million. As Anita Quigley noted, writing in the Daily Telegraph, '... a mere dent in the overall budget.' Ms Quigley also noted, 'I can think of far worse ways my taxes are being spent - such as a $3.3 million Federal Government grant on the flop film Visitors which returned a lousy $34,276 at the box-office.'
It has also been claimed that reducing the number of funded cycles is likely to see a return to multiple implants of fertilised ovum with correspondingly higher rates of premature, multiple births.
AMA Queensland President and IVF specialist Dr David Molloy has noted the $7 million saving would be negated by just 10 sets of multiple premature births in one year as it costs $500,000 to $750,000 to keep such premature babies alive.
4. A reduction in Medicare funding will harm perspective parents
The Education Minister Brendan Nelson, a doctor and former president of the AMA is said to have argued against the proposal in Cabinet.
It has been claimed that Dr Nelson argued that the projected savings did not justify the pain that would be inflicted on potential parents denied the opportunity to continue IVF procedures because of the restrictions on Medicare funding available.
A woman who has successfully had children using IVF wrote in a letter published in The Age on April 26, 2005, 'It was the most gruelling experience of my life; when I suffered a near-breakdown after our eighth attempt, a counsellor told me that eight IVF attempts were the same, emotionally, as eight miscarriages, except they were less recognised in society.
We are already a marginalised group; please don't add more obstacles and heartache to our lives by imposing limits. It has to be done when we are financially and emotionally ready. If that means five attempts in one year or one, please let that be our decision. We paid more than $35,000 to have our children, and that does not include the government subsidy. We sacrificed and suffered immeasurably. It was worth every second of pain, but I would not wish this journey on any one. Please don't make it harder.'
It has been noted that most couples do not achieve a pregnancy within three cycles in a given year and will thus either have to pay for any subsequent treatments in that year themsleves or wait until the following year to begin treatment again. The longer a couple postpones treatment, the less successful it is likely to be.
It has also been argued that limiting Medicare funding would restrict the availability of IVF treatment to wealthy couples.
5. Such a policy runs counter to the Government's desire to boost the Australian birth rate
The Federal Government is keen to see a jump in Australia's birth rate. Twelve months ago when Mr Costello handed down his last budget, the federal Treasurer claimed, 'If you can have children it's a good thing to do. You should have, if you can - not everyone can - one for your husband and one for your wife and one for the country.'
In last year's federal Budget, the Government introduced the $3,000 baby bonus and increased family payments in a bid to boost the nation's flagging fertility rates and reduce the economic challenges posed by the ageing population.
Critics claim that the new proposed restrictions on IVF funding contradict this aim to boost Australia's population.
IVF specialist Professor Michael Chapman has argued that IVF is making a small but valuable contribution to Australia's population growth. Professor Chapman has noted, 'IVF is now contributing almost 3 percent of all births in Australia.'
Professor Chapman wrote to the Government, claiming the change would be at odds with the push to increase Australia's population.
'Since IVF started in Australia there have been 61,000 births from IVF, and 30,000 of those have been in the last 5 years, so any constraint on that would be bad for Australia,' the Professor argued.
Dr John McBain, the chairman of the Melbourne IVF Group, has further noted, 'More than 30 per cent of all the babies who are born through IVF come from cycles beyond three cycles of trying.' This would appear to mean that if the current Medicare limitations had been in place some 20,000 IVF births may not have occurred.
Further implications
The federal Government's willingness to consider reducing the extent of Medicare funding of IVF appears to be at least in part a response to the cost-inflating effects of the Medicare safety net it put in place in the lead-up to the last federal election. Under the provisions of the safety net low-income families would have 80 per cent of their out-of-pocket medical expenses meet after their medical costs exceed $300 in a given calendar year. For other families 80 per cent of their out-of-pocket medical expenses are to be meet once their medical costs have exceeded $700 in a given calendar year.
The impact of this safety net has been seen as responsible for much of the blow-out in the cost of IVF procedures funded by Medicare. During an ABC Radio interview on April 27, 2005, Mr Abbott claimed, '... in 2003, before the Safety Net was introduced, Medicare spent $50 million on IVF rebates and in 2004 with the Safety Net, Medicare spent $79 million on IVF rebates and about $28 million of that increase was due to the Safety Net.'
The Government has announced that it is altering the operation of the safety net in an attempt to reduce costs. However the announced changes, raising the level of out-of-pocket expenses before the safety net cuts in to $500 and $1000 respectively, will have no impact on reducing the extent of Medicare payouts for IVF procedures. One treatment cycle for IVF costs approximately $8000.
However, cost alone seems unlikely to explain the willingness among some in the Government to reduce Medicare funding for IVF procedures. The proposals discussed before the May 2005 budget were likely to save only $7 million in a given calendar year. This is a very small sum to save in the context of total budget expenditure on health.
The Government may simply have been flying a kite, attempting to determine the readiness of key groups within the electorate to accept an alteration to the principles that have to this point determined Medicare payments. If a medical procedure is on the Medicare schedule it currently attracts payment if it is the appropriate treatment for a particular condition. What was proposed regarding IVF treatments is a radical undermining of this principle. The Government would be able to determine that certain treatments should not attract Medicare funding either because they are not 'essential' or 'life-saving' or because they have a poor likelihood of success.
It may be that the Government was curious to see if it could begin to alter the principle behind the payment of Medicare rebates using a small group (IVF couples and especially those where the woman is over 42) with little apparent political clout. If that were the Government's intention it clearly underestimated the capacity of this group and IVF doctors and researchers to bring political pressure to bear.
However the issue has not been put to rest. The proposal, which was not given form in the May budget, is now being reviewed by an expert panel. The Opposition leader, Mr Kim Beazley, believes this is part of a larger push to have many 'non-essential' procedures no longer able to be claimed for under Medicare.
Newspaper sources used to compile this outline
The Age
29/4/05, page 23, comment by Sushi Das, 'The case for cutting IVF: rubbery figures and cynical spin'
30/4/05, Insight section, page 1, analysis by Jo Chandler, 'The politics of IVF'
2/5/05, page 20, editorial, 'Why alter IVF policy?'
2/5/05, page 6, news item by David Wroe, 'Costello's IVF statistics "wrong"'
5/5/05, page 3, news item by Michelle Grattan, 'Planned IVF cuts to be reviewed'
The Australian
2/5/05, page 2, news item by Shanahan and Colman, 'No backdown on IVF cuts'
2/5/05, page 8, letters under heading, 'We just want more little Australians'
29/4/05, page 2, news item by Samantha Maiden, 'Goward joins the fight on IVF cuts'
30/4/05, page 4, news item by Samantha Maiden, 'Abbott admits IVF claim wrong'
5/5/05, page 11, comment by Mike Steketee, 'Footing the bill for baby'
5/5/05, page 14, analysis by Samantha Maiden and Clare Pirani, 'Pregnant pause on IVF'
Herald-Sun
29/4/05, page 15, news item by Jason Frenkel, 'More Libs rebel over IVF age cap'
3/5/05, page 12, news item by Jason Frenkel, 'PM firm on IVF advice'
3/5/05, page 18, comment by Michael Cook, 'The big business of babies'