A Baby, or Cash Back

In fact, the committee concluded that "the shared-risk form of payment for IVF is an option that might be ethically offered to patients without health insurance for IVF" if patients are properly informed of the costs, criteria and chances of success in the program.

'Put Up or Shut Up'

Shady Grove Fertility was a pioneer in the shared-risk movement when it introduced its plan in 1993, said Robert Stillman, a reproductive endocrinologist there.

The program, he said, "functions as a self-insurance trust. It's an option for those without insurance. I call it the 'put up or shut up' plan. In many forms of medical practice, it's impossible to have fees based on outcome of service. But here, you either have a baby or you don't. Some plans are based on whether the woman gets pregnant" -- not ideal, since 16 percent of pregnancies caused by assisted reproductive technologies end in miscarriage, according to the Centers for Disease Control and Prevention -- "but ours is based on a baby."

Stillman said he'd prefer to do away with shared-risk plans -- if there were something better to take their place. "If you had full insurance reimbursement [for IVF], you could eliminate all shared-risk programs," he said.

His proof? Most of the group's shared-risk patients come from Virginia and the District -- jurisdictions that don't mandate coverage for IVF procedures. In contrast, he says, "Maryland is a partially mandated state -- if you have more than 50 employees, aren't federal, fulfill medically reasonable criteria, and your employer wants coverage for IVF, the insurance company can't refuse to cover it."

Shady Grove Fertility's brochure lays out the costs for IVF: A single cycle of IVF, on a pay-as-you-go basis, costs $8,500 plus a substantial additional amount for the required drugs. It's an additional $1,350 per cycle to freeze embryos, and $2,150 for each implantation of thawed embryos.

Under the shared-risk program, the patient pays $20,000 up front, which is a global fee covering all IVF, embryos freezing and implantations. (Prices are higher if additional services, such as using donor eggs, are chosen.) After Leanna Curry's experience, the clinic increased the number of cycles covered from three to four -- and now is changing it to an unlimited number, provided the clinic's doctors agree that continued attempts are appropriate. Most patients, though, will choose the money-back option rather than go four or more cycles, admits Stillman.

"If the patient gets pregnant on the first cycle, they pay more than they would for fee-for-service," said Stillman. "At the second cycle, it's about break-even. At three or four, it's a savings. Our risk is that, if the patient doesn't get pregnant, we've spent our resources without remuneration."

Medication costs can run an additional $2,500 to $4,000 per cycle. Some health insurance plans cover the drugs, even if they don't pay for the IVF procedures.

Stillman denies any cherry-picking, saying his clinic's criteria for participation in the shared-risk program are "relatively liberal": The woman must be younger than 39 (unless using donor eggs), "with basically normal hormone levels and a normal uterus." A physician committee at the clinic must approve any applicant to the program, but the center claims that 70 percent of all the practice's patients qualify.