Debat indl

1

Debat indlæg Brugerbetaling på reproduktion?
Anders Nyboe Andersen, Professor Fertilitetsklinik
ken, 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 unwilling
The willing
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 912281-94, 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?languageENreferenceA
  6-0024/2008 ) 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 2009. Public - private
 
   
 
 
 
 
24
ART 2009. Public - private
ART Public Private All
IVF / ICSI 6521 5017 11538
Oocyte donation 102 128 230
FER 2120 996 3116
All 8743 6141 14884
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 lt 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 lt 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.