As of August 2020, less than half of the states in America have some form of mandated insurance coverage for fertility treatments. Some require coverage for IVF, some cover preservation, but more than 30 states still have no requirement for covering fertility treatments in any form. But why? Is coverage really beneficial on the business side of the fertility field?
On this episode of Inside Reproductive Health, Griffin spoke with writer and women’s health advocate, Jennifer “Jay” Palumbo. Jay is currently the Chief Executive Officer at Wonder Woman Writer, LLC and is an avid women’s health advocate. From her award-willing blog “The Two Week Wait” to working at major fertility benefits companies, her experience has helped shape her mission to advocate for women’s health needs, especially when it comes to infertility.
In this episode, we uncover the pros and cons of mandated coverage from both the patient and the clinic side.
To get started on a marketing plan for your company, complete the Goal and Competitive Diagnostic at FertilityBridge.com.
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Welcome to Inside Reproductive Health, the shoptalk of the fertility field. Here, you'll hear authentic and unscripted conversations about practice management, patient relations, and business development from the most forward-thinking experts in our field.
Wall Street and Silicon Valley both want your patients, but there is a plan if you're willing to take action. Visit fertilitybridge.com to learn about the first piece of building a Fertility Marketing System--The Goal and Competitive Diagnostic. Now, here's the founder of Fertility Bridge and the host of Inside Reproductive Health, Griffin Jones.
JONES 0:53
Today on Inside Reproductive Health, I'm joined by Jennifer Palumbo. She's the Chief Executive at Wonder Woman Writer, LLC. She's a freelance writer and avid women's health advocate. Her blog aptly named “The Two Week Wait” was awarded the Hope award for the best blog from RESOLVE and was also named the best IVF blog by Egg Donation Friends. Her articles have been featured in Time Magazine, Parents Magazine, HuffPost, Scary Mommy as an infertility subject matter expert. She's also been interviewed on news outlets like CNN, NPR, Fox, NBC, BBC America, was featured in the documentary Vegas Babies. When it comes to the press, she gets around. Ms. Palumbo, Jay, welcome to Inside Reproductive Health.
PALUMBO 1:37
Thank you so much. I always love talking to you.
JONES 1:40
A lot of people know who you are, because you're active on social media, you're a really good networker. You're very extroverted. And when there's an in person event like Night of Hope or RESOLVE Advocacy Day, you may welcome people and get to know people so a lot of people know who you are, but I don't think a lot of people know your background with the advocacy for benefits and helping to introduce fertility coverage into the corporate world. And I'd like to explore that with you a little bit today.
PALUMBO 2:19
So yeah, that'd be great.
JONES 2:20
Where did that start?
PALUMBO 2:21
So it's such an--well, I was gonna say it's such an interesting story, but of course, it's interesting to me--but I was working at an investment banking company, and that was where I got married and well, not at the bank, but when I worked there, I got married, I started trying to conceive and we had what is still pretty common insurance, which is like $10,000 for infertility coverage, and that's the end of it. And trying to pay for IVF beyond that, because statistics show it definitely takes usually more than one, it's not ideal. And so my second IVF, I had to do a clinical trial, which was crazy because I was injecting myself with a mystery drug, but I did it because it was free. And then the third was like crowdsourcing--my parents chipped in, my sister chipped in, you know, we all struggled to try to afford this. And while I was working there and going through this, I started blogging about my journey. And that's The “Two Week Wait” and a company called Fertility Authority was following my blog kind of around the time I was doing a clinical trial, and they said, Would you write for us? So I started writing for them. I got hired then by them in 2012. Because really infertility changed the trajectory of my total career, my life, who I hang out with, my friends, everything, and Fertility Authority was a D2C company. And I was the international call center at the very beginning. It was only me fielding calls from all over the country, and I would talk to, without exaggeration, thousands of people who needed treatment who didn't have access to care, insurance for IVF, even insurance for IUI. And when Fertility Authority got bought in 2014, it became Progyny. And we kind of took all of this information directly from patients and became a B2B company where we sold fertility benefits to employers. And that's basically how that all happened.
JONES 4:29
And so now it seems like what was nascent just a couple--it's still probably nascent today--but was almost unheard of maybe 10 years ago with fertility preservation benefits, other fertility coverage benefits. At the timeline you're describing 2014, Fertility Authority becoming Progyny, when you start to see this becoming something that's unveiled to a lot of different corporations and now, Jay, it seems like we're constantly seeing another major group broker benefits in this way. And what was that like? What was the tipping point in your summation? Or have we not even gotten to the tipping point yet?
PALUMBO 5:17
It's such a good question because even in 2012, when I was hired by Fertility Authority, they were just doing vitrification. Like I would actually call clinics and say, Are you doing a slow freeze or a fast freeze, to find out information to send patients to because I kind of did fertility matchmaking. And then you're at 2015 and I remember we just started talking about how to develop the benefit for employers, what it would entail. And one of the big things that Progyny did and still does is included genetic testing, which when you have genetic testing, like PGT-A, it reduces, hopefully, you know, ideally, the time to pregnancy and it reduces the chance of miscarriage. And what that means is then you can transfer a single embryo, you don't have to put two in because you can only afford, you know, one IVF cycle because that was happening before then. And so the benefit at the time was very groundbreaking because it was basically saying you are choosing your fertility treatment based on science and not on dollar amount. So, at the time, it was like a hard sell to most. And I remember one client that we tried to pitch to was, they basically said, Well, what are we going to do next? Start covering people's plastic surgery? So at the time they were equating fertility treatment with, you know, getting a tummy tuck or a nose job. And now like you said, from 2012, now vitrification has become mainstream, to 2015, we now roll out this new fertility benefit to 2020 where there's so many other competitors in the market. You know, there's Carrot Fertility and Maven and Stork Fertility Benefits. And I actually find that really exciting because it's showing that there's a need. What I would love more than anything is if we had more mandated coverage, but that's another conversation. But I think what's happening now and what we still need to see is more companies understanding that $1 amount doesn't always cover the treatment that you need. And that genetic testing, I do think can be incredibly powerful.
JONES 7:35
I was sort of thinking they're two different things. You're not completely disfair, but separate things in my mind of your advocacy for benefits and then just what you do as a content writer, and then as you're talking about how employers attitudes have shifted and realize now that it's very, very intertwined because it was the work of yourself and others that have really gotten a lot more attention for fertility coverage. And I don't think that we would be having Progyny or Facebook or Google or Amazon doing a lot of what they are doing and offering what they're offering if it wasn't for a groundwork of awareness that was laid over a long period of time.
PALUMBO 8:27
Yeah, and I think particularly with Fertility--sorry, Progyny, you know, it was founded by Gina Bartasi, who I know was on your podcast, and she went through her own infertility journey, and I think once you go through it, and you see the holes and the gaps--. Like Fertility Authority, was allowed to work there actually went through it firsthand and Progyny was formed out of that. And so, I think because Gina also knew about the lack of insurance coverage and I suffered it directly and other women like Jennifer Redmond, who worked there at the time, we all knew firsthand about that gap. And then on the other side of mandated coverage, there's RESOLVE and Risa Levine certainly here in New York, which is where I am, who have been advocating hard to get mandated coverage, because right now, our President's changing all the time, there's only 17 states that offer coverage. So I do think, you know, the famous case Plessy v. Ferguson, separate but not equal. I almost feel like it's the same thing with companies like Maven, Carrot, Progyny, and mandated coverage. The mandated coverage gives people who don't work for Amazon, Facebook, it you know, the bigger companies, at least some access to care, while the people who do work for these forward-thinking companies at least have access to more generous benefits like PGT-A and more cycles. But, I do think the thing that still bothers me is there are companies like IBM who, I think they have $20,000 coverage, it's still generous, but you and I both know, that could be depending on where you're located in the United States, that could be one IVF. So even still with $20,000 it's not--I think as robust as it needs to be for the medical condition that infertility is.
JONES 10:18
So the companies that you described, not the employers but Maven, Progyny, Carrot, or--would we call them brokers? Would that be the right word to describe that class of company that offers fertility benefits to big companies?
PALUMBO 10:35
I don’t know why you couldn't? We usually call them add-ons or third party kind of negotiator because they're the ones who are like the go-between the employer, insurance company, and clinics--I always think of a triangle. And so they negotiate down the retail rates with the clinics in their network. So the clinics will see an influx usually of patient flow in return and the employers will be able to offer some of these clinics to their employees. So it's sort of a win/win for everybody. But there are always certain clinics that just don't want to participate. Because maybe they have their own financing program that they want to sell to be perfectly honest with you. Or for some reason, they just don't want to be in network, you know, every clinic is different, has their own personality, so some are for it, and some want to perhaps push like maybe a multi-cycle discount or something like that, of their own.
JONES 11:31
As things stand right now, do you think for these negotiation groups that mandates passing in states like New York very recently, is good for them? Or does it sort of bring back the old guard of insurance back to the table and give them a little less relevance? I guess what I'm asking is, is it better for models--the business model like that of selling benefits to big employers--is that better for them in a business level when mandates are present or not?
PALUMBO
It's such a smart question. And I'm not just saying that because it's you, but it really is because even when I was--when I was at Fertility Authority, I would attend Advocacy Day. And then when I was at Progyny, there was sort of a question like, Well, wait a minute, is that a conflict of interest or not? And it sort of depended who you asked. But to me personally, I never saw it as a conflict of interest because it is like companies--like if you if your company does have Carrot or Progyny or even I think Win has their own benefit and there are other people out there who offer it--it's still not, to me at least, apples to apples. The mandated coverage right now in New York that just was effective as January 1, 2020, it's still only for large employers or are self-funded, like there's always some sort of qualifier to be able to acquire that. It's not the same if you can hair again, like Progyny’s benefits where they have something called a Smart Cycle and they include genetic testing, to mandated coverage, it doesn't include genetic testing. It does have, I believe, a three IVF limit from what I recall and so I don't--I think it's for different target audiences, so I never saw it as a conflict. But I am understanding that not everyone would agree with me on that, you know.
JONES 13:26
Do you think that it becomes one more person in a crowded room? And I'm essentially sharing the sentiment that I often get from physicians and I had a meeting with different physicians and I've heard this sentiment before one person put it in their own terms of, you know, we just keep taking a haircut--meaning that the doctors asked to do more, that there's more people involved in the process, there's more people now veering for patient money--and I see both sides, I can see when things would be positive when things would be negative thing. I think, ultimately, as a business person, the big question is, are we adding value or not? Because if we're adding value, then we're worth whatever we're charging in whatever business it is. And if we're not, then we're not. And because only some businesses are highly successful, it's likely that there may be many players that come along in different areas that don't really add that, that only take. And on one hand, you have thousands more people having access because someone is bringing this to the corporations at a solution that can scale, that's showing them that's important, that's making it executable. And then on the other hand, one could view and say, well, I'm getting beat up on these agreements, you know, something I might pay X percent one year and then I have to pay Y percent the next year. And without, like, the details of any company, but just referring to that dynamic, how do you see it?
PALUMBO 15:08
It's, it's funny, I think like you and I see all sides of it. I remember, again in 2012, there were doctors that were upset that there was just insurance coverage. Like this is even before any fertility benefits were even on the scene! They were like--I actually talked to one doctor, one reproductive endocrinologist in New York, who was bummed about insurance and he requested, he's like, if you can send me any egg freezing patients or donor egg patients, that would be great because they're cash paying. Again, this was back in 2012. So they wanted to get the cash paying patients and he actually joked that he may have to get rid of his fifth house. Now, I mentioned this for a reason, because I do think on one hand, as a patient, some of the prices, the markup is not maybe the most accurate, and I say that with love and respect to all involved. You know--
JONES 16:06
What do you mean by mark up?
PALUMBO 16:07
Meaning like, there's been research that for the embryologist, for the lab for everything, maybe it's really only $5,000, but if it's a well-known clinic that boasts, I should say, success rates, you know, that are out of this world. They'll say with us, it's $10,000 no matter what. No matter how much it really costs them. And again, I say this as respectfully as possible. That's not true for everyone. There are some clinics, who probably their margins are not ideal, they probably should make it higher. But there are some clinics who bring up their margins high because of reputation. There are clinics who were first to use the vitrification method for egg freezing so they have these, you know, this incredible history and so patients will be like, Oh, wow, I know these two clinics really are well-known for egg freezing. I'm going to go to them even if they are more expensive. So they don't necessarily have to touch their margins. But then if you have newer clinics, and then this I feel compassionate towards them, but if you have newer clinics on the scene, even if their doctors are board-certified and they've had 25 years experience, but they're newer clinics, they will take more of a haircut because they have to get those patients. And something that we talked about a lot on when I worked for a D2C fertility company was basically how, the more there's transparency in the business, and the more patients educate themselves, it'll drive down the price. That's great for patients. It's not maybe ideal, as you said for certain clinics and doctors. And again--
JONES 17:43
Well, it doesn't seem like it's frickin happened yet, has it?
PALUMBO 17:46
No, I know! I thought that that was a big conversation at that time, I would say in 2013-2014. The more transparency there is, the more the patients are educated, it will really drive down the price. No, it just hasn't happened yet. And I know that with some doctors, like you look at Dr. Kiltz at CNY, I think he actually does offer more of a fair price for what he does. And he makes it up in volume because people travel to him, as you know. And I'm not trying to endorse anyone over anyone because every clinic, every doctor has a different expertise. And they're in a different location. If you're in Texas, there's some fantastic REIs in Texas, but you don't have a lot of options. Do you know what I’m saying? So that doesn't drive down the price anymore.
JONES 18:34
I mean, depending on what market you're in, there's certainly some rural markets in Texas, which I imagine that you'd have to drive a long way for a provider and then in Huston, Dallas, those are both pretty crowded places.
PALUMBO 18:47
Exactly. And I get asked all the time, oh, New York must have higher, you know, the highest IVF prices, not necessarily! There are other states that they are--if you have a lot of competition that drives down the price more than transparency in my opinion. So there are times where New York is actually cheaper, Manhattan is cheaper for an IVF cycle or egg freezing than if you're in the middle of nowhere, respectfully, because you don't have any competition to drive down the price. So I get it because there are different REs, different skill sets, different locations, and different patient needs. And I think you do have to make sure you cover your costs and you keep the lights on and then hopefully, you know, get a little bit of profit to keep yourself going to do marketing. But from a patient standpoint, you want to be able to not feel like you've been taken advantage of. And you know, one thing I do think that's interesting about you and I, if I could just add, is I think because of our roles and our work history, we really can see both sides, where not necessarily everyone can.
JONES 19:57
Yeah, I think it's especially interesting from your point of view, because you've been a patient, you've advocated for so long, you've worked with both clinics and other groups and on the business side. And I wonder, you know, how you see things playing out with so many new players in the field, some of whom are coming from private equity and venture capital. And I was at a meeting recently and the physician was saying, you know, how when some of the PE folks or some of the VC folks come up, especially--but maybe anyone else on the business side--and they say our field and I do that all the time, because I'm trying to take ownership of what I'm doing here, as I say, our field like in the same way I say, my neighborhood or our country or whatever, I'm trying to take the civic ownership and his view was that very often, you know, physicians are rolling their eyes at that because what do you mean, our field? This is our field meaning the doctors. And I think just because of the complexity of economies of scale, that there's no way that that can really be the case anymore. But you're coming from--you've been a patient. And this is not just a hobby for you. It's woven into your career and how you spend your time. And how are you seeing the involvement, the arrival of people with business interests, and how that ultimately impacts the standard of care?
PALUMBO 21:42
Well, in the last year, I think I have a call almost every two weeks from a VC firm, about fertility benefits. I have one tomorrow, because they're really interested if this is the area that they should invest in. And so I talked about these things a good amount and I always get asked interesting questions--like, there's always one that I'm like--Damn, because there's so many different angles to look at it. I can, you know, if I was on the debate team, I can argue all sides of it. I can argue as a patient.
JONES 22:13
So do that then, argue both sides of that.
PALUMBO 22:17
Well, I think as a patient, it's so critically painful, like the thing I always say is a lot of insurance companies are like, well, you're not going to die from infertility. You know what I mean? This is not like a medical diagnosis where it's live or die. But when you look at the studies of the incredible emotional impact it has on infertility patients, they say it's the equivalent of cancer and my running joke is we may not die from infertility, but we feel like it, you know, we feel like dying. When you have infertility, it very much can be a medical diagnosis. It can be endometriosis, it could be PCOS. There could be a male factor, it is medical, and I get very stabby when I hear insurance companies or employers, or even, you know, our representatives, because you and I certainly attend Advocacy Day every year, when they don't think it's a medical diagnosis. It is. It is a disease and a malfunction of the reproductive system and to be told that you don't have access to care, or you don't, you know, like the people on Wall Street, maybe have certain fertility benefits, but how about the people on Main Street? You know? Why don't they have the same access? And of course, you can get into a whole argument about economic status and can only rich people afford treatment. And so I do think it's unfair that if someone has a medical condition, they've been, you know, wounded in the line of duty, that's come up a lot with that's for IVF, why would they be denied that access? So there's that. From an employer side, to be honest with you, I think it's a no brainer from an employer side. I mean, I just even if I didn't work in the Employee Benefits space, you think you're saving money by not offering fertility benefits, but then check out your NICU costs. Check out the high pregnancy complications you have when you don't have that benefit because patients are missing work a lot. They're occupied with their fertility, there may be transferring two embryos, maybe three, because they don't have a lot of coverage and now that employee is in and out of seeing doctors, plus they have more of a propensity for high risk pregnancies, they have preeclampsia, they now are pregnant with twins, and they give birth early, the babies are in the NICU--it is going to affect employers one way or another. So why not offer a benefit where your employees aren’t like, Oh God how am I gonna afford the next cycle? or and people are leaving companies with They don't have coverage. We see that all the time that people,
JONES 25:02
And people are leaving companies when they don’t have coverage. They see that all the time--
PALUMBO 25:04
Yes, it’s a retention tool!
JONES 25:07
So that they can actually go through treatment. And I think it started with a few avant garde employers saying we know that our employees really want this. Let's use this as an advantage in the marketplace. But eventually, it just becomes a standard benefit, I think we're getting close to that, no?
PALUMBO 25:25
Yeah, but I still think I still think some companies are still not fully educated on the whole experience. What I will say--meaning the whole patient experience of, you know, recurrent pregnancy loss, that's a good reason to do genetic testing. What is the advantage of freezing your eggs? I mean, even you know, I also work with the Alliance for Fertility Preservation. I was floored when I found out that if you have a cancer diagnosis, your insurance typically doesn't cover fertility preservation. Like I thought, oh, well, surely if you have cancer, they will, not just infertility, but right now it's still in the minority. That's why there is Alliance for Fertility Preservation and Chick Mission and companies like that. So even when you have a cancer diagnosis, and either the cancer or the treatment for the cancer can permanently negatively impact your fertility, insurances, or employers I should say, aren't always covering it, either or. And I guess getting back to your earlier point, I can see why clinics would be like, Okay, so this works out for the patient to have fertility benefits, this works out for the employer to have fertility benefits, and I'm getting screwed. Because I'm the one who's now taking, you know, a cut on the margin or taking more patients and etc, and so forth. And so I totally can see that perspective. But I still think that it actually at the end of the day is in their best interest to advocate not only for fertility benefits, but for mandated coverage. Will it hurt them financially in certain aspects? Yes. But will they get more patients in the long run? Yes. I mean, I still think that they would get more patients. Isn’t that what they want? And I always say from a marketing standpoint, especially for Advocacy Day--I sent out a whole mass email to doctors and clinics last year, again, coming from a unique perspective, being like, I realize on the surface, you may be like, Oh, God, I don't want to go to Advocacy Day and take time away from my clinic or my patients. But I was saying that both from just a karma feeling, but also from a marketing feeling, patients really do respond to people they see out there advocating for them to have access to coverage and not just--and this is going to be me being very blunt--but not just capitalizing on their infertility. They actually want you to have that access. They want you to have that family, they care about you being properly diagnosed and treated. And I do think it's their advantage both just personally ethically, but also marketing wise. So again, I think I'm always thinking of both sides of it.
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JONES 30:06
The marketing I think is for--and I know this because this is what we do with companies--the people that are most interested in it are the people that are hurting, which just tends to be a segment of the I would say that the overall field, it's often smaller provider groups that are starting to feel the squeeze in smaller markets, usually, and then the high growth groups, just the groups that they want to build their practice group to be in multiple markets, or at least really be the provider in their market. Those are the ones most interested in marketing. I would say at least three quarters of the field is pretty darn indifferent to it. And the reason why they are is because, like, We're busy, we're busy. We're doing well in some cases, we've got an eight-week new patient waitlist. And you're telling me that you want us to see all these more people for less money? And so I think that if this model really is going--if this model really is dominating--the employer-covered model or the insurance model--the delivery of care really has to change dramatically, doesn't it?
PALUMBO 31:21
Oh, God, yeah. I think you hit the nail on the head. Because the thing is, at the end of the day, I mean, I still think certain doctors possess. Let me be so clear. I was gonna say at the end of the day, the technology is the same. But I still think there's something to be said for what doctor you go to, how they treat you, how they diagnose you--I still think doctors have incredible insights. They have certain specialties. Some really are very passionate about recurrent pregnancy loss. Some are very interested in PCOS. If you have a specific condition, I still do think you can't just be like, Well, all the technology is the same. Who cares. I do think there are advantages to doing your homework and look at the doctor and their experience and what they're passionate about, but I do think customer experience now takes center stage. Because if technology is roughly the same, if you do have more of a choice in your area, who's the one that goes the extra mile and makes you feel like you're really valued? And that's when clinics, I think, look at brand and what they're known for and what they're associated with. And that, I do think--it's amazing, particularly when I was at Fertility Authority, I would get feedback from patients all the time. And I remember one time--this is one of my favorite stories--a patient called me and this was in Chicago where there's a bunch of clinics and said, I don't think I can go back to this doctor because all of the magazines in his waiting room were old. I always tell that story and critics are like, well, that's just stupid. I'm like, but is it? Because if you have someone coming to you and you want the most cutting edge reproductive technology and they have a People Magazine talking about how Princess Diana is getting married. You’ve got to wonder!
JONES 33:12
This is what I mean, yeah!
PALUMBO 33:14
It comes down to the little details.
JONES 33:16
So what I think what many, especially independent physicians would say Jay, is that's exactly what we're talking about. We are trying to provide the best experience and differentiate in a way where we're able to give more attention. And we simply cannot do that if we're making 15% less money, 20% less money, whatever it is on a particular patient, and we're expected to see hundreds more over the course of the year. And so I think their reluctance often to having nurses do IUIs or to have advanced providers do retrievals or to train non-REI OB/GYNs on IVF. I think their reluctance is Well, that's my responsibility. I often talk to my clients is that this is what we offer as independent providers, and why would somebody want to go to a larger group where they're scaling that customer experience where I'm being a physician in the truest form and spending more time with my patient? I think that there's definitely a struggle of what they should and must be doing as the physician versus what needs to be passed on so that they can scale to the economic reality that we're talking about.
PALUMBO 34:38
Yeah, I think, and maybe I'm wrong--and please feel free to weigh in--but I think, too, that things are still so new, that not that long ago. I mean, in our lifetime, people were still using paper charts. Just hear me out. Like, this wasn't that long ago. So like part of me thinks some of it is that they're not used to automation or using technology probably as best as they could for administrative stuff. However, that being said, I agree completely with them, but I think that's more of a fault of managed care. Because even like OB/GYNs, who are not necessarily in the reproductive endocrinology world, or even primary care physicians, or any doctors in any field feel like they are doing more for less. And I think that's almost part of a larger problem. I just think, reproductive endocrinologists, this is still new territory for them compared to maybe you know, your general practitioner, but so I think they're still trying to figure it out because not that long ago, there was no insurance coverage. Like, really. When I first started trying to conceive, which was in 2009, I mean, none of this was talked about. I didn't know anything about egg freezing being available. It wasn't discussed. You know, ASRM removed the experimental label long after I started trying to conceive. So I guess in overall, the technology, the reproductive technology and even the electronic--you know, the EMRs of clinics are still new in some. So I think some of it, like I said is, there probably are places to automate, there probably are places of inefficiencies to improve upon however, it also, I think, is just a problem with insurance and managed care in general, which I don't have the answer at all for that. I don’t know, do you agree?
JONES 36:38
Well, I’m not totally sure. I'm not really convinced one way or the other night. That's why I want to ask you this question from the patient perspective. Because this reality of more insurance involvement, more employers is not going away, and therefore, things are scaling in a different way and some things need to change. I'm not a clinician, so I can’t advise on what that is clinically. But I want to ask your perspective as a patient, and your opinion might be different because you have such deep relationships with different docs, but do you think that as a patient, do you need to see your REI for the majority of the visit, every single visit? Or if a care team really is dialed in, and the system is really robust, and the people within the system are truly focused on patient care, can you see your physician only a couple of times through the course of a cycle, you know, popping into the ultrasound, in your initial consult, but for the most part, you're dealing with the nurse, you're dealing with techs, you might be dealing with an advanced provider, what do you think as a patient?
PALUMBO 37:56
I barely saw my reproductive endocrinologist. I went to a university-based practice, and they have a bunch of REs on staff. She saw me for my initial diagnostic visits. She had a protocol. And then whatever day my retrieval fell on or the transfer, that's the Re I saw. And that was almost a little secret I gave to patients. When they were like, Oh, this one doctor, I really have to see him but he has like an eight month no joke, waiting list. I was like, Make an appointment with whoever's free, because you probably will see that talk there anyway, it does not matter.
JONES 38:43
But it does in some places, part of their marketing, especially for single practitioners, part of their marketing positioning is that you're going to see your doc every visit.
PALUMBO 38:55
Well, and that's a marketing strategy in my opinion. And every patient is different. Because even for example, you know, with--I'm trying not to use specific names--with some companies, you get assigned one person to be with you throughout the entire journey. Okay? But you have to talk to them on the phone. Someone like me, I would hate that. I like texting. I like ZocDoc. I don't want to talk to anybody. I have stuff to do. I'd rather it all be automated.
JONES 39:20
That surprises me about you, by the way. It doesn't surprise me about most patients, but does surprise me about you.
PALUMBO 39:26
I know well, and it's only because I'm juggling so much because I am, as you said, very extroverted and I love people. But when it comes to my care, and certainly when I was deep in the trenches, you know, I'm hormonal and emotional. I don't really want to talk to anybody. So there are some patients, and I remember this when I used to have infertility brunches with my fellow infertiles, I would have it at my house, and some people really wanted their REs to be their best friends. They want to see the same RE at every visit. But then there were other people, and this was me, who I could care, I just wanted to get pregnant. If you know me and you're telling the medical team what to do, I don't care if I see or not, you know, we're not dating, but some patients do. So I think if you are a solo practitioner, use that as your marketing. We will be there for every appointment. I will be the one who will do the IUI, I will be there for your follow up appointments. I will be there. So that's a great leverage to market with. But then I still think, again, I'm looking at this almost more from both a patient marketing standpoint, if you are a university-based practice, so you have a lot of doctors, market that! You have a collective mind overseeing your care, and some patients like that. So I just think there's so many people who have different preferences that you have to decide what clinic you want to be, what your brand is, what you want to be known for. Then go with that. And I'm sure a patient will connect with that because there's no one answer to every patient, you know, there just isn't.
JONES 41:02
Yeah. And I think, though, if we're looking at it, what is the market bear, not just preferences, but not just what would I prefer. Sure, I might prefer to see my doc every single time, but am I willing to pay for it? I'd love to see my dentist the whole time, but am I willing to pay twice as much as I would Inspire that where I'm going to see my dental hygienist and I really end up liking him and then don't even miss the dentist. And I use this example sometimes and I think it probably drives fertility doctors crazy, but I do--
PALUMBO 31:37
I think it's a great one.
JONES 41:39
I think at the end of the day, people need to feel cared for and the who is caring for them can vary wildly, and for some people, it just might not be the physician most of the time--for many people it might not be the physician most of the time, at least not at the right level that the market would bear. So I think that larger networks, the ones backed by private equity, are making a bet on that. I think they're betting that most patients just prefer to have a robust communication system. They prefer to have things really organized. They need to have people that really care for them. But that doesn't need to be the doc every time and I think many independent practice groups are making a bet that--and I don't think they're necessarily making a market bet, I think their bet is coming from what they feel obliged to do. And I wonder if that's hurting them, market wise, because of this reality of benefits? So those are things for people to consider. Another thing to consider as well, could I have the best of both worlds? And I sometimes hear clinics saying, Well, what if we forget these negotiator companies, brokers, whatever we're calling--what if we forget them approach the employers by ourselves and so strike a deal with them? And it's better--
PALUMBO 43:02
I get asked that all the time.
JONES 43:05
All the time right? It always comes up in some kind of markets. It's initially--
PALUMBO 43:09
And even in all these advisory calls that I do, it’s usually why doesn't the employer go directly? It's usually they ask why doesn't the employer do it? Why doesn’t the employer go directly to either their insurance company or to the clinics? And I mean, people use, as you said, brokers, I mean, it's not uncommon, but I don't really have an answer. I don't know why they don’t. It's easier to have someone else do it. I mean, I thought--
JONES 43:38
Well, that’s what I was going to ask because it comes up often and I think it can be done in certain circumstances. But in terms of, you know, scaling something like that, my impression is just good luck. I just think that there's so much involved there. And so, you know, can you talk a little bit about what's actually involved in that because it seems like an entire workforce?
PALUMBO 44:00
Yes! Both with my work experience--and I'm basing this only on my work experience, not my patient experience--every clinic, again, has different margins. And so it's painful to build a network. You know, not only do you want to have the best clinics that you really need to thoroughly vet them with whatever qualifiers are important to you as a company, because like I said, now there's more companies in the field. So you may want to build a certain network based on one thing where a company may want to--you know, because that could be a competitive thing as well. My company A can say, Well, we've got this network and Company B will say Our network’s different or something like that. And then some fertility services now are trying to tell clinics they can only be in one network, which that's going to be really fun. I don't know what's gonna happen with that. But the thing is, every clinic has to be dealt with differently. So how many clinics are there in the United States?
JONES 44:56
Like 450, somewhere around there.
PALUMBO 44:58
Yeah. So you've got a provider network going to each clinic being like, Alright, how much can we take off your margin? You're literally negotiating the retail rates with every single clinic slash doctor. And, you know, in my simple mind, I'm like, wouldn't you just say, Okay, everyone, we're going to do a 10% you know, discount? You can't do that. You just can't. It could be a huge clinic with three locations. Or it could be one guy, you know, who's got one clinic and one location. And so it has to be individualized, so it's really painful.
JONES 45:39
Do you think it can work at the local level? Can Smithtown Fertility go to the Smithtown Ford dealership or the Smithtown regional bank? And do you think they could pull it off at the local level? Or is it still so much work?
PALUMBO 45:55
I think it would probably still be. I just think there's certain things where there's set prices and if you want to do, let's say, an egg freezing cycle, and you call five different clinics in five different locations, five different backgrounds, you're going to get a range, you know? You'll probably get a range from $5,000 to 10,000, but none of them will be Oh, we’re all this. But in certain areas--if you call New York clinics, they're all about $5,000, maybe $5,000-5,050, excuse me, $5,500. But if you called egg freezing in New York, and then egg freezing, and I don't know, San Antonio, it would be different. And so I think that's probably why, like I said, it's just easier to have a third party handle all that. They have the network set, and that's it. As opposed to doing it yourself. The thing I don't know, though, is that's the employer negotiating with the clinics, but the thing I don't have an answer for still is why the employer doesn't negotiate something with the insurance companies like just insurance coverage for fertility benefits. Does that make sense?
JONES 47:00
Yes.
PALUMBO 47:01
That I don't know.
JONES 47:02
I would more expect that answer from you, but I would expect the company that specializes in it to say that we can just do it more effectively and more cheaply.
PALUMBO 47:11
To outsource it, sort of.
JONES 47:12
I think so. But that would be a nice perspective to explore. Well, Jay, how would you want to conclude with our audience about advocacy about access to care and particularly within the context of expanding benefits and treatment coverage through employers?
PALUMBO 47:32
Well, there's, I mean, there's various ways that you can advocate for yourself. If you are working for a company that doesn't have fertility benefits, there is so much data supporting that when someone advocates for themselves to their HR department or the decision maker on benefits, they actually do see results. I know that kind of outs you, so some people may not be comfortable with that option. But you do have that option If you are cool with it, go to your HR pros and be like, Hey, have you thought about this? Adding this to our benefits, there are other people here who are struggling with infertility, statistically. And here's all the data. RESOLVE actually has a PDF you can download--RESOLVE, the National Infertility Association--of a study that they did with EMD Serono, about ways you can advocate for yourself to your HR department, you can literally go in, hand it to your HR department and be like look at these statistics, it actually will be in your benefit to offer fertility coverage. So you can do that. However, some people don't necessarily want to tell their HR person that they're going through infertility, they are private about that. So you can write your local representative who can advocate within your own state to whoever is in your district, about mandated coverage. And of course, you can again if you feel comfortable with it, and can afford it, attend Advocacy Day. So I mean, I still think even if you are private about it, you do have options. I mean, of course we know that there's clinical trials and fertility grants, but in terms of the greater good, I think if you can manage it, I say advocate at your company and within your state I mean, why not set the world on fire and help your fellow infertile!
JONES 49:24
A call to action that I'm not going to try to top. Jay Palumbo, thanks so much for coming on Inside Reproductive Health.
PALUMBO 49:31
Thank you.
***
You’ve been listening to the Inside Reproductive Health Podcast with Griffin Jones. If you're ready to take action to make sure that your practice drives beyond the revolutionary changes that are happening in our field and in society, visit fertiltybridge.com to begin the first piece of the Fertility Marketing System, the Goal and Competitive Diagnostic. Thank you for listening to Inside Reproductive Health.