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Why IVF Doctors Leave Their Practice: The Reasons Every REI Fellow and Practice Owner Should Know

By Griffin Jones

Physicians with the letters, REI, after their names don’t come cheap.

“Any Fellows you can introduce us to?” I’m often asked at PCRS and ASRM (the Pacific Coast Reproductive Society and American Society for Reproductive Medicine annual meetings, for those not in the field).

“Third years?” I demur, “Nope, they’re all signed. Second years? What month is it? Nope, they’re signed too. I know some first years. Want to talk to them?”

“Yeah, I guess so,” the hiring physicians usually concede.

Reproductive Endocrinology and Infertility (REI) specialists are in such demand, soon enough, we’ll be recruiting med students. So when you’re fortunate enough to find someone who may be able to purchase equity of your practice, allow you to exit for retirement, or at the very least, meet current or growing patient demand as an employee, you probably want the relationship to be successful.

It seems to me, however, that the trend of practice partnerships who break up and associate docs who leave before becoming partners is on the rise. I say “seems” because our sample size of 1,200 fertility specialists in North America is inherently small. I don’t have any data, but I know eight associate doctors who thought they were on a partnership track AND left their practice in the last eighteen months. I know of three other partners who broke up in the same number of time.

I spoke with four associate fertility specialists who wanted to be in independent, private practice and who wanted to become partners. I de-identified their information and they allowed me to share their stories with you. They were brave in doing so, and did as much for the benefit of younger fertility doctors selecting a potential practice and practice owners recruiting a potential partner.

There are multiple sides to every story which is why I take good care not to name any of the practices nor physicians involved. Having negotiated many business deals in the fertility field, however, it is not difficult for me to picture the scenarios as they were described to me.

Any recent client of Fertility Bridge can tell you that I insist on being explicit and redundant in the early stages of an engagement. I have found, almost without exception, that the more strictly expectations are expressed in the beginning, the less likely they will actually ever need to be enforced. The results of the anecdotes you are about to read thread a common pattern wherein the prospective partners and the practice principals clearly had different expectations. In my estimation, crucial expectations were neither explicitly nor repeatedly agreed upon by both parties before teaming up together.

Perhaps carefully considering the accounts of these four brave REI physicians will give you better insight to prevent a long and costly signing or hiring mistake.

Fertility Doctor #1
left a small independent practice in a small market to join a large practice group in a large market.

When I was looking at the first practice I joined, the initial discussions always started with what they were looking for and what I wanted from them. The contract was then offered, and the details negotiated. My salary was a total low-ball offer and it became tense when I countered, but in the end we agreed to a number. I had been offered a partnership in verbal discussions, but it was apparent there was no plan for this to actually happen. I was quickly aware the promises were shallow. It was mentioned that it would be an option after I proved to the practice I was worthy and there would be a monetary buy-in. The initial discussions leading up to the contract took 2 weeks.

This practice verbally offered me a “sweat equity” ownership where I would be paid less for the first 4 years, then would be given 25% of the practice free of charge. The other non-partner who started 2 years before me was offered the same arrangement and, as of 3 years into their employment, a legal contract was never put together to make them a partner. From the beginning, it seemed fishy and that didn’t reassure me.

The partners never attempted to reassure my feelings. I asked them to draft a contract for the other potential partner, believing if they did, I would be reassured. They ignored my requests.

Within two months of joining, I was suddenly aware that the promises and the culture of the practice were not consistent with my goals. I officially resigned after 8 months.

There were so many red flags that I realize now indicated that it wouldn’t be a good fit. Mostly, the promise of free partnership with no buy-in sounded too good to be true, and I was always skeptical. When I started, the “vibe” was very odd, too. The staff seemed unwilling to accept a new person and there were a lot of “behind closed doors” discussions about how to respond to “new ideas,” aka standards of care that were not being followed, but I suggested we adhere to. It was also made clear early on that my other interests, such as academics and professional committee membership was not supported by the practice.

When it comes to selecting a practice for new REIs, start with knowing where you want to be geographically. Most people either want to live in a city, or they don’t. Then see who is available in the town or city you choose. Check SART stats and ask friends/colleagues about the group. Decide if you want to be in academics or not, but really, this will be dictated a bit by how geographically selective you are.

Be sure your salary, bonus structure, and benefits are very clear. Don’t expect partnership to be set in the original contract.

Be skeptical of overly vague or short contracts—most are very wordy and lengthy. Ask to speak to other group members, especially new ones, to see how their contracts and promises matched up. Partners rarely discuss details of partnership, so don’t be bothered by some secrecy.

Fertility Doctor #2
left a small independent practice in a small market to start their own practice.

I can share with you that you never exactly know how a position is going to go prior to you joining, no matter how good the planning. However, in my position there were signs both subtle and others like a glaring siren that perhaps the practice was not picture perfect after all.

I was embraced by the support staff. However, the physicians were standoffish. In retrospect, I believe that they were all the while looking for an employee and not a partner, despite saying they were looking for a partner constantly.

Ultimately, the practice I believe is/was looking to sell. I learned of that by accident and did not want to be a part of the sale. I decided that my values were not aligned with those that I worked for. I did not believe partnership was ever going to happen because of a sale or potential sale. If my values weren't aligned with my bosses, then I felt the situation would really never improve--I would be out on an island. I felt that I had much more to contribute to my community and I wanted my contribution to resonate with my value system, have a wonderful work culture, and build something that would be impactful for the patients I serve.

It is for that reason, and many others, that I decided to open my own place.

To new REIs, I would say, if possible, visit the practice when they are working to assess the things that don't come out of an interview. Even then, they may be on their best behavior. But if they seem standoffish, defensive, that will probably be what they are like to work with.

Fertility Doctor #3
left a small independent practice in a small market to start their own practice.

I was at a university program and I went to the only independent private practice in the area. There were multiple doctors on the verge of retirement, so I thought it would be easier to become partner by buying out the retiring partners rather than starting my own practice.

The partners wanted to lock me in so they could sell to a private equity firm, so partnership was offered immediately. I hired an experienced medical practice consultant that cost me $15-20,000 over the course of two years. He didn’t believe in 10% growth year over year with multiple doctors who were nearing retirement. He felt that I would lose between $3 and $10 million dollars in selling to private equity over the course of my career. So, instead of immediate partnership, I agreed to work as an employee until partnership was agreed upon or not. A non-compete wasn’t required. This agreement was initially set for a year, and then it was extended once I realized it was going to take longer. It took 6 months to reach that agreement.

In equity deals, older doctors have the upper hand.

The initial appraisal stated that the practice was expected to grow by 12% in EBITDA in my first year as an associate, but it actually decreased by 5%. My consultant determined that the practice may have been overvalued by 50% to 100% and advised me to see what valuation would look like if projections weren’t met. Since the initial projections weren’t met, the contract allowed for a dispute of the appraisal, but the partners refused a second one.

At this practice, the physicians had a reputation for being very business-oriented and trying to get their way in a negotiation. A previous associate physician left practice before buying-in. Three doctors previously had chance to buy-in and did not. Those should have been my first red flags.

I decided to leave when I realized that if I had bought in at the appraised price, I would be bankrupt right now. The partners weren’t willing to reassess the appraisal and practice valuation. My consultant felt that the appraisal process had been hijacked, and the partners did not acknowledge this point of view. So, I decided to start a practice with my own culture.

If you’re a new REI heading into a new practice and partnership is discussed, hire a consultant on day one, before an appraiser even gets involved.  Once the appraiser sets a valuation, they have to save face. Appraisals are not necessarily objective, especially if all parties don’t put their input in from the beginning. Do not wait for the appraisal process—you must have your input from the very beginning. I’m a young physician who knows nothing about the business of medicine. It took me a good year or two to understand how ownership works.

Partnership is going to mean several million dollars over the course of your career, even if that means spending money on a consultant when money is short right out of Fellowship. Try to negotiate against a non-compete if partnership is offered immediately. If partnership is not offered immediately, non-competes are essential because the partner physicians help the associate to build the practice.

You can’t put everything in writing. In my case, we had terms in writing and they were not honored. You have to work with people who you can trust, though you can’t trust people implicitly.

Fertility Doctor #4
left a small independent practice in a large market to join a large fertility network.

I chose to join the small practice in the first place because it was in the city I wanted to be in. I thought there was opportunity for growth, both in my career and financially, and have autonomy.

I wanted to be on partnership track from the beginning and thought I would go on to become one of more eventual partners. The understanding was that I would become an equal partner after two years, after meeting certain benchmarks. The original contract was a standard employment contract and it included one paragraph about opportunity for partnership, but it was vague. I had such little interaction with the practice owner(s).

The benchmarks were set, my buy-in and what I had to bill would each be a certain amount . That’s when the owners’ character really started to come out--in the contract negotiation. Partners can say that they work harder than others to justify a higher base salary for themselves or to retain more control or equity. The contract had a clause in it that stated if/when partners violate the terms of an agreement, you can’t sue them, so partners always had the upper hand.

In the practice itself, things were told to me that they were a certain way and, it turned out, they were not. The practice was inefficient and there was double booking of physicians. I wanted work/life balance, but it never really seemed to get there.

As new REIs, we don’t understand our power. We feel compelled because of our medical training. I felt like nothing was ever up to par and I often made suggestions that went unheard.

After talking to several other potential employer and partners, I finally found a new clinic. The new group I joined supported my initiatives, operational recommendations, and preferences for work-life balance. I wanted a group approach and so did they.

Because of my experience, I was gun-shy about joining a new partnership track, though my new group pushed for it. At this time, I just didn’t want it, so I signed on as an employee.

If you’re new to the field, make sure you have the same goals as the people you are joining, both day-to-day and long term, in financial and patient care. Investigate red flags and warning signs. No one will give you what you want if you don’t ask for it, including scheduling, compensation, vacation, partnership, continuing education. Hire a good lawyer from the beginning--someone who will advocate for you, not just draft a contract. 

——

Keep the plan clear.
It’s a better experience for everyone.

It is very difficulty for REI practice principals to find new doctors and it is equally hard for young fertility specialists to choose their career fertility center. It is tremendously expensive for both to make the wrong decision. It drains your mental and emotional energy.

In episode 9 of Inside Reproductive Health, I speak to Holly Hutchison, co-owner of Reproductive Health Center in Tucson, Arizona. You might listen to Holly’s advice on how to set expectations between reproductive centers and fertility doctors. From the accounts you just read as well as more extensive business development work with IVF centers, here are some of the expectations that you want to clearly define before any partnership track or even employment agreement.

  • What percent of equity will be available for purchase? Minimum? Maximum?

  • Over what time?

  • New Patient Visit Requirements

  • Procedure Volume Requirements

  • Multiple of salary required to be billed to buy in

  • Working hours

  • Vacation policy

  • Management responsibilities

  • Marketing responsibilities

  • Earn out

  • Exit agreement

  • Practice valuation

  • Terms for reassessing practice valuation

To hiring principals and young fertility doctors alike, it is incumbent upon both to agree to these expectations, conceptually, verbally, and then in detail and in a legal contract. They must be repeated ad nauseum.

You may be worried about walking away from a deal. Don’t be. I do it all time. I don’t want happy prospects. I want happy clients. So too is it for you who want a long, healthy, profitable, happy partnership. Better a few uncomfortable conversations and some hours invested, instead of two years, hundreds of thousands of dollars, and your mental and emotional bandwidth.

What other expectations did I not include that you believe are requisite?

We have helped over a dozen fertility practices align their vision among their partners and staff. If you think our methodology would help you, learn more about the Goal and Competitive Diagnostic.

Fertility Company Profile: The New Marketplace for IVF Patient Acquisition

By Griffin Jones

Consolidation.

If you had to reduce the water-cooler talk of our field to one topic, it would be exactly this: the consolidation of IVF centers, fertility pharmacies, brokers, genetics companies and others, purchased with private equity money.

I wrote about these players, and the collective unease about them, in 2018. I have talked about it on the IRH podcast with guests such as doctors John Storment and David Sable. I hear the apprehensions and I share some of them.

Are we capable of betraying our patients’ best interest because of obligations to financial stakeholders?

That’s a very sound concern for the delivery of fertility care. Furthermore, it’s very likely that there are examples wherein this concern is justified.

I own Fertility Bridge outright, 100%. I often make decisions based on what I want for the relationships of our clients and employees. If I had to answer to many different shareholders, we would likely do things very differently.

Conversely, I also see examples where this pressure disrupts the status quo and forces innovation and efficiency when we have to compete to earn patients’ selection. Sometimes, the independent centers with the least competition are the least likely to invest in patient experience and team culture.

Either way, I do not see the consolidation of REI practice groups as the single greatest disruption coming to the field. Not by a long shot. In 2018, I also wrote that technological revolution dwarfs any disruption caused by the sale of IVF practice ownership to private equity.

While others are looking to Wall Street, I have my eye on Silicon Valley.

Consider it this way:

The independent REI practice is the local, 100 room hotel.

 

They’re worried about the Marriott building a 1,200 room, mid-rise on the waterfront.

I’m worried about AirBnB.

One view looks at larger and more dominant competitors in the same marketplace. I’m looking at a whole new marketplace.

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The model for the delivery of healthcare, including fertility care, has become too estranged from the conveniences that patients are used to when researching, considering, receiving, purchasing, and evaluating goods and services as consumers.

Our patients under age 30 have conceivably never called by phone to invite a friend over, break up with a significant other, or even order food. Yet, for virtually every fertility center, there is ultimately no other way to schedule a new patient visit.

Please take my next admonition as commentary on the mechanics of patient relations and not on providers’ devotion to service; I know the depth and sincerity of so many practitioners’ vocations.

We’ve been too slow to adapt and have grown out of touch with our patient demographic. For some, it’s already too late.

I don’t envision large fertility groups or boutique REI practices going away, but another class is emerging to capture the middle, the entry, and everything around.

There is a wide opening to provide the user experience of patient acquisition and patient retention that the current demographic demands. With the right application, and/or scaled acquisition strategy, one or two platforms can become the gateway through which patients enter. Many companies are jockeying for that position. Some of them may win, or the winner may not yet be in the marketplace. The extent to which they’re able to scale is the degree of leverage they have over providers.

Put frankly, someone is building a better mouse trap than you have so they can sell (who would have been) your own patients back to you.

Many have tried and not (yet) succeeded, but it would be hubris to think that others won’t.

Here are some of these players now, and what they’re up to.

Important disclaimer: Neither I, nor Fertility Bridge, have a direct commercial relationship with these companies at time of writing, though we certainly may in the future. No information in this article comes from conversations that I have had with the executives of these companies. This profile is not a revelation of insider knowledge. Rather, it is a curated synopsis of public information. My observations and opinions are exactly those, based on information that has been publicly released by these companies or covered in the press.


CONSUMER APPS:


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GLOW

The tech-forward platform for serves fertility patients and connects them with clinics by providing:

  • Glow- Ovulation and fertility tracker

    - Includes:

    • Fertility Calendar

    • Daily health log

    • Health insights

    • App syncs with partners app

  • Glow Community

  • Glow Nurture - Pregnancy app

  • Glow Baby - Baby Tracker

  • Eve by Glow- period tracker and sex tips

Glow Fertility is segmented into a direct-to-consumer programs and a separate employee benefits program.

  1. Direct-to-consumer programs:
    Glow predicts ovulation patterns and fertility probability based on user data inputs and supports women with services such as egg freezing and IVF. In addition to helping clients navigate the process of getting pregnant, Glow also facilitates access to healthcare providers (with whom the Glow team negotiates discounts to reduce the financial burden of historically expensive fertility treatments).

  2. Employee benefits program:
    On the employer side, the Glow Fertility Program negotiates contracts between employers and fertility care providers.

Millions of women input data on menstrual periods, doctor visits, sleep habits, sexual activity, and birth control (in addition to over 35 additional basal health data points), and Glow has all of that data.

Although Glow does not publicly share the full details behind it’s business model, the firm charges businesses for the employee benefits program, and is also able to charge a fee for facilitating access to services from preferred healthcare providers. Glow also offers women personalized consultations through its direct-to-consumer channel, offering one free session before converting to a charge for service model.

History and Funding:

  • Launched in 2013 by Max Levchin (co-founder of Paypal)

  • Glow originally spun out of PayPal Co-Founder and CTO Max Levchin’s business incubator, HVF.

  • According to Crunchbase, Glow has raised over $23 million in venture capital, $17 million of which was raised in a 2014 Series B round that included Founders Fund and Andreessen Horowtiz, reports Vox.


EMPLOYEE BENEFITS:


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CARROT

Carrot is a startup out of Y Combinator working with employers to offer fertility care like egg-freezing and in vitro fertilization (IVF) as a workplace benefit.

Provides affordable options for those struggling with infertility by partnering with employers to add coverage for fertility services. They offer customizable plans to employers to include varying levels of fertility coverage at a sliding, per-employee dollar amount.

Founded by:

  • Tammy Sun, CEO

  • Dr. Asima Ahmad, Medicine

  • Juli Insinger, Growth

  • Arun Venkatesan, Engineering

Funding:

  • Total funding: $15.2 million

  • According to CrunchBase, Carrot has raised $15.2 million over four rounds, one angel, two seeds, and a series A. Their lead investors have been UnCork Capital with 3.6 million and CRV with $11.5 million.


 

NU BUNDLE:

A benefit system employers can add to attract top talent.

Also offers services to help members understand their options, with guidance before, during, and after treatment. Services for members include:

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  • Their family planning concierge, which reports to provide members with caring, live guidance, and support at every stage of the journey.

  • Help for members maximize existing benefits.

  • Access to preferred pricing at top clinics and pharmacies.

  • Access to customized fertility payment options.

Nubundle offers its products as a voluntary employee benefit, limiting the costs to employers. Employers pay a flat annual admin fee.

Founders

  • Chris D'Cruz

  • John Ciasulli

Funding

  • Total funding: $1.5 million

  • In a seed round, NuBundle raised $1.5 million from three investors led by Lightbank.


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STORK CLUB

Family/fertility benefit suites for companies.

In 2018, Stork Club expanded their core offering by introducing a comprehensive suite of Flexible Family Benefits that include both Fertility and Parental programs designed for large enterprises.

Stork Club advertises to be the only enterprise-ready family benefits provider designed for self-funded employers. They process claims and pay providers directly, letting your team focus on more important goals.

They have employee-facing web and mobile apps to help employers on-board, manage, and validate new programs with vetted provider partners.

History

  • Founder, CEO: Jeni Mayorskaya

  • Early Stork Club investors and advisers include key employees from LinkedIn, One Medical, and Facebook .

Funding

  • They appear to be funded by slow ventures, but it is unknown how much money they have raised.


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PROGYNY

Right now, Progyny is the fertility benefits company.

They provide fertility solutions for self-insured employers.

Some may remember, Fertility Authority, the consumer facing company and fertility clinic review platform that negotiated reproductive health benefits. The company changed its name to Progyny in 2015 after acquiring, or being acquired by, Menlo Park-based Auxogyn, the inventor of Eeva. They quickly sprinted ahead to lead the race of fertility benefits broker.

In my opinion, this is a one-horse race at the moment, with their young, new competitors looking to be the person who can disrupt their early lead as Lyft did to Uber.

History:

  • Founded in 2008 as Fertility Authority, became Progyny in 2015

  • CEO: David Schlanger

  • Headquarters are located in New York, New York

Funding:

  • Total funding: $99.5 million in ten rounds from six investors, as documented by CrunchBase,

    • Who led the rounds has not been released.

    • Though we do know they raised $15 million in a new round in 2016.


THE FINANCIERS


Now this group is different. They’re not a new wave of tech companies launched from or by Silicon Valley serial entrepreneurs. However, by default, they do serve as lead generation and another entry point for patient acquisition from which they can bring new patients to fertility centers.

Also, I speculate a potential scenario in which one or more of these companies are acquired for easier, quicker, and more expansive entry into the fertility field.

Think about it. Many of these companies have an outdated user experience and some of the founders may be ready to cash out of the game rather than reinvest and overhaul. Again, this is Griffin Jones putting his Jim Kramer hat on and being purely speculative.


 

WIN Fertility:

Maybe they belong in the employer benefit group, but a few things set them apart:

They have been in the field for two decades.

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WIN offers benefits through employers and affordable options for treatment through practices for those without insurance or for those who have exhausted their insurance benefits.

WIN integrates with national and regional insurance carriers, as well as the nation’s largest pharmacy benefit managers to procure fertility services. WIN patients are qualified prior to fertility treatment.

Available 24 hours a day, 7 days a week, WIN’s Nurse Care Managers guide patients through every step of their fertility journey.

History

  • Originally founded as an independent women’s health management company

  • Founded in 2000

  • President and CEO: Roger Shedlin


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Attain Fertility

ATTAIN FERTILITY:

Attain makes themselves known for being the original multi-cycle plan provider. They offer bundled IVF cycle plans, called Multi-Cycle Discount Programs, that include multiple IVF cycles for a one-time, discounted fixed fee.

Being owned by IntegraMed they are affiliated with 40 practices, 130 locations, and more than 180 Reproductive Endocrinologists in their US wide network.

How it works:

  • Some patients qualify for their Multi-Cycle Discount Program + REFUND. This offers patients who meet certain criteria the potential of getting a refund if their IVF cycles are unsuccessful.

Estimated revenue:

  • $15.4 million

History

  • Founded by Pam Schuman


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ARC Fertility

ARC says they are the access point to the “nation’s largest network” of fertility professionals and offer innovative financing options.

More specifically, ARC offers fertility treatment packages, refund guarantees, and finance options to people living with infertility.

Value proposition to clinics and/or patients:

  • Largest network

  • Most trusted

  • Doesn’t own/operate clinics -> looking out of patients best interest

ARC’s fertility care packages can be bundled with medication and genetic testing services and bundle the cost of services into one monthly payment.

History:

  • ARC was founded by David Adamson, MD.


THE WILDCARD


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Fertility IQ

The most comprehensive review platform for fertility specialists and fertility clinics.

With FertilityIQ, prospective patients search by location or by a specific doctor or clinic name. Doctor profiles are detailed with aggregated metrics including communication quality, degree of individual attention, responsiveness, and overall recommendation. Patients’ summarize their experiences with doctors and clinics -- from the doctor’s approach to diagnosis and treatment protocols, to the nursing staff’s level of organization, to the competence of the clinic billing department.

History and Funding:

  • The founders of Fertility IQ, Jake and Deborah Anderson-Bialis, say they will never take marketing dollars from clinics. Rather than seek capital from outside investors, the couple decided early on to self-fund FertilityIQ.

  • Founded in 2015, went live in 2016

One of my clients once told me that they were weary of Fertility IQ because they thought they were building a mousetrap and they didn’t know what it was. I’m not weary because I believe Jake and Deborah have built their platform from an authentic ethos and are serving the market in a genuine and desperately needed way. Where the mousetrap will lead, I have no idea but it’s already a darn good one. Fertility IQ offers the best user experience for fertility clinic selection and has some of the best consumer generated data in the field.


Conclusion:

Up to now, I have presented private equity backed consolidation and venture capital backed innovation as two separate phenomena, though they certainly don’t have to be. What will happen when the largest fertility networks, their parent companies, or private equity firms, acquire the largest scale platforms for patient acquisition, financing, distribution etc? Vise versa?

Resilient businesses survive revolution and later thrive because they adapt to capitalize from these disruptive forces rather than be replaced by them. There is more opportunity for the independent REI practice than there has ever been before, but it isn’t coming from doing business the same old way. It requires new strategy, paying close attention to the new players in the market, and using them for their benefit.

If you would like help in adapting to these forces and benefiting from the disruption rather than being pained by it, learn more about how to implement the Fertility Marketing System.

Four Reasons the Tech Revolution Has Disrupted Fertility, and Why Practice Owners are Frustrated

By Griffin Jones

CHANGING TECHNOLOGY

Part 4 of a four part series on the main business challenges facing fertility centers because of the shift from "small clinic" to "entrepreneurial endeavor"

For some IVF centers, the change has already done them in. For others, it is the level playing field needed to thrive against massively funded competitors. No phenomenon presents a greater threat, nor a greater opportunity to today’s fertility centers than the technological revolution through which our society is living.

So far, we've deeply explored the four major implications of the following axiom: today's fertility practice is no longer a small, independent healthcare clinic, but an entrepreneurial venture. We talked about business structure, strategy and vision, and accelerated competition. These three tenets pale in comparison to our society’s rapidly changing technological and social behavior.

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While all four of these elements have caused the tectonic shift from small healthcare office to entrepreneurial venture, none are more significant than this one, the drastic change of technology and society.

In this article, we mostly refer to consumer technology. Leave alone advances in medicine and laboratory technology, though their convergence may ultimately be indistinguishable. Rather than individually analyze various silos of the tech sector— such as social media, e-commerce, augmented reality, and artificial intelligence—we will examine how our relationships with our patients are changing, and more rapidly than we may realize, as a result of the speed of the changes happening in tech and society. These are just four implications of how advances in technology have changed our society, our patients, and consequently, our practices.

  1. Information exchange has accelerated at an uneven pace, which has led to

  2. Problems meeting needs and expectations which has contributed to the need to form

  3. Connected communities of patients who have both equalized and imbalanced

  4. Competitive advantages and disadvantages between large and small fertility practice groups.

And it’s only the beginning.

1). INformation EXCHAnge: Patients need more than providers can give

Travel back with me to the mid 1990’s. While today’s REI Fellows ran home from grade school to watch the latest episode of Saved By the Bell, the second generation of fertility sub-specialists left the universities to open their own fertility practices or start REI divisions at the hospitals. We’re referring to those who came after the pioneer generation of Howard Jones and Patrick Steptoe. Really, this class of baby-boomer REIs is the first generation of the fertility care provider whom we know today.

Now let’s imagine a couple from the same time period. They’ve been unable to conceive after two years of trying. How would they have found information on their

  • Diagnosis
    They could go to the bookstore. There was likely a book or two that offered good introductory information on infertility and/or how to get pregnant. But how is one supposed to keep a best selling thriller like The Fastest Way to Get Pregnant Naturally by Christopher D. Williams, MD on the shelves for long? Maybe there was a seminar in their area. But how would they have found out about it?

  • Support How would someone struggling with infertility have found professional or peer support? Could they just ask around town? RESOLVE was around, but it's not as though one could look them up in the yellow pages.

  • Treatment How did patients find their fertility provider? Would we have to hope that their OB/GYN or primary provider knew enough about emerging fertility care to direct them to the new sub-specialists in their area?

Think about the most powerful man in the world at that time, U.S. President, Bill Clinton. One of the most powerful supercomputers to which he had access was the Intel Paragon XP/140. Today, every one of your patients walks around with a supercomputer more powerful than that in their pocket. Because of that, our patients have access to more information than each of the world leaders from that time period as well. Information asymmetry is over, and it didn’t take long for these supercomputers to conquer our social habits.

The adoption of smart phones more than doubled from mid 2011 to late 2017 from 35% to 77%. 92% of adults ages 18-49 own a smartphone. You went to work one day and most of your patients did not have all of the world’s information at their fingertips. You came back to the same office six years later, and they did. The exchange of information has changed, but patients have outpaced their practices in their means to deliver and receive information, and that poses a problem in meeting patient expectations.

2). unable to meet patient expectation: not speaking the same language

“Not to use social media platforms is to be culturally incompetent. As a physician, we are supposed to give medical advice in a language the patient understands. Not doing so is considered to be medically inappropriate and can lead to adverse outcomes. If large segments of the population get the majority of their information digitally, isn’t it incumbent upon healthcare providers to provide information in an accessible, understandable way?”-Dr. Serena H. Chen, MD, REI

On a webinar that I conducted in August 2018, the most common challenge reported by fertility practice owners and managers was increasingly high patient expectations. Because patients have adopted the new methods of information exchange much more quickly, communication needs are frequently not met. This imbalance can negatively impact a fertility center’s relationship with its patients.

Patients are reaching out to practices through Facebook Messenger and Instagram at a quickly increasing rate. Patients spend most of their communication time on these channels, yet some practices don’t even have a contact form on their website. For younger patients, this is the equivalent of not having a telephone. On an average day, almost 40% of millenials interact with their smartphone more than anything or anyone else, including their significant other, according to 2016 research from Bank of America.

Practices are reporting challenges with meeting patient expectations, partly because technology has raised expectations of response time to a standard that staff cannot meet. Even if the expectations are unfair or unrealistic, fertility clinics are unable to reset those expectations if they are unable to effectively exchange information in balance.

  • Phone Calls
    Today's patients reluctantly call you to schedule an appointment. Tomorrow's patients simply won’t. Every year, the idea of making a phone call to schedule a new patient appointment is all the more foreign. When they are consumers, patients are accustomed to instant transactions, as with transportation, hotels, entertainment, and food. A survey from the United Kingdom found that more than 25% of smartphone owners never use their phone to make a call, up from only 4% 3 years prior.

  • Text Messaging
    Pew also states that Americans made over 12 phone calls a day in 2011. In 2015, however, a report by Informate shows that Americans make or answer only 6 phone calls a day, while sending and receiving 32 texts and spending 14 minutes on Chat. By the time institutes like Pew can even report their conclusions, the changes have already accelerated. 

  • Chatbots
    69% of consumers prefer interaction with chatbots for quick answers. Our prospective and current patients want (and expect) answers faster than we can respond to them. Think of the twenty most frequently asked questions that your front office staff has to answer over and over. They may even be answered as FAQs on your website. People expect these answers immediately, and the technology exists to meet that speed. See the example chabot flow below that can be used for your Facebook Messenger or website chat.

The future of chatbots for fertility centers

The future of chatbots for fertility centers

The data suggest that clinics are unable to set and reset expectations with patients because the information exchange is imbalanced in such way that is insufficient to the patient. If patients and centers are not communicating in the same media, they are not speaking the same language. Consider this data point from the same Bank of America study: “the majority (67 percent) of Americans feel the appropriate response time to a text is under an hour, with 43 percent citing under 10 minutes and 10 percent thinking it should be instantly”. Contrast this with how long it takes your already work-loaded staff to respond to patients who are anxiously awaiting their test results. So they turn to each other.

3). COnnected communities of patients…and a chance to lead them

With the information exchange so out of balance, how are patients meant to process their information overload? Technologist Alex Kouts argues that reasoning by proxy, is the reliance on other people or organizations to offload one’s cognitive load, for forming a conclusion on complex subjects. Many patients rely on the experiences and opinions of their peers to help them process the very complex information they receive about infertility.

Part of the reason behind a massive social behavior change in our patient population is that people are now starting to talk about infertility. In the past, how could patients have connected with others to talk about their experience with infertility? Today, many people still struggle with infertility in silence, but hundreds of thousands of people worldwide are changing that.

#TTC stands for “trying to conceive” on social media. As of July 2018, the infertility hashtag had been used over 580,000 times and the #ttcsisters hashtag has been used almost 330,300 times on Instagram. There are thousands of infertility support groups and pages on Facebook, hundreds of infertility blogs, and dozens of podcasts about fertility. 

The cat is out of the bag. Good!

If we want to encourage people who are struggling with infertility to pursue medical advice, then we want them to talk. People are now talking publicly about a very pressing problem which you are more qualified to address than virtually anyone in their area. By becoming the voice for people with infertility in your area, and the forum for which they can connect with information and support, we create a natural and honest referral system. To the extent that you can encourage this system by truly providing values to prospective patients, you will never want for new patients.

Smaller fertility practices have access to a word-of-mouth referral network that was never previously available to them. In Part 3 of this blog series, we discussed the major advantages that large, private equity backed practice groups have over independent fertility centers. Thankfully, large practice groups aren't so much better equipped to adapt to these changing habits as we are.

4). COMPETitive advantages and disadvantages: rigged game or level playing field?

Many patients don’t see a fertility specialist when they need to because they are scared and they have no idea what seeing a fertility doctor will be like. They don’t know who to trust, but they do trust their friends and relatives. In years past, most people would not have known that their cousin, co-worker, or college roommate struggled through many of the same problems which they currently face, much less that they saw a fertility specialist, whom, and how happy they were with him or her. Now, hundreds of people in a person's social network can see when they post a picture of their beautiful family to their fertility center's social media channels, and publicly thank their fertility doctor and care team.

Larger practice groups often spend more money on social media advertising, yes, that is true. Because of that they are taking patients from practices who are not active on social media. But those practices that constantly create content and engage their community are acquiring new patients by word-of-mouth faster than ever. In fact, some practices don't need to spend any money at all on social media advertising, because there organic reach is so high. If dozens to hundreds of patients refer your practice in a given month and help persuade strangers who are looking for social proof, you will never want for new patients again.

Large corporations can outspend your marketing budget. They will and they are. They can create referral programs for large OB/GYN groups. They can leverage better deals with insurance companies. But there is a kink in their armor: they have to keep up with patients' attention as much as you do. People struggling with infertility want to give you their attention. Many times, they think about nothing other than their problem and you have at least part of the solution. If you make the effort to build trust with them and help them where they spend the most attention, you can reach them in such a way that large competitors cannot.

The tech revolution and reproductive health

The tech revolution and reproductive health

ONLY the beginning

We are only at the very beginning of this technological revolution, which is greater than that of Johann Guttenberg and the printing press. Marketing for fertility clinics is only one facet of how consumer technology has changed reproductive health. Companies and products are invented every day that can change our field forever. Consider these breakthroughs and their potential ramifications in our field.

Think of AI in the IVF lab

Think of AI in the IVF lab

Artificial Intelligence

Error rates for image labeling have fallen from 28.5% to below 2.5% since 2010. On this specific test, AI is now more accurate than human performance. Imagine artificial intelligence being used to

  • Score embyro quality

  • Predict success of recommended prognosis

  • Real time diagnosis

virtual reality impact on Assisted Reproductive Technology

Virtual and Augmented Reality

Statista estimates that there are 171 million active users of augmented reality in 2018. A 2016 poll of consumers in the United States by ClickZ found that more than a third (37%) have now used either their own or someone else’s VR headset. In the not distant future, VR and AR may be used to

  • Provide initial consults

  • Tour the practice and IVF lab

  • Take CME lectures and courses

How will block chain affect Assisted Reproductive Technology?

Blockchain

Blockchain technology scopes far beyond the function of currency. Blockchain is the digitized, decentralized, public ledger of transactions of virtually any kind. The number of Blockchain wallets has been growing since the creation of the Bitcoin virtual currency in 2009, reaching over 25 million Blockchain wallet users at the end of June 2018. Accenture estimates that 30% of operating costs could be eliminated using Blockchain. Blockchain development is still in its very early life, but it could be used in reproductive health to

  • Replace electronic medical records

  • Finance treatment

  • Integrate systems such as billing, records, results, and treatment protocol

change is here

Whether we like it or not, the REI practice of 2019 can no longer be designed as a small medical clinic. Whether its motives are profit driven or in service to the betterment of humanity, or anywhere along that spectrum, it is an entrepreneurial venture. We’ve examined how the world has changed dynamically in the last two decades and will change even more in the next two. To succeed, fertility centers need to be structured as an entity that is led by a visionary, with a strategy and vision that account for powerful competitors and the ability to adapt as quickly to social and technological changes as quickly as our patients do.

The variables for which we need to account are infinite if we try to keep pace with our society’s technological revolution as a whole. If we manage to keep pace with our patients, however, we have access to a breadth of opportunity the likes of which the world has never seen.


 

 

The Battle for the IVF Market: 5 Wall Street backed companies vs. private practice

By Griffin Jones

In Venture Capital fertilization

Part 3 of a four part series on the main business challenges facing fertility centers because of the shift from "small clinic" to "entrepreneurial endeavor"

Multi-million dollar private equity firms offer fertility practices an ultimatum: sell part of their practice, or have their market-share siphoned away.

Major firms spend hundreds of millions of dollars nationwide because they are in a race to consolidate as much of the fragmented IVF market as they can. This is only to speak of companies who own and operate networks of fertility clinics. In parallel, in 2017, PitchBook tallied more than $178 million invested into startups developing fertility products. In our series about fertility practices’ tectonic shift from small clinic to entrepreneurial venture, we’ve detailed the challenges that independent fertility practices face that their big new competitors don’t. So who are these new titans, and what are they up to?

Merger and acquisition pattern of fertility centers

Merger and acquisition pattern of fertility centers

Important disclaimer: Neither I, nor Fertility Bridge have a direct commercial relationship with these companies at time of writing, though we certainly may in the future. We work or have worked with clinics in some of their networks. This profile is not a revelation of insider knowledge. Rather, it is a curated synopsis of public information. My observations and opinions are exactly those, based on information that has been publicly released by these companies or covered in the press.

compete with or join them. just don't pretend they don't exist

deciding to sell fertility practice

I have good friends that work for these companies or have affiliated their practices with them. Some might be very happy with their corporate partners and some might not be. It could be an excellent decision for your practice to sell equity to one of these firms or engage in a different level of strategic partnership with them. For some practice owners, a relationship with one of these firms is the answer to a lot of headaches. The stress of operations is shared with someone else, so providers can focus on practicing medicine.

Other practice principals feel they would lose control over the way they treat patients. They have their own vision for their culture and operations. If you’ve been struggling with this decision, I suggest reading part 2 of our series on vision and strategy, to see where you stand. This might be a long conversation, or several, with your business partner, spouse, clergyman, or bartender. You have to make the decision that’s right for you, your family, and your practice. There’s no right or wrong answer in a vacuum. Whether you decide to fight ‘em or join ‘em, however, we just can’t pretend these major new players don’t exist.

Second important disclaimer: It can be very fashionable to say these companies are more interested in their quarterly profits than the best interest of the patient. There may be cases when business pressures affect personal care. But I would be just as quick to point out that these companies might better serve patients in certain areas because they are better suited to face the challenges that we talked about throughtout this series. Their bankrolls may come from Wall Street, but the people that I know that work for these fertility networks are just as passionate about serving patients as those in private practice. Nevertheless, neither you, nor I, nor they get to pass final judgement on the quality of their output. The patient market decides.

The (Relatively) New Kids on the block

If we covered all newer companies in non-direct competition with fertility practices, this blog post would be longer than Don Quixote. In this article, we profile those networks who directly compete with other fertility centers. We also learn about the private equity firms behind them. Once again we ask ourselves, what is the plan?

Now let’s meet the people who want to buy you out or blow you over.

1). PRELUDE FERTILITY

Fertility acquisition strategy

Fertility acquisition strategy

Prelude Fertility splashed into reproductive headlines in the fall of 2016 when Forbes magazine reported on The 200 Million Dollar Startup That Wants to Stop the Biological Clock. Where does a startup get $200 million and how have they acquired market-share so quickly? Meet the war chest and strategic acquisitions behind Prelude’s rapid market entry.

  • Lee Equity Partners. If Prelude’s coffers total $200 million, and Lee Equity’s buy-in was in line with their disclosed portfolio, then one might speculate that 25 to 50% of Prelude’s initial funding came from Lee Equity Partners. Massive capital from Lee Equity Partners has allowed Prelude to accelerate their acquisition of existing companies, and have they ever.
     
  • RBA. In October 2016, Prelude reported that it had acquired Reproductive Biology Associates (RBA) of Atlanta. RBA is the largest IVF practice group in the state of Georgia. Perhaps more importantly, RBA came with their sister company, My Egg Bank.
     
  • MyEggBank was created by RBA in 2010. According to their corporate timeline, their affiliate network grew from 22 clinics in 2012 to 109 in 2017. They report that over 4,400 babies have been born from MyEggBank donor eggs.
     
  • Vivere Health. Why buy one IVF lab at a time when you could acquire several at once? In a parallel running story, Prelude reported acquiring Vivere Health in October 2017. Vivere Health, LLC was founded in 2010 in partnership with Houston Fertility Institute. After an impressive acquisition journey of its own, Vivere Health had owned and operated IVF clinics and labs in
    • Austin
    • Dallas
    • Houston
    • New Orleans
    • Florida
    • Arizona
    • Kentucky

In April 2016, Vivere was listed in Fortune Magazine as one of the fastest growing female-owned companies in the United States.

Prelude says that their strategic goal is national scale. With a few more acquisitions of this pattern and magnitude, they will have achieved that end.

2). IVI RMA Global

If you’re less familiar with European originated IVI , Reproductive Medicine Associates (RMA) might ring a bell.

  • IVI was founded in Valencia, Spain in 1990. They own subsidiaries in genetic testing, IVF lab consulting, research and development, and stem sell banking, to name a few. In 2016, IVI owned and operated 60 clinic locations in 11 countries and treated over 60,000 patients.
     
  • Nova IVI. Major fertility networks aren’t relegated to the United States. They come from all over the globe and their expansion is international. In April 2012, IVI acquired Nova Pulse IVF and now owns and operates one of the largest fertility networks in India. Nova IVI reports over 19,000 IVF pregnancies in India alone.
     
  • RMA. According to their own PR announcement, RMA of New Jersey grew 70% in new patient volume from 2012 to 2017. I am unclear on RMA of New Jersey’s exact relationship with other RMA network clinics in the United States. Clinics under the RMA name operate in
    • New Jersey
    • New York
    • Pennsylvania
    • Florida
    • Connecticut
    • Michigan
    • Texas
    • Florida

In February 2017, IVI announced that their merger with RMA of New Jersey would make them the largest fertility network in the world. In a horridly translated press release, IVI reports that they own 70% of the new company while RMA of New Jersey owns 30%. They mention their combined 2,400 employees, including 200 physicians and 300 research scientists across 70 clinics in 13 countries.

3). INTEGRAMED

Integramed Fertility’s model is different from many fertility networks. Private equity is only one of three relationship models for Integramed. They also sell services for marketing and practice management that do not involve taking equity in the practice.

  • Integramed Fertility is a division of Integramed America and they report to be the largest fertility network in North America. With 2,200 employees and affiliate employees, the network is comprised of 39 centers at 153 locations across 32 states and the District of Columbia.
     
  • Attain Fertility. Integramed owns Attain Fertility, a patient-facing IVF finance program. They offer multi cycle programs, multi cycle programs with refunds, and bundling with additional services such as PGS and third party services. Subsequently, Attain functions as a lead generation company. Patients can search for Attain Fertility member clinics by doctor or by geographic area and Attain funnels those new patient leads to the clinic. Their business model is similar to that of ARC Fertility.
     
  • Sagard Holdings. Similar to how Prelude Fertility acquires practices through the funding of Lee Equity Partners, Integramed’s capital comes from Sagard Holdings. Integramed had been a publicly traded company, but Sagard reportedly took them off of the Stock Market in 2012 for just under $170 million.

4). OVATION FERTILITY

Ovation Fertility was founded in 2015 by physicians at Texas Fertility Center after a “major private equity investment to form a national network of assisted reproductive technology (ART) labratories”. At time of writing, Ovation Fertility owns and operates six IVF labs in five U.S. states.

  • California
  • Texas
  • Louisiana
  • Nevada
  • Tennessee

The private equity manager behind Ovation's capital is MTS Health Services.

May meritocracy win all in the competition for best serving the patient population.

May meritocracy win all in the competition for best serving the patient population.

5). CCRM

The Colorado Center for Reproductive Medicine, CCRM as you fondly know them, enters new markets by acquisition like everyone else. Perhaps more than the other groups, however, CCRM enters new market areas through De Novo clinics. This means they help develop new labs and clinics in strong markets. In recent years, CCRM has opened or acquired IVF labs and practices in

  • Atlanta
  • Boston
  • Houston
  • Minneapolis
  • New York
  • Northern Virginia
  • Southern California
  • San Francisco Bay Area
  • Toronto

CCRM markets their lab advantages in every one of their markets. Since 2015, the private equity behind CCRM’s expansion comes at least partly from TA Associates in Boston. TA reports having raised over $18 billion in capital across their portfolio.

HONORABLE MENTION

In this article, we’ve only talked about your direct competitors. There are more companies from China and elsewhere that are buying fertility practices at high multiples that I don’t know very much about. There are large practice groups without private equity that acquire other clinics into their group. We didn’t even mention the new competitors that siphon market-share by offering new solutions or focusing on particular services. Here are just a few:

You don’t need to find Indiana and Arizona on a map to see that Boston IVF has interest in expanding beyond the northeast. Boston IVF is the “preferred provider of fertility services” for 15 different major health insurance plans. Boston IVF is the clinical affiliate of the Beth Israel Deaconess Medical Center and Harvard Medical School REI fellowship program. How would you like that advantage for recruiting new physicians? If there is a private equity firm associated with Boston IVF, I didn’t find it.

WHAT DOES IT all MEAN FOR YOU?

What’s a good ol' independently owned fertility practice group to do? Is there an opportunity for you to compete and thrive in this radically different world? You might look at regional banks or craft breweries. A century ago, every city in North America boasted their own local brewery, likely several. Beer became commoditized, and the corporations with the best distribution, market share, and financial leverage acquired or vanquished their competitors. By the 1990s, we were left with Anheuser-Busch, Miller, and Coors. South African Breweries  purchased Miller  and Molson-Coors (another merged mega conglomerate) in 2008 to become SABMiller-Coors, and finally merged with Anheuser-Busch/InBev (another merged mega conglomerate) in 2016 .

The past twenty years should have been a terrible period to start a brewery. Yet, quite to the contrary, independent breweries opened all over the country and took marketshare from the big players, now at 23% . Middle market companies like Sam Adams and Yuengling grew their own sales and grew by acquiring small breweries. The cycle continues. We see the same pattern among regional banks, and I believe we are seeing it in our field as well.

Small practices join together to become mid-size practices, and large companies acquire both small and mid-size groups. Then, physicians leave big practice groups and academic institutions to start the cycle anew. (I’ve got my eye on you, Vios Fertility). I don’t believe that all independent practices will be acquired or wiped out. The current and coming landscapes are just exceedingly difficult for unintentional REI entrepreneurs.

if you can't beat 'em, join 'em

when fertility centers join big practice groups

What will happen if you're unprepared for these competitors when the next economic recession starts? What will you do if 30-40% of the money in the marketplace goes away, seemingly over night? What would that do to your IVF volume? To your new patient visits?

Entrepreneurial competition isn't the only answer. It might make sense to sell equity in your practice or control of your lab. It could be the answer to a lot of your problems. One of the companies profiled in this article might be a great fit for your office. If we want to sell our practice, and want to go into the negotiation with “strong upside”, plenty of options, and not as a “distressed asset”, what is the plan?

if you can't join 'em, beat 'em

Nick Foles superbowl.jpg

On the other hand, the idea of giving up control and direction of your practice might eat you alive. Only you can make that decision. By taking market-share from big competitors now, as opposed to letting them take ours, we can prepare for an economic downturn in which we will not only survive, but thrive. If we are going to defend and grow market share against majorly funded competitors, what is the plan? 

We’ll conclude our series on IVF centers’ tectonic shift from small healthcare practice to entrepreneurial venture with perhaps their greatest challenge of all. Yet, it’s also their greatest opportunity and their chance to beat their giant new competitors where they lag.

In Part 4, we discuss the biggest change ever to occur in human communication and technology.

The one that dwarfs the revolution of the printing press.

The one we're living through right now.

What is the plan?

The 7 Worst Responses to Fertility Doctor Reviews on the Internet

By Griffin Jones

"The customer is always right"

Who knew this hyperbole, coined by Harry Selfridge in 1909, declaring his department store's commitment to customer service, would go on to become a thorn in the side of employees everywhere? It's a terrific internal mantra to aspire toward, but it can be very harmful when interpreted as a universal rule. Customers, or in our case, patients, may sometimes project their frustrations on to you or your staff and no one has the right to be abusive to your team members. Maintaining the notion that a single patient's point of view is infallible can put unfair stress on our employees. Gordon Bethune, former CEO of Continental Airlines, says that when companies don't support their employees when a customer is out of line, resentment results and service deteriorates. If we don't care for and support our staff members, how can they in turn care for and support our patients? 

I can't say I agree with the first part of this sentiment, but certainly the latter

I can't say I agree with the first part of this sentiment, but certainly the latter

In the case of public reviews of our practices, feedback isn't necessarily valuable when it comes from a focus group of one, but rather when we observe recurring themes from multiple people. The patient (singular) might not always be right, but the patients (plural, collective) are ALWAYS right. We should err in favor of the patient's perspective because it defines for us a higher standard of performance. But how do we respond to a negative comment when it's just plain unfair or untrue?  If you know in your heart of hearts that a particular reviewer is in the wrong, and you've truly done everything you can to make things right, you don't have to respond at all. If you're uncertain, or you want to publicly affirm your practice's genuine concern for every single patient, I have a better axiom for you:

"the patient might as well be right"

Remember, we're dealing with the court of public opinion. Miranda rights apply; anything you say can and will be used against you. For that reason, I'm concerned with the way many practices (cough, physicians) react to defend their case. Prospective patients reading our reviews have no way of knowing what really happened within the walls of your office. They can only judge us by how we respond in kind. Instead of winning the benefit of the doubt, we may say something to fall out of favor.  What's worse, physicians frequently disclose protected health information (PHI) when they attempt to argue their side of the story. To show you just how much our words can produce a completely undesired effect, I pulled seven real-life examples of how fertility specialists and practice administrators have answered negative public criticism. Warning: they go from bad to worse.

7 worst responses to fertility doctor reviews on the internet

7). Less is more

This response starts and ends just fine, but the physician gives into the temptation to make a correction. Responses to negative reviews are not the venue to discuss treatment protocol, or success rates, for that matter. The first two and last two sentences would have been fine for this response. Keep it short and take the conversation offline.

6). some battles aren't worth fighting

I didn't include the review here because it was very long. It was indeed an attack on the doctor himself. For that reason, it's better not to respond. We should respond to all negative reviews where we can at least offer a resolution, and none of those to which we cannot. When the commentary is a direct attack, nothing can be gained from turning the monologue into a dialogue, especially when it is the only response on the page.

5). Let your positive reviews speak for you...not the other way around

We don't get to determine if a reviewer's post is "excessively negative", our readers do. People browsing the page will notice when most people have a very high opinion of us. Pointing it out to them makes us look defensive. Besides, referring to this patients' initial consult and following correspondence discloses PHI.

4). Let it go, just let it go

As you can see at the top of this review, this doctor has a stellar online reputation. This is one of his only negative reviews. He doesn't need to defend his honor, his most delighted patients have already done that for them. Still, the response goes on to drag out the argument and include PHI. Very dangerous. 

3). No one can tell patients how to feel

"Just relax" or "stop worrying and it will happen" are two phrases that our patients unequivocally detest. Though likely not intended this way, insisting that a patient's bad news was delivered appropriately, when he or she feels the opposite, follows a similar vein. The practice's rapport is undermined and once again, more PHI.

2). No, seriously. let it go

Another REI, whose patients overwhelmingly love him otherwise. Responding to this single negative review in this way leaves a poor impression that is probably not representative of who he is as a physician. I don't see any of the 18 identifiers of PHI in this exchange, but it strikes me as an unnecessary risk.

1). I know it hurts, it's just not the place

I didn't include this review because the response is plenty long as it is. Besides, the doctor painstakingly recaps everything. I won't mince words, this is the worst response to a fertility center review that I have ever seen. I don't necessarily fault the physician for feeling this way. These comments seem to have really hurt him. He may have really cared about this patient and put forth his best effort to provide her with exceptional care. It sounds like he wanted to be completely transparent about the potential outcome. The patient didn't receive it that way, and that must be terribly disappointing. It's simply not the appropriate place to express one's disappointment. This response is one of the only accounts that prospective patients have to judge this physician's personality. Without knowing anything else about this doctor, fertility patients are left with a very poor impression.

hold your fire

You have three options when someone leaves negative criticism about you or your practice. You can

  1. Not reply at all
  2. Have a trained, neutral representative answer on your behalf
  3. Wait until your head is clear enough to leave a brief, solution-oriented response

I don't share these seven examples with you in jest. The way in which our words can betray us is a very serious concern. It's a threat to your brand and often, a legal liability. What may feel vindicating for a moment could be disastrous to your public image for a much longer time. Your time and energy are better spent on constantly adapting to collective patient feedback and delivering the best possible experience to the people you serve. You have my permission to give yourself permission to not be perfect. While it's necessary to devoutly heed collective patient opinion, there are times when you just aren't able to please certain individuals. Our goal in responding to negative reviews is not to defend our case in a particular incident but rather to show that we deeply care about how our patients perceive their interaction with us.

You can read my six critical rules for responding to negative reviews right here. If you want to reply to a negative remark that someone made about you online, and you don't want to make matters worse, just send me an e-mail or give me a call. We'll write a much better response that could make the patient feel better, will hopefully make you feel better, and will certainly make prospective patients feel better about you. 

 

Why Would Anyone Else Care About Infertility? How I Became an Ally to a Community I Had Nothing to Do With

By Griffin Jones

"Don't worry, you can always adopt"

I don't know if I ever had a conversation with anyone struggling with infertility (about the topic) before a few years ago. If I had, I probably would have said something silly like the above. I would have said it with the best of intentions, and hopefully, I would have kept an open mind. I knew nothing about infertility.  I had barely heard of IVF. I had no idea what a reproductive endocrinologist (RE) was. I am a young male with zero medical background and no personal connection to infertility. On paper, I was the least likely person to become an ally of the infertility community. And that's the very reason it seemed so important to become one.

caring about infertility

expanding the community

Whatever the issue at hand, progress will be limited if the consequences only apply to the people directly affected. This is true if we're talking about small issues at the local school board or large ones like repealing laws that ban same-sex marriage. Every community needs allies who are not "native" to their background for credibility and traction. I found infertility awareness to be an important concern that needed attention from more people than only couples struggling to conceive. It looked like they needed reinforcements, might be one way to put it. Still, there are infinite communities that I don't belong to that need support from the broader public. Why this one?

acknowledging the right to feel

There is a particular nuance in the way the infertility community is treated that piqued my curiosity. I still can't totally articulate it, but it has to do with we, as a society, not letting people feel what they need to feel. Responses like "at least you have one child already", or "stop worrying about it and it will happen" are pretty consistent with how we react to a lot of feelings that we don't totally understand. We jump to the "solution" because we want the feelings of hurt to end immediately. Sometimes out of compassion, sometimes out of laziness, and probably anywhere in between.

"You'll find someone else."
"You'll land a new job."  
"It's not so bad."

I wanted to shut up for a minute and allow people their right to feel.

ThAT blurry area between Sympathy and Empathy

Judging how other people should feel seems to stem from trying to equate someone's reality to our own. We often compare experiences as though they could possibly be the same, instead of drawing from them to imagine how someone feels. Dictionary.com describes sympathy as "feeling compassion, sorrow, or pity for the hardships that another person encounters, while empathy is putting yourself in the shoes of another".  The only way to know the pain of infertility (or cancer, or the loss of a spouse, or absolutely anything you could imagine) is to experience it personally.

Relating to imagine what people feel, not knowing exactly what they feel.

Relating to imagine what people feel, not knowing exactly what they feel.

We might not be able to fully understand someone's experience that we don't share, but we can usually empathize when we try.  I've never had to go through the "two week wait", but I know how anxious and frustrated I become when someone tells me to "just relax". People might not pester you about when you're going to have kids when that's what you want more than anything in the world. You may, however, know the soul-wrenching feeling you get when people ask you about a life goal that you're trying your best to achieve, and you have no idea when it will happen. Interacting with people with infertility has made me more aware of imagining what people might feel, in all kinds of scenarios, instead of judging what they should feel.

Playing for the team that drafted me

I noticed the community that emerges from this longing to be understood when I first started doing social media for fertility centers in 2014. Some people who had children because of assisted reproductive technology (ART) were so overjoyed that they wanted to tell the world about it. The emotional attachments they had to their doctors and care team was palpable. They exuded a sense of triumph that comes only from a prolonged period of hard times. I had worked with several other business categories in the past and never seen anything like it. Then I wondered about the people that haven't had success or are still on their journey. What do they need help with? So I took it upon myself to e-mail the group leader of every RESOLVE support group in America. You'll be able to read more about that in my memoir, The Unlikely Tale of How I Became Besties with the National Infertility Association. Turns out, you're not supposed to do that. Before the nice people at RESOLVE could contact me to say "hey knock that off, guy", I had already talked with dozens of people dealing with infertility over the phone and via e-mail conversations. Their reception of me sealed the deal that these were people I could get behind.

If you don't get this analogy, you're going to have to re-watch Jerry Maguire

If you don't get this analogy, you're going to have to re-watch Jerry Maguire

I was completely upfront about who I was. "Hi, I'm a marketer and I'm thinking about starting a business for fertility practices. I would love to know what information you really wanted from your clinic(s) that you just couldn't get". I'll translate this for you:

"Hey, I'm some dude that knows nothing about you, nothing about your problem, nothing about medicine, and I would maybe like to possibly make some money some day".

"Go f yourself" would have been a perfectly reasonable response. But I didn't get that at all (maybe once). Instead, people were generally very eager to talk to me. They told me a lot. They told me about a whole bunch of stuff I had never heard of before...stuff that most people would consider very private that I didn't even ask about. They even thanked me for doing my research. Thank me? A marketer? Didn't they know that marketer is just one or two rungs better on the scum ladder than investment banker? I had never been acknowledged like this before--why them? I realized right away it was because they were yearning to be listened to. I learned first hand how little they felt understood, even by their clinics. I felt armed.

I jumped on Instagram to engage with the #ttc (trying to conceive) community there. Same thing. "Hey everyone. I'm a marketer. I don't know your journey, but I promise I will out-listen anyone who tries to compete with me in the business I'm building". Once again, I've been totally humbled by the welcome I've received, both online and in person. I get occasional shout-outs, words of encouragement, and people keeping tabs on me. I've been a marketer for ten years now and I've never received that from any other segment I've worked with. That is a very rewarding thing about working with a population with whom the stakes are so high. Shit matters. People don't feel that way when they buy a Hyundai Sonata. Even though I work with clinics, and not directly with patients, it's the patients that get me excited about what I do.

Stay classy, #infertilitycommunity

My guardedly optimistic prediction for the future is that public awareness around infertility will grow significantly. When it does, I hope the discipline of listening to and trying to imagine the feelings of others wins over the comparison of struggles. Affording people their right to feel and the humility of using experiences to empathize instead of drawing contrast are amazing lessons in humanity. I realize that I am totally idealizing the values of a very diverse and massive population of people. But that's what they are--ideals. And those are what made me want to be an ally to a community I originally had nothing to do with. 

 

What 22 Infertility Bloggers Hated About Choosing Their Fertility Clinic

By Griffin Jones

"a prudent question is one half of wisdom"--francis bacon

Recently, someone who is very involved in the field of infertility reinforced what hundreds of patients have told me for two years; there's an astounding gap between the way many fertility practices deliver their services and what patients want and expect. That's exactly why our company has the word "Bridge" in its name. According to a study conducted in 2012 by Forrester, 80% of companies say they deliver superior service to their customers. Meanwhile, only 8% of those companies received a superior customer rating. If you're seeking treatment for infertility, the delivery of the services you receive should be nothing less than superior. No clinic is entitled to your selection. Even in states and countries where some rounds of IVF are covered, there are still many circumstances in which you could pay tens of thousands of dollars of your own money. If you live in a large enough area, or are able to travel, you have a choice. Your choice isn't an easy one to make, given how much is at stake. I don't own any fertility centers (...yet), but because we direct their marketing based on what you tell us, I'll speak about them in the first person voice.

Getting out of our own way

infertility blogger round up

As fertility practice groups, we sometimes spend a lot of money in an attempt to help you make that decision. Or at least we think we do. Sometimes we try to grow our practices without any strong understanding of what you need to feel comfortable (and eventually very satisfied) to move forward with treatment at our center or someone else's. We frequently forget that there is a simpler way of earning your choice. We could remove the unnecessary challenges, annoyances, uncertainties, and causes for anxiety that you face when you are searching for a fertility specialist. How do we build not just a proven marketing system, but an entire practice culture, around what goes through your mind when you debate coming to our clinic, another practice group, or seeking no treatment at all? This is a laborious and continuing process, but I had a crazy idea of where to start when I entered this field, and I decided to do it again.

I asked you.

In early 2015, I wrote a report from interviews with several infertility peer support group leaders. This time, I decided to ask over twenty prominent infertility bloggers to candidly answer the same short question. One question isn't enough to understand everything involved in how you decide which practice will play this instrumental role in your life, and what we need to do to make you feel very good about that decision. We need as much feedback as we can possibly get. We need to ask follow up questions, issue patient satisfaction surveys, read what you say anonymously about us online, take action on your collective input and repeat that process forever. Still, in their own right, the candid answers of several different people to the same question is very insightful. I chose bloggers because they have not only a wealth of personal experience, but also because they are each in contact with hundreds of other people who deal with infertility. They are on the pulse of the infertility community. As you'll read, there are several reasons why people choose clinics, and they're not mutually exclusive. 

20 infertility bloggers all answered one question

20 infertility bloggers all answered one question

What was the most annoying part about choosing your fertility clinic?"

OVERWHELMING OPTIONS

In Due Time , @caroline_induetime 
"There are too many clinics to choose from. It's so hard to choose one".

No Bun in the Oven @nobunintheoven 
"Choosing a fertility clinic is an overwhelming experience because it's an expensive process! The most annoying part of finding my clinic was finding reliable experiences about the doctors. Where is the Rate My Fertility Doctor website? Where can a couple go to find real life experiences on these professionals who are getting paid tens of thousands of dollars for treatment? It was hard to find and we were ultimately left shopping at several clinics before finding the 'right one' for us".

Hoping for a Best@hopingforbabybest
"Wondering if you made the right choice".

Anonymous 

"Just scared of making the wrong choice".

UNCLEAR COSTS/BILLING

Smart Fertility Choices, @SmartFertilityChoices
"It was difficult to understand the entire cost involved in doing a cycle".

Rad Kitten@RadKitten
"Cost first and foremost. Second is beside manner. I'm not just a paycheck, I'm a person".

TTC a Taxson Baby@ttcataxsonbaby
"The most annoying part about choosing my fertility clinic was finding out that they don't take either of our insurances! Annoying and frustrating"!

Happiness Glass@happinessglass_
"That insurance dictates where you can or cannot go. Also I chose based on location/convenience to me rather than quality of service".

Amateur Nester, @amateurnester
"I found it frustrating that most clinics didn't have their costs listed on their websites. It would have made planning much easier if we'd had this information up front".

Its Positive Living, @its_positive
"Insurance (not having many options to chose from in my network/being tied to my network ... I have an HMO)".

THE RIGHT FIT WITH THE RIGHT PERSONNEL

The 2 Week Wait, @the2weekwait
"It was finding both a doctor and suggested protocol I truly felt enthusiastic about. To me, success rates can be manipulated, other patient opinions can vary and ultimately - nothing is more reliable than your own gut. If a doctor clicks with you, if the treatment suggested makes sense and you feel good about, that's all you need".

PCOS Diva, @PCOSDiva
It is disappointing when doctors do not have a solid understanding of how to treat PCOS using lifestyle modification as first line therapy.

Expecting Anything, @expectinganything
The most annoying part for me was the "marketing" behind this process by doctors/clinics. I mean, I get that it's a business for them, but some doctors forget that we are human, and this is real life shit for us! They all have different "sell tactics". They either beat you down and make you feel really bad or depressed about your situation, or they try to be overly sincere and emotional. We just want some facts and compassion people! Is it that hard!? I don't need to see all of the trophies "ie, baby pictures" plastered on the walls or some premeditated sob story. Show me your success rates and that you give a shit. It's that easy!

Our Misconception@ourmisconception
"The gatekeepers. You know the receptionists. These are the first faces you will see and the first you speak to when scheduling a consult or an appointment. They will be the ones that set the tone for the rest of the patient/user experience. Having navigated a cacophony of medical offices, this is an area/industry where empathy, education of the patient and social etiquette need to be greatly invested in as it lacks in most cases. My husband once had to spell out craniotomy to the appointment scheduler of his brain surgeons office. True story".

Triumphs and Trials@triumphsandtrials
"The most annoying part was going in to it blindly. Not knowing what the doctors were like and if they would be a good fit".

Anonymous 
"I needed an individualized approach on my treatment and a specialist who is willing to spare time to answer my questions and stay on top of all the details about my case. Not every clinic can do that due to patient volume. I was glad I was able to find the clinic I dreamed for after trying a big center in bay area, CA".

A LACK OF ALTERNATIVES

Infertile Soil, @infertilesoil
"In Canada you need to be referred to a fertility clinic (sometimes clinics will charge you if you don't have a referral) and many times doctors will refer you to just one particular clinic.

SIFTING THROUGH COMPLICATED INFORMATION

Trials Bring Joy@chels819
"Navigating outdated SART data".

AN EASY CHOICE FROM A TRUSTED SOURCE

Secret Infertility@FranMeadows
"I had a transition with ease since my OB/GYN referred me over to a fertility doctor that they personally used. This helped me feel more confident from the moment I walked through their doors. There was nothing annoying about me choosing a doctor".

 Life Abundant@lifeabundant_jw
"Nothing. My OB is able to do everything except IVF and is very knowledgeable in infertility treatment practice after doing her residency in a fertility clinic, so I have gotten lucky and have the best of both worlds. If we need IVF, I'll have to go elsewhere, and I will connect with her residency clinic and the doctor she trained under".

LET'S NOT MAKE THIS ANY HARDER THAN IT HAS TO BE

Hilariously Infertile, @hilariously_infertile
Uhhh. Being freakin' infertile is the most annoying part about choosing a fertility clinic.

Waiting In Hope, @waiting_in_hope
Honestly the most annoying part about choosing a fertility clinic is having to choose one AT ALL. Having to acknowledge the need for a fertility clinic/reproductive endocrinologist is heart breaking. It’s an acceptance that something is wrong. You have to grieve the loss of having a baby the “normal OB/GYN” route. And that it just might not be "easy".

Give the people what they want

As much as it's a service to you to equip you with clear information to make your decision, really, it's in our own best interest. The most effective way to grow our practices is through the detailed execution of a very simple premise: give you what you want. You can't decide on a clinic because you have no idea how SART success rates are being presented? Guess we need to make a video explaining SART data in plain English. You can't compare IVF costs between our competitors because no one will give you a straight answer? Sounds like we need to make an IVF cost checklist that you can download to compare potential additional costs. You felt isolated during your time at our practice because we never told you about support groups in our area? Apparently we need to make sure all of our patients go home knowing about the online, professional, and peer support resources that are available to them. In the age of ubiquitous communication, there is no shortage of ways to be able to collect and validate your input. Some clinics will ignore you and tell themselves they do a great job of getting you the information you want. Others will heed your suggestions and grow because of it. These are the clinics that deserve your choice, because you deserve nothing less.

Do you have something you want to say about your experience with your practice? Good, bad, or neutral? Please leave a comment or send me an e-mail! I would love to hear what you have to say.

6 Topics You Need to Know to Run a Successful Fertility Practice: 2016 ARM meeting recap

By Griffin Jones

Time to get down to business

Thursday, May 5th and Friday, May 6th marked the 2016 annual meeting of the Association of Reproductive Mangers (ARM). The professional group of the American Society for Reproductive Medicine (ASRM) convened on a pair of gorgeous near-summer days in downtown Chicago. Roughly 100 practice administrators attended, coming from single-physician fertility clinics to multi-state practice groups. At the welcome reception on Thursday, ARM Chair Brad Senstra invited the group to introduce themselves and enjoy dinner with someone they hadn't yet met. It was an in-person networking and educational opportunity that isn't especially common for practice admins. Here's some of what we learned

1). Salary Surveys, Benefits, and Calculation of Total Compensation

Sara Mooney, Human Resources Manager at Seattle Reproductive Medicine (SRM), opened the meeting on Friday by addressing many of the common issues that we face when reviewing and rewarding our team members. Sara recommends an online tool called Payscale, to review the pay averages of positions by geographic area and years of experience. Tools like Payscale generate reports that you can share with your employees, so that they understand when you are compensating them at a higher percentile relative to your competitors. Even when pay increases are not in the budget or may simply not be timely, there are other ways of rewarding your team, such as peer recognition from employee comment cards, added vacation time, and small gifts such as restaurant gift cards or sweets.

Carla Giambona, Director of Human Resources at IntegraMed Fertility, tackled the topic of benefits and calculating total compensation. It's important that employees know what your practice pays into their health and overall benefits package. Very often, employees view their salary as their total compensation. In reality, the practice may well be spending an additional 50% of that on health insurance coverage and other benefits. Premiums are among the biggest staff expenses to practices so engaging your team in wellness activities is a way to reduce your premium costs. Carla cautions however, that wellness engagement is a longer term strategy whose benefits will likely not be seen in the form of premium reductions within two or three years. 

2). Values Development and Implementation

Marianne Kreiner, Chief Human Resources Officer at Shady Grove Fertility, shared a meaningful (and very fun) exercise from one of the most successful practice cultures in the country. The total audience was divided into small groups of around eight people. Each subgroup was given a list of 150 words; desirable qualities for any team. Teams were welcome to add a word to the list if they preferred a quality that wasn't mentioned. Each person selected their twenty most preferred words and then group voting reduced the list to twelve and finally three words. The subgroups merged with one another and repeated the process with their combined word pools until finally the two halves of the entire audience came together as one to decide upon the chosen values that they felt represented their group culture. Want to know something about this ARM group? You must be hiring class acts. Independently, both halves of the audience chose "integrity" among their final three characteristics, a word that wasn't listed in the original 150. 

3). Leadership 

"Leadership does not carry a title," asserts Brad Senstra, Executive Director at SRM. Senstra explains four ways that leaders can encourage leadership, and therefore exhibit it in themselves. 

  1. Clarifying Values
  2. Inspiring a Shared Vision
  3. Enabling Others
  4. Encouraging the Heart

Above all, what sustains leaders, is that they love what they do. "Leaders build character by enabling others to act."

Example of leadership from Brad's talk. If the  story of these two dogs  doesn't rock your soul, then you don't have one.

Example of leadership from Brad's talk. If the story of these two dogs doesn't rock your soul, then you don't have one.

4). National Public Health Action Plan for the Detection, Prevention, and Management of Infertility

Dmitry Kissin, MD of the Centers for Disease Control (CDC) delivered some reassuring news about the agency's efforts to address infertility as a public issue. The mission of the National Assisted Reproductive Technology Surveillance System (NASS) is to promote the health of women and men who receive infertility services, the health of pregnancies achieved through these services, and the health of infants conceived through these services, by conducting surveillance and research, creating and maintaining strategic partnerships, and moving science to practice. Among NASS's goals to address infertility as a public health concern, are to develop a standardized case definition of infertility and to eliminate disparities in access to affordable infertility services.

5). Patient Services

Lisa Duran, CEO of patient focused, Reconceived, facilitated an exercise that can be replicated with both your patients and your personnel. Duran uses the Myers-Briggs personality survey to identify how people with different personality profiles communicate in distinct ways. The 16 distinctive personality types are determined by a combination of preferences.

Learn where you fall in this spectrum.

Learn where you fall in this spectrum.

  • Do you prefer to focus on the outer world or on your own inner world?
    • Extroversion (E) or Introversion (I)
  • Do you prefer to focus on the basic information you take in or do you prefer to interpret and add meaning?
    • Sensing (S) or Intuition (N)
  • When making decisions, do you prefer to first look at logic and consistency or first look at the people and special circumstances?
    • Thinking (T) or Feeling (F)
  • In dealing with the outside world, do you prefer to get things decided or do you prefer to stay open to new information and options?
    •  Judging (J) or Perceiving (P)

Duran says its helpful to know patients' preferences because people with different personality profiles frequently equate to "speaking a different language to one another". I learned that I'm an ENFJ (the teacher) and I found the summary to be pretty spot-on.

6). The Knights at the Round Table(s)

I could only attend one of the round tables, and it certainly won't surprise you that I chose marketing. Jacqueline Sharp of HRC Fertility moderated the table of very different practice groups. All four squares of the big market, small market, small practice, large practice quadrant were represented. I continue to be fascinated by how different practices use different models to affect patient volumes.  Some groups follow the recommended 3-5% of total revenue as a marketing budget. Many practices have no planned budget at all, but rather approve or reject marketing investments as they arise. Proving return on investment (ROI) is a challenge for all of us--and I'm excited to  continue to address that challenge.

Come one, come all

This was my first ARM meeting and I plan to be back next year, which means I would recommend it to you. The content of the meeting is beneficial not only to administrators and those involved in practice development, but also to nurses and physicians. The ARM group offers what is probably the most team-comprehensive programming within ASRM. The input of others in our professional society helps us to build teams that grow, super-serve patients, and are just downright pleasant to work with. If you'd like to get to know the group and their topics before you board a plane to Chicago next year, join us for some of the incredible round-tables and symposiums that they'll be hosting at the ASRM Scientific Congress in Salt Lake City. See you in October!

5 Hidden Patterns Uncovered Across the Top 25 Fertility Doctors in Patient Reviews

By Griffin Jones

What a world it is where patients can form an opinion about their fertility doctor before they even schedule an appointment. A 2013 study shows that 90% of respondents reported that online reviews influenced their purchase decisions. Through public feedback from their peers, people dealing with infertility have a plethora of information to make their decision from online review sites that exist for the benefit of the patient. Here's where it gets interesting.  Fertility centers can also benefit from online reviews--good, bad, or neutral--by using them to deeply understand and adapt to patient habits. By carefully examining the online reputations of the most highly rated fertility specialists in the country, we have further decoded the messages that patients are sending loud and clear.

We know from initial research that the success of an individual's treatments using Assisted Reproductive Technology (ART) greatly influences how they write their review of their fertility clinic. Positive fertility clinic reviews are three and a half times more likely to mention a baby or pregnancy than to mention lack of success or make no mention at all. Equally, negative reviews are three times more likely to reference leaving the practice before success than to mention a baby or to make no mention at all. We also know that positive fertility center reviews outnumber negative reviews by more than 2 to 1. Getting some ideas from Joseph Davis, DO of RMA of New York, we wanted to dig beyond these observations to try to answer more questions: 

  1. Do the same patterns apply to fertility doctors with almost no negative reviews?
  2. Does an REI's rating correspond to his or her practice's success rates?
  3. Do the clinics with the highest success rates have high online ratings?
  4. What is the correlation between an REI's gender and his or her online reputation?
  5. Are younger docs rated more highly than their veteran colleagues? 

Limits to the data

First,  several review sites are popular for rating fertility doctors, and they are not uniform. Some sites, like Healthgrades, offer only star ratings without qualitative responses. Other sites likes Fertility Authority, Vitals, Google, and Zocdoc have the option to leave star ratings with or without comments. Yelp and RateMDs include qualitative responses with their reviews. Yelp tends to be more deeply populated by place (practice) reviews as opposed to reviews for individual doctors. In the latest phase of this research project analyzing fertility doctor reviews, I chose to use RateMDs because it is the easiest platform to search by sub-specialty.

There are 2,264 reproductive endocrinologists listed on RateMDs, mostly from the United States and Canada. We can search them by both highest-rated overall and per metropolitan area. Still, RateMDs isn't a perfect source. There are many duplicate profiles and only 1,205 (53%) of the physician profiles have any reviews at all. Furthermore, the rate of adoption for every review site varies widely by market. On RateMDs for example, there are 929 reviews of reproductive endocrinologists in Toronto, but in a very similarly-sized market, Houston, there are only 380. Lastly, you may be listed as an OBGYN, and not as an REI (or both in the case of duplicate listings). With that said, when we check someone's RateMDs rating (if they have ten or more reviews) against reviews on other platforms, we find they are consistent. 

I'm really excited by a newer review site that Dr. Dan Nayot brought to my attention, called Fertility IQ. You may have thought it was my site if I sent you the link to your listing. It isn't. Though I sometimes wish it was, because much of the data that I aggregate manually, they will soon be able to export with the click of a button. Most doctors don't yet have enough reviews for meaningful comparison, but I see this site becoming very popular over the next six to twenty-four months. The user experience (UX) for patients is outstanding and the site validates patient authenticity. Both the qualitative and quantitative questions are more in-depth than any other channel. Above all, there is a market need for a uniform, clean, and extensive platform to compare fertility doctors and clinics, and I hope this is it. In the meantime, I manually scour reviews for data like a cyber caveman.

Fertility IQ's home page

Fertility IQ's home page

Of course, there are limits to ranking clinics by IVF success rates as well. Partly because the Society for Assisted Reproductive Technology (SART) appeals that success rates not be used to compare clinics. Consequently, they don't rank them in a spreadsheet that we can easily pull. So we use the site, fertilitysucceessrates.com. While Fertility Success Rates makes it easy to check the top 25 clinics in the United States, some clinics are missing from the site's overall listings, even though their data can be found in the annual CDC report. Despite the limits in our data, we continue to notice some interesting patterns. 

1). Do the same patterns apply to doctors with almost no negative reviews?

Yes...and no. I analyzed the first ten reviews of each of the top 25 rated reproductive endocrinologists. Of the 250 reviews

  • 164 explicitly referenced a baby or pregnancy
  • 70 contained neither a reference to a baby or pregnancy nor mention of lack of success
  • 1 mentioned a lack of IVF success
  • 10 described that they were still in treatment
  • 3 referenced treatment other than ART
  • 2 were negative reviews
Top 25 fertility doctor reviews mention pregnancy

So these doctors were actually even more likely to have their reviewers mention a baby or pregnancy than their colleagues at large, 66% compared with 60%. What's interesting is that their reviewers were also almost twice as likely to make no mention at all, 28% to 16%. The difference came from those who described still undergoing treatment; 14% for all positive fertility clinic reviews and only 4% for these top 25. Only 1% of these reviews were negative or explicitly referenced a lack of success in treatment. What could be the reason? We know these doctors don't enjoy IVF success rates of 99%. Let's come back to this after we investigate how clinical success rates impact online reputation.

2). Does an REI's rating correspond to his or her practice's success rates?

No. Watch as we take the top 25 ranked reproductive endocrinologists on RateMDs. Then we check them against the top 25 clinics from the 2013 SART reports. Do you have any guesses of how many doctors appeared in both spreadsheets?

Randle Corfman, MD of the Midwest Center for Reproductive Health was the only one. In other words, while success of ART treatment largely predicts how someone will leave a review, success rates do not directly correlate to a physician's online reputation. 

These are the highest rated reproductive endocrinologists on ratemds.com 

These are the highest rated reproductive endocrinologists on ratemds.com 

3). Do practices with higher success rates have higher online ratings?

Not by much. It should be stated that practice ratings can be even more difficult to garner than individual physician ratings. For those in the top 25 in success rates, I used the review site that offered the most ratings per clinic. If there were less than ten responses for a clinic on any one review site, I left their rating blank. In a rating scale of one to five, the ratings of 19 of the top 25 clinics in success rates ranged from 2 to 4.5. The mean rating was 3.7 and the median was 3.5. The median for fertility centers at large lies between 3 and 3.5. 

Top 25 U.S. fertility clinics by 2013 success rates

Top 25 U.S. fertility clinics by 2013 success rates

4). What is the correlation between the gender of the REI and his or her online rating?

The correlation (or lack thereof) of a physician's gender to fertility doctor reviews will be interesting to further explore.

  • Do patients have higher standards of judgement for one gender?
  • Does each gender tend to employ different communication styles that are more or less effective?
  • Do patient biases cause a message to be received differently from one gender than another?

This is what the current data show us:

  • Of the top 50 rated REIs on RateMDs, 22% are women and 78% are men.
  • Of the bottom 50 (of those with a minimum of ten reviews), exactly 50% are men and 50% are women. 
Top 50 rated fertility doctors in US
*Of those with ten reviews or more

*Of those with ten reviews or more

To try to offer some context, Valerie Baker, MD, President of the Society for Reproductive Endocrinology and Infertility (SREI), references a recent REI workforce study published by Fertility and Sterility. 38% of the respondents were female and 61% were male. 

5). What is the correlation between ratings and years in practice?

I often hear people say that new physicians coming out of residency and fellowship are more savvy of their online reputations than are veterans in the field. I don't know that we have a sufficient way of being able to validate or disprove this inference at this time. We would have to know the year that every REI completed her or his fellowship and their ages; data that isn't easy to find. I can only offer some marketing insight.

I see at least three doctors in the top 25 who I know are under age 40. Two of them are the top rated fertility doctors in metro areas of larger than six million people. Newer doctors can leverage a high online rating to negotiate a partnership plan with a recruiting practice because they can build their online reputation and social media loyalty to become the highest rated fertility doctor in their area before they even complete their fellowship. Conversely, recruiting clinics can look at a physician's online rating and social media presence to make more educated personnel decisions. 

Decoding the bigger picture

What lessons are we left with? No clinic and no physician can boast IVF success rates of 99% or anywhere close to it. Yet we count at least a few dozen doctors whose negative reviews are less than 1% of their online reputation. When we look even closer, we see that while success of individual ART treatments influences patient reviews, clinics' success rates don't necessarily predict their online ratings.

This shows us that we are not destined to have a third of our patients report dissatisfaction. As success rates majorly improve across the field, we see that patients still expect more from their care experience than just clinical treatment. Patients who haven't found success through ART may not leave rave reviews or promote their practice on social media and we can appreciate that. Still, if we can deliver to them a better experience than they ever would have had without us, they may not feel as though their only recourse is to express their disappointment online. Analyzing how fertility clinic ratings relate to ART success rates helps us understand exactly to what patients hold their fertility centers accountable.