Debat indlæg Brugerbetaling på reproduktion?

1. Debat indlæg Brugerbetaling på reproduktion? Anders Nyboe Andersen, Professor Fertilitetsklinikken, Rigshospitalet Hindsgavl, september 2010

2. Brugerbetaling kunstig befrugtning • Så kører sagen igen…. • I 1998 udarbejdedes i Sundhedsministeriet på initiativ af den socialdemokratiske Nyrup regering rapporten: ”Redegørelse fra arbejdsgruppen om brugerbetaling for kunstig befrugtning” Sundhedministeriet, Marts 1998.

3. Humane forplantning • De frivilligt frugtbare Fødslerne • De frivilligt ufrugtbare Kontraception • De ufrivilligt frugtbare Abortus Provocatus • De ufrivilligt ufrugtbare De infertile Hvem er mest ”syge” Hvem er de ”fleste” Er der etisk/moralske overtoner? (”KUNSTIG” befrugtning…. HC Andersen)

4. Forslagene til brugerbetalingpå reproduktion • Sectio på maternal request (kunstig fødsel) 14.375 • Abortus provocatus 4.800 • Normal og ukompliceret fødsel 9.050 • Dagsafgift, barsel efter normal fødsel 2.600 • Kunstig befrugtning 19.280 • Sterilisation , kvinde 8.300 • Sterilisation, mand 4.200 • Refertilisation, kvinde 17.000 • Refertilisation, mand med mikrokir. 21.000

5. Forslagene til brugerbetalingpå reproduktion Den forudgående side var pure opspind….. …bortset fra lige netop området: ”kunstig” befrugtning

6. Ideal Health Technology “Successful” Appropriate Acceptable Available Accessible Affordable And we could add: ….for all those that could benefit from the technology, based on the concept of equal access for all citizens to health services that is an integrated part of modern European thinking

7. European Parliament Report G. ”Infertility is one of the causes of demographic decline and it should be recognised as a public-health concern and as a social problem affecting both men and women” 26. ”Notes that infertility is a medical condition recognised by WHO that can have severe effects such as depression; points out that infertility is on the increase …; calls on the Member States to ensure the right of couples to guarantee universal access to infertility treatment and medically assisted procreation by taking steps with a view to reducing the financial and other obstacles” European Parliament. Report on the demographic future of Europe. (2007/2156(INI)), 30th January 2008

8. ART cycles / mio inhabitants performed at clinics located in different regions. Denmark, 2008 1.206 3.221 3.750 1.568 851 Numbers are related to location of clinics Data from Danish Fertility Society, 2009

9. Danmark - internationalt

10. ART cycles / million in Europe, 2006(Countries with complete recording) Denmark, Belgium France, UK, Germany ↓ ↓ ↓ ESHRE EIM, Data from 2006, Amsterdam July 2009.

11. Percentage of infants born after ART (2007) Belgium: underestimation due to substantial ”loss of follow-up of deliveries”

12. ART cycles per million inhabitants versus the Gross Domestic Product in some European countries,2002. The willing The unwilling NO CH IS BE DK IR NL SF DE IT UK FR SE SP SL PO GR HU RU PL BU LA The unable Slide from Arne Sunde

13. ART cycles / million in selected countries around the world,2002 Canada? ICMART World Report, 2002. Hum Reprod, 2009, 24, 2310

14. Successful ART for the infertile population

15. Is ART successful in Montana or Wyoming ? Montana Wyoming

16. ART cycles / million in different states United States Is ART succesful in Massachusetts? ↓ In Wyoming ? ↓ Wright et al. Surveillance Summaries, 2006, 55, SS-4

17. Chambers GM et al: Fertil Steril 91:2281-94, 2009 17

18. The demographic aspects • The EU parlament wrote in its report: ”On the demographic future of Europe” (http://www.europarl.europa.eu/sides/getDoc.do?language=EN&reference=A6-0024/2008 ): “Whereas infertility is one of the causes of demographic decline and whereas it should be recognised as a public-health concern and as a social problem affecting both men and women; reminds the Commission of the 'Call for action on infertility and demography' which was issued by the Parliament in 2005 and called upon the Commission to put forward recommendations in this area”

19. The demographic aspects • 26. ”Notes that infertility is a medical condition recognised by WHO that can have severe effects such as depression; points out that infertility is on the increase …; calls on the Member States to ensure the right of couples to guarantee universal access to infertility treatment and medically assisted procreation by taking steps with a view to reducing the financial and other obstacles” European Parliament. Report on the demographic future of Europe. (2007/2156(INI)), 30th January 2008

20. Offentligt betalt Fertilitetsbehandling, Europa

21. Countries with re-imbursement of ART Belgien 6 cycles Holland 4 cycles Hvis gravid yderligere 4 Serbien nu vedtaget 2 free cycles

22. Offentligt betalt Fertilitetsbehandling, Danmark

23. IUI – public cycles (n) Fertility clinic 3546 Gyn/obst. Dept. 497 Consultants with public support to IUI 3380 All 7 423 IUI – Private cycles (n) Fertility clinics 6599 Mid-wife clinics (IUI-Donor) 4872 All 11 471 IUI 2009. Public - private

24. ART 2009. Public - private

25. Brugerbetaling, kunstig befrugtning Når medicin og tandlæge ydelser medregnes, financieres ca. 17% af de danske sundhedsudgifter via brugerbetaling. Overordnede formål med brugerbetaling. • Brugerbetaling som efterspørgselsregulering. • Brugerbetaling som indtægtsgenerering

26. Brugerbetaling, kunstig befrugtning Brugerbetaling som efterspørgsels regulering. Formodning om at man får sorteret overflødige ydelser fra eller at man får ”forbrugeren” / patienten til at tilpasse sin efterspørgsel, således at der vælges den ydelse hvor man får mest for pengene. • Barnløse …. vælge adoption • Barnløse …. vælge andre behandlingsformer, fx nogle gange operation af æggelederne, mange laparoskopier? • Dæmpe efterspørgslen – etiske overvejelser

27. Brugerbetaling, kunstig befrugtning Brugerbetaling som indtægtsgenerering Mindske behov for skattefinanciering Frigøre midler til andre sundhedsopgaver Finansiere en udbygning af kapaciteten indenfor området Øge konkurrence mellem klinikkerne (offentligt-privat og offentligt-offentligt)

28. Brugerbetaling, kunstig befrugtningArgumenterne FOR Besparelse Konkurrence (bedre service, mere effektivt) Regulerings (overforbrug ”gratis medicin”) Sygdoms (ikke sygdom…….) Adoptions (sidestilling) Det etiske (uacceptabel teknik – bør begrænses) Prioritet

29. Brugerbetaling, kunstig befrugtningArgumenterne IMOD Lighed Administration Besværlig og bøvlet Kvalitet Vælger behandling ud fra pris og ikke det medicinsk rigtige Kvalitet Forskning, udvikling, uddannelse? Sygdom Er sygdom – reproduktionssygdom Afgrænsning Hvordan, til hvem…. Besparelsen ”Små-beløb”. Lang sigt ingen besparelse

30. Sundhedsøkonomiske betragtninger • In recent years, policy analysts, politicians and academics have started to ask whether the small, but meaningful contribution of births attributed to assisted reproduction can help minimise the fiscal effects of ageing populations. In Denmark, the cost per assisted reproduction technology (ART)-conceived live birth ranges from kr. 82,673 to kr.194,797 per child depending on the age of the woman treated Viewed as a public investment, treatment costs required to create an IVF-conceived child represent a positive return for the Danish government of kr.1,368,000 per child at year 50 representing a 7 – 16 fold return on investment.

31. ART as an investment

32. Impact of change in re-imbursement. The German example • Before January 2004: 4 cycles fully re-imbursed • New regulations after January 2004: 3 cycles 50% re-imbursed Married couples, female age 24 - 40 Husband age < 50

33. Is ART succesful in Germany in 2004 and 2005? ▲▲ Data from DIR

34. From Ricardo Felberbaum

35. Hvor ”effektiv” er offentlig ART i DK”

36. Success for the infertile couples What is the chance that we have a child within a certain time-span if we enter your ART program or a National program?

37. A Danish cohort study • Prospective longitudinal cohort study with 5-years follow-up on deliveries • 1338 women from 4 public Danish IVF clinics initiating ART in 2000-2001 • Data sources • Danish Medical Birth register (n = 1338 women) • 5-years follow-up questionnaire (n = 817 women) Pinborg, Schmidt, Andersen. Hum Reprod, in press

38. Percentage who were successful – delivered. 929/1338 (69.4%) after 5-years follow-up Percentage of all women (%) Stratified for age < 35 years: 74.9% 35 - 39 years: 52.2%

39. Cumulative first delivery rates 5-years follow-up questionnaire cohort, n = 817 Women with at least one birth, n = 610 74.7% Percentage of total (%) 37,6% 16,5% 9,9% 6,7% 4,0% Years after treatment start

40. Successful ARTThe infertile population • ART has to be used by the infertile population in order to be successful • Available – accessible at costs (physical, emotional and financial) that are acceptable to couples so that ART is used

41. Success for the infertile populationconclusion As professionals we need to be active in political decision making as well as among professional colleaques to make ART accessible, affordable and acceptable for those who need it, by: • Incorporation of ART programs into National Health Programs – emphasize the population aspect (European and Korean examples) • Make clinics geographically available around the country • Reduce the costs in private and public clinics • Reduce stress / burden and inappropriate restrictions to enter ART programs • Reduce stress / burden and thus drop-out during ther course of treatments

42. Potential need for ART Average current National use of ART is much below the optimal (5-8.000 cycles/mio) needed if all eligible couples should be given the full benefits of ART. ”International estimates of infertility prevalence and treatment-seeking: potential need and demand for infertility medical care” Jacky Boivin1,4, Laura Bunting1, John A. Collins2 and Karl G. Nygren3 . Hum. Reprod, 2007, 22, 1506

43. Causes of inequalities in availability ART • Relevant therapy not legal in specific countries Consequence: law evasion – cross border reproductive care • Not affordable for many – lack of re-imbursement through National Health Programs or compulsary insurances. Consequence: Socio-economic inequalities • Technology not acceptable for some – do not start or drop-out before completion of an appropriate number of cycles Consequence: Lower use, higher drop-out and loss of pregnancies

44. The overall use of ART • The current prevalence of infertility, linked to delayed childbearing • The ”threshold for treatment” ( Threshold by professionals and patients) • Couples acceptance to undergo ART Their perceptions of the benefits (delivery rates) risks, inconvenience and ”cost” of ART. • Couples acceptance of repetitive cycles (drop-out problem)

45. Couples acceptance of ART • Should be efficacious Delivery rates • The risks OHSS Ovarian cancer Triplets • Should be accessible Finance Distance • The burden of doing it visits to clinic bloodtests, oocyte retrieval injections

46. Threshold to refer to ART by the doctors Tradition Ease of referral Professional guidelines Political criterias for referral (Who ”qualify for ART”)

47. Let me propose that….. • ART is more accessible and used in those European countries that have the following profile ART is considered a simple treatment Low-dose protocols Low cost Single embryo transfer NHS ART - a sign of acceptance from society - not just economy Regulated and monitored by society – this cause trust and confidence in ART

48. Brugerbetaling det vil ændre vores måde at arbejde og tænke på Fra patient til kunde

49. Tak for opmærksomheden….