Shawn Winsor describes the importance of surveying patients and providers regarding their experiences of Ontario’s new publicly-funded IVF program.
Recently, Ontario became the second Canadian province, after Quebec, to broadly fund fertility services. Currently, the Government of Ontario funds unlimited rounds of artificial insemination including intrauterine insemination (IUI) and one in vitro fertilization (IVF) cycle per lifetime for women under the age of 43, including the one-at-a-time transfer of viable embryos created from the single IVF cycle.
For the previous twenty years, Ontario only funded IVF for the treatment of blocked fallopian tubes. The decision to limit government funding in this way aims, in part, to control healthcare expenditures by restricting funding to ‘medically necessary’ services.
Although the term medically necessary is not defined in the Canada Health Act, we can glean some understanding of the term from past decisions made by Ontario’s Ministry of Health to de-insure certain services, such as IVF. It seems that criteria such as clinical effectiveness and economic cost are used to determine whether a treatment or program is medically necessary and, therefore, worth funding. Using this calculus, IVF had been found not to be cost-effective for treating infertility beyond the one use for which it was funded. The public was nominally consulted about this at the time and concerns were voiced by an advisory panel about the long-term consequences of this decision for Ontarians. The advisory panel chair and two of her public members asserted that the systemic implications of removing IVF from Ministry of Health oversight for all indications other than blocked fallopian tubes were not adequately addressed.
In 2009, the province’s Expert Panel on Infertility and Adoption issued its recommendations for how to improve Ontario’s adoption system and access to fertility services. This was the culmination of a far more extensive public and provider consultation process which revealed that Ontarians experienced multiple barriers to accessing fertility services. These barriers included difficulties getting information about factors affecting infertility, where to find accredited fertility services, the high cost and poor geographic distribution of fertility clinics, and restrictions on access to services for same-sex couples and single people.
In 2014, in an effort to help determine the parameters of its new publicly-funded IVF program, the province struck a new panel, this time of healthcare providers and the public, for a “time-limited advisory process.” This group’s key recommendations addressed some of the barriers that were previously identified, such as cost, quality assurance, and access for non-medical infertility. Other access challenges were not addressed, however, because the province deemed ‘access’ outside of the panel’s scope of review. These gaps have not been explicitly addressed by the province. Instead, by electing to fund IVF outside of the provincial medicare plan and not establishing clear guidelines (beyond patient eligibility criteria) on how the allocated funds are to be distributed, the province has largely left it for individual fertility clinics to determine which eligible patients will receive publicly-funded services and where.
Accordingly, significant questions remain about the effectiveness and accessibility of Ontario’s new funding model for assisted reproduction fertility services. Will it meet the needs of infertile patients? Will it help to resolve infertility which afflicts approximately 16% of Ontario’s couples?
Ontario has identified limits for the number of fertility patients that can be publicly funded annually. Beyond this, however, the province has not provided direction on how clinics should manage their wait lists. For patients who are close to the 43 years of age cut-off, being on a wait list for over a year—as many clinic wait lists are now—or failing to become pregnant with treatment before hitting that cut-off may mean the difference between having a child and not. Further, there are concerns expressed by both patients and clinicians that patients are poorly informed about the additional cost of expensive drugs critical to fertility treatment. These drugs, which are not funded by the province, can total in the thousands per IVF cycle.
To help answer questions about the impact of Ontario’s publicly-funded IVF program, a province-wide survey for patients and providers is now underway. It will help to identify how public policy as well as patients’ and healthcare providers’ perceptions of publicly funded IVF influence patient and provider decision-making about: access to fertility services and the quality of care provided. This is the first study in Ontario since the reintroduction of publicly-funded IVF to examine the perceptions of patients and providers on these critical issues.
The findings from this study will be important because the Ontario Government’s decision to fund IVF in a special program outside of Medicare strongly suggests that it is trialing this new approach to the provision of publicly-funded healthcare. Time and experience will determine whether the province elects to continue, change, or cancel the program. Integral to this decision-maing will be the knowledge shared by Ontarians who have experienced this program as patients or providers.
Shawn Winsor is a Vanier Canada Scholar and PhD Candidate at the Centre for Health Economics and Policy Analysis at McMaster University, a Lecturer at Dalla Lana School of Public Health at the University of Toronto, and the Ethicist at TRIO Fertility, Toronto.