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Hum. Reprod. Advance Access originally published online on September 19, 2007
Human Reproduction 2007 22(11):3027-3030; doi:10.1093/humrep/dem293
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© The Author 2007. Published by Oxford University Press on behalf of the European Society of Human Reproduction and Embryology. All rights reserved. For Permissions, please email: journals.permissions@oxfordjournals.org

Stronger reduction of assisted reproduction technique treatment cycle numbers in economically weak geographical regions following the German healthcare modernization law in 2004

G. Griesinger1, K. Diedrich and C. Altgassen

Department of Obstetrics and Gynecology, University Clinic of Schleswig-Holstein, Campus Luebeck, Ratzeburger Allee 160, 23538 Luebeck, Germany

1 Correspondence address. Tel: +49-451-500-2134; Fax: +49-451-500-2170; E-mail: georg.griesinger{at}frauenklinik.uni-luebeck.de


   Abstract
Top
 Abstract
Introduction
 Materials and Methods
 Results
 Discussion
 References
 
BACKGROUND: As part of the German healthcare modernization law implemented in 2004, infertile couples face a 50% co-payment of the total assisted reproduction technique (ART) treatment costs. This has led to a drastic reduction in ART treatment cycle numbers after January 2004. The hypothesis tested in the present study was that the number of ART treatment cycles in different German federal states changed differentially after implementation of the law, depending on the economical power of the individual state in terms of gross domestic product per capita (GDP pc).

METHODS: This was a retrospective data exploratory study. Data from the German IVF registry and the German Federal Statistics Office were utilized. Main outcome parameter was the proportional difference of ART treatment numbers between the time periods 2002–2003 and 2004–2005 stratified for the 16 German federal states. The federal states were grouped by Tukey-Hinges percentile analysis of GDP pc.

RESULTS: The reduction of ART treatment cycle number was strongest in the lowest GDP pc group of federal states (Kruskal–Wallis P = 0.038). Mean reduction in ART cycle numbers was 51.5%, 35.7% and 38.8% in the 0–25th, 25–75th and 75–100th GDP pc percentile group, respectively.

CONCLUSIONS: Conclusively, reduction in ART treatment cycle numbers following the German healthcare modernization law was significantly stronger in economically weak geographical regions.

Key words: assisted reproduction techniques/Germany/gross domestic product/infertility/economy


   Introduction
Top
 Abstract
 Introduction
Materials and Methods
 Results
 Discussion
 References
 
Couples undergoing infertility treatment in Germany need to contribute a 50% co-payment toward the total treatment costs (including drugs) associated with assisted reproduction techniques (ART), following the implementation of the German healthcare modernization law in January 2004 (GMG, 2004Go). Only women covered by the social healthcare system, between the age 25 and 40 years, with a male partner younger than 51 years, qualify for 50% reimbursement of maximally three IVF cycles. Previous to January 2004, all financial costs of maximally four IVF treatment cycles were fully reimbursed by the public health insurance system without restriction by a lower age limit. This change in practice has led to a drastic decrease in ART treatment numbers as reported by the German IVF registry (DIR, 2005Go).

In line with a European trend of an increasing demand for infertility treatment (Andersen et al., 2007Go), ART cycle numbers in Germany peaked at 105 576 in 2003, whereas numbers fell below 62 000 ART cycles after the implementation of the healthcare modernization law (Fig. 1). It is likely that this reduction mostly results from the mandatory 50% co-payment (Thaele and Uszkoreit, 2007Go), which might financially overburden couples in need of infertility treatment, especially those living in geographical regions with little average financial spending power such as the former Eastern German states.


Figure 1
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  		Figure 1: Total number of ART treatment cycles performed in Germany 1995–2005

 
Therefore, the hypothesis tested in the present study was that the number of ART treatment cycles in different German federal states changed differentially after implementation of the healthcare modernization law depending on the economical power of the individual state in terms of gross domestic product per capita (GDP pc).


   Materials and Methods
Top
 Abstract
 Introduction
 Materials and Methods
Results
 Discussion
 References
 
The present study was a retrospective data exploratory study conducted in April 2007. Cycle number data and number of IVF centers stratified for the German federal states were retrieved from the computerized database of the German IVF registry for the time period 2002–2005. Data on population size and economical indices were retrieved from the German Federal Statistical Office (2007)Go for the same time period. ART treatment cycle number summarizes the number of infertility treatment cycles utilizing IVF, ICSI, IVF and ICSI, gamete intra-Fallopian transfer and transfer of frozen-thawed embryos.

The main outcome parameter was the proportional difference of ART treatment numbers between the time periods 2002–2003 and 2004–2005 stratified for the 16 German federal states. It was chosen to calculate a mean cycle number from the 2 years before and after the healthcare law implementation to level out short-term effects resulting from a pull-in effect caused by the premonition of the introduction of the new legislation in 2003.

The proportional change in cycle numbers was compared between the three groups of federal states objectively defined by Tukey-Hinges percentile analysis of mean GDP pc (calculated for the time period of 2002–2005) by Kruskal–Wallis test.


   Results
Top
 Abstract
 Introduction
 Materials and Methods
 Results
Discussion
 References
 
Data on ART treatment cycle numbers were available for 14 of the 16 federal states. For the federal states Brandenburg and Rhineland-Pfalz, data were not released by the IVF registry because of data protection concerns.

Table 1 depicts the economical indices and IVF treatment numbers in relation to population size for the 16 federal states for the years 2002 and 2005. The lowest GDP pc is found in the former Eastern German states (Brandenburg, Mecklenburg-Western Pomerania, Saxony, Saxony-Anhalt and Thuringia). ART cycle number per 106 capita varies strongly from 1.9 in Thuringia to 23 in Hamburg in the year 2005.


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  		Table 1: Economic indices and provision of ART treatment stratified for the German federal states and sorted by GDP pc (2005)

 
The total number of German IVF centers slightly increased during the time period 2002–2005 with 112, 116, 120 and 117 centers in the years 2002, 2003, 2004 and 2005, respectively.

Tukey-Hinges percentile analysis of GDP pc resulted in three groups of federal states with 18 093, 23 899 and 35 776 {euro} mean GDP pc according to the 0–25th, 25–75th and 75–100th percentile group. Figure 2 shows that the reduction of ART treatment cycle number was strongest in the lowest GDP pc percentile group (Kruskal–Wallis P = 0.038). Mean reduction in ART cycle numbers was 51.5%, 35.7% and 38.8% in the 0–25th, 25–75th and 75–100th GDP pc percentile group, respectively.


Figure 2
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  		Figure 2: Reduction of ART treatment cycles between the time-periods 2002–2003 and 2004–2005 stratified by federal state

Numbers on columns represent reduction in %. Federal states sorted by GDP pc ascending from left to right (filled bar is the 0–25th percentile group for GDP pc; dark grey bar the 25–75th percentile group for GDP pc; light grey bar the 75–100th percentile group for GDP pc). MV, Mecklenburg-Western Pomerania; TH, Thuringia; ST, Saxony-Anhalt; SN, Saxony; NI, Lower-Saxony; BW, Baden-Wurttemberg; BE, Berlin; SH, Schleswig-Holstein; SL, Saarland; NW, North Rhine-Westphalia; BY, Bavaria; HE, Hesse; HB, Bremen; HH, Hamburg

 

   Discussion
Top
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
References
 
The implementation of the German healthcare modernization law in 2004 resulted in a dramatic reduction of ART treatment in Germany. The present study indicates that this reduction was strongest in economically weaker geographical regions.

It is likely that the financial burden resulting from the 50% co-payment for treatment accounts for this observation, as provision of IVF in terms of center numbers remained stable  in the evaluated time period. Similarly, GDP pc and population size in the individual federal states showed only marginal fluctuations between 2002 and 2005.

It is obligatory for all clinics within Germany to report each treatment cycle to the register by means of a computerized system. The coverage of the register is believed to be very close to 100% for the treatment reports; however, only treatment cycles performed in Germany are documented. It is estimated that a significant number of German patients choose to undergo infertility treatment outside Germany in order to circumvent restrictions imposed by the German Embryo Protection Act (ESchG), although exact numbers are not available. Speculatively, the number of patients choosing treatment abroad has increased after January 2004, because co-payment and age limits further reduced the attractiveness of infertility treatment in Germany. Therefore, the reduction in IVF treatment documented in the German registry after January 2004 is likely to be an overestimate, and the ‘true’ number of treatment cycles per 106 capita as depicted in Table 1 is possibly higher.

However, it is evident that only couples with a stronger socio-economic background can afford ART treatment abroad, whereas socio-economically weaker couples more heavily depend on governmental support which will only fund treatment within Germany. Moreover, only couples above a certain income threshold can have private health insurance in Germany, which in many cases fully reimburses IVF treatment.

Ideally, individual patient data should be evaluated to investigate the impact of the health care modernization law on patient choices and behavior in different socio-economic classes. Because no such data are available, we choose the present approach as a best approximation. However, this approach is based on two main assumptions: (i) GDP pc accurately reflects the average financial spending power of the populations and (ii) residency (federal state) and location of treatment within Germany are the same for all patients. It is important to acknowledge that some imprecision will be inevitably present in this analysis, because obviously both assumptions cannot be fully true.

Nevertheless, the present data strongly suggest that the German healthcare modernization law over-proportionally affected IVF treatment volume in geographical regions in which couples most likely to strongly depend on governmentally funded healthcare reside.

Recently, it has been suggested that the legislation implemented in 2004 results in a yearly loss of about 10 000 babies in Germany (Thaele and Uszkoreit, 2007Go). This might be considered especially relevant, as birth rates in Germany are at the lower end of the European birth statistics (European Population Committee of the Council of Europe, 2005Go). Furthermore, birth rates in the former Eastern German states have been lowest already within Germany since 1990 (Pohl, 1995Go; German Federal Statistical Office, 2007Go). The pronounced decrease in ART cycles since 2004 might further consolidate this situation.

Beyond considerations of demographic development, the authors of the current text would like to advocate a view of infertility as a serious disease. The inability to have children can be a personal tragedy—regardless of financial wealth—and often compounded by a social stigma. Infertility treatment is therefore more than only a medical need, and it should be a component of the primary healthcare system, at least in an industrialized western European country. We think that the German state should strive for easing access to ART treatment, especially for the financially weak.


   Acknowledgments
 
We thank Wolfgang Dahncke, head of the statistical department of the German IVF registry, for his help with the data extraction.


   References
Top
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
 References
 
Andersen AN, Goossens V, Gianaroli L, Felberbaum R, de Mouzon J, Nygren KG. Assisted reproductive technology in Europe, 2003. Results generated from European registers by ESHRE. Hum Reprod (2007) 22:1513–1525.[Abstract/Free Full Text]

German Federal Statistical Office. Bevölkerung nach Bundeslaendern zum 31.12.2006' and ‘Bruttoinlandsprodukt 2006 fuer Deutschland. (2007) (http://www.destatist.de).

DIR (Deutsches IVF Register). Annual report from the German IVF registry 2005. (2005) (http://www.deutsches-ivf-register.de).

European Population Committee of the Council of Europe. Recent Demographic Developments in Europe 2004 (2005) 4. ISBN 10:92-871-5665-4.

GMG. Gesetz zur Modernisierung der gesetzlichen Krankenkassen. 14 November 2003. (2004) (BGBl. I p. 2190).

Pohl K. Kinderwunsch und Familienplanung in Ost- und Westdeutschland. Zeitschrift für Bevölkerungsforschung (1995) 20:67–100.

Thaele M, Uszkoreit M. Legislature’s impact on the outcome of infertility treatments—the German political contradiction. Pharm Policy Law (2007) 9:221–227.

Submitted on June 13, 2007; resubmitted on August 3, 2007; accepted on August 15, 2007.


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