How to Increase IVF Patient Retention an Interview with Dr. Alice Domar

Show Notes: In this episode, Griffin talks to Dr. Alice Domar, a psychologist and the co-creator or Ferticalm and Fertistrong apps. After many studies, Dr. Domar concluded that the infertility practices needed to become more patient centered care in order to reduce the dropout rates of those patients who have insurance. The number one reason for infertility patient dropout is stress. Reducing that stress can help patients to stay in treatment and then in turn help practices to keep business up.

Some stats:

13% of patients drop out because physician recommended it.
50% drop out because of emotional burden

Of those who drop out:
40% said it was too stressful
25% said they couldn’t afford the out of pocket cost,
25% said they lost insurance coverage
24% said they conceived spontaneously

Of those that said stress was the reason they dropped out, the top sources of stress were:
65% already having given IVF their best chance
48% feeling too stressed to continue
36% said infertility was taking too much of a toll on their relationship

Griffin: Today I’m with Dr. Alice Domar, PhD, who is the executive director of Mars center, for the mind body health center, and the director of mind body services at Boston IVF. She established the very first ever mind body center for women’s health. She has been a guest on Dateline, CNN, PBS, CBS, Good Morning America, among many others. She is a board member of a number of organizations, including but not limited to, Resolve- the national infertility association, and she has helped launch the apps Ferticalm and Fertistrong. Dr. Alice Domar- Ali- Welcome to the program

Domar: Thanks Griffin, nice to be here.

Griffin: I brought you on for the specific purpose because you and I have been on the circuit for the last few years speaking at conferences, and very often I’m talking about how to get patients and you’re talking about how to keep them. You’ve done a lot of research and even though i’ve heard you speak probably six or seven times, I often find some of the research to be surprising to me or counterintuitive, and nobody knows it better than you, so today i want to talk about drop out, about patient retention, about training for providers and staff and the reasons why patients drop out and what we can do to keep them.

Domar: Yup, that’s been my research focus for about four years now.

Griffin: How did you start with that? If I’m looking at things purely from a business perspective I would interested in that, because there’s a case for bringing people in the door and then you want to make sure that they stay. Also from the standpoint of producing the best treatment and help people if you can’t help them.

Domar: I think the first time I became aware of the epidemic of dropouts in our patient population, was actually Fertility and Sterility came to me in 2004 and they were about to publish four studies out of Europe, all of which looked at reasons for insured patients to drop out. They asked me to read all four and write an editorial. That was actually the first time the issue came to my attention. Until 2004 i assumed what everyone else assumed, there are only three reasons patients drop out of treatment- number one is pregnancy which is a very good reason, number two is because the physician said, your prognosis is too poor, you need to consider donor egg, donor sperm, whatever, but i’m not going to have you go through another cycle using your eggs or your partner’s sperm. So that’s physician censoring. The third reason is money. Much more common in the US because much more patients in Europe have coverage, but there are patients who run out of coverage too. So everybody assumed and wrote about those three reasons for drop out.

However, what all four studies that came out in 2004 showed, in fact patients who don’t have insurance the number one reason they drop out is money. There are patients who have the means and keep recycling, but patients who can’t afford it either don’t start treatment or drop out and there’s not a whole lot you can do from a psychological perspective. What was really shocking about all these studies was how incredibly rare it was for patients to drop out because of physician censoring. On average only about 13% of patients drop out because physician recommended it. The number one reason of all four studies was stress. It is now called the emotional burden of care. Patients very consistently reported that stress was the number one reason why they dropped out.

Griffin: So physician censoring is about 13% and that’s lower, what is the emotional burden of care registering at?

Domar: I think for most of the studies it was about 50%. It was far far higher than the physician censoring.

Griffin: is emotional burden divided into subsegments at all? Like depression or anxiety or stress between partners?

Domar: in those early days, no. They gave you a list, and it was really the burden of care that was the answer. I then did a small study after that because I was curious to see if i would find the same result in the US. We did a small study where we followed patients at Boston IVF who dropped out, who did have insurance, and once again, the number one reason for dropout was stress. We asked a little bit about the stress but it wasn’t that detailed. So fast forward, it was about four years ago, I had been spending most of my career looking at the impact of psychological interventions on distress and pregnancy rates, and about four years ago, a meta analysis out of Europe came out that once and for all proved that psychological interventions decreased the stress and improved pregnancy rates. I thought okay, now there is a meta analysis, I don’t need to spend my time clinically doing this. So four years ago I focused all my research on dropout rates. Because Boston IVF is so huge we actually started to look at our database. So we did a study of about 11,000-12,000 patients, who had cycled at Boston IVF, it was published last June, and we found once again, the number one reason was stress. We did break it down, and I believe a big component was the impact of the treatment on their relationship.

Griffin: Treatment of their relationship with staff, with providers…?

Domar: No, the impact of the treatment between the partners, within their marriage. In that study, we had a large number of patients, we were able to come up with more definitive information. What was surprising to me was, yes burden of care, stress was number one, but what was really surprising to me was, at Boston IVF we have a mandate where six IVF cycles are covered for most people. And we only looked at people who have insurance coverage, but a relatively close second reason for dropouts was the copays. Someone from CA or NY who is paying $15-20,000 for a cycle is going to laugh at someone from MA, who is paying maybe 20% copays or paying for their medication, but it was still a big factor. Not as big as stress, but it was still a factor.

Griffin: this might be a rabbit hole, but is there a psychological factor of some in there. To your point in other states its much higher, maybe it's not equally as high but if it’s still significantly high in mandated states, simply the sump cost, of feeling like this is not going to work out or hasn’t worked out, it's good money after bad, do you have a way of anecdotally hypothesizing on that.

Domar: I think what’s interesting in MA, because we have this mandate, people have an expectation that their cycle will be fully covered. I know if you look at the Mind Body program I run, I’ve taught people all over the world, how to run the mind body program. At Boston IVF, because of all sorts of bizarre insurance things, patients have to self pay for the Mind Body program. So Boston IVF has made the decision to make it almost like a loss leader because it provides so much to patients. The program is $495 which is not a huge amount of money. Now I taught someone in CA how to run the program, and they charge $2,000 for the program and they have an even busier time filling their groups than we do. Because I think it California people think, okay, its $15,000 for an IVF cycle what’s another $2,000 for the mind body program, verses in MA there’s this expectation that everything will be covered and I can’t possibly pay $500 for the program. So some of it is psychological, or that it’s simply because of the mandate and people of all socioeconomic backgrounds are able to do IVF so $500 for some people is a massive amount of money and they just can’t do it. Perhaps that’s why copays are such an issue here. It really is stress though and I think every study I know of that has looked at the dropout rates of insured patients, emotional stress is consistently number one.

Griffin: So when we say dropout rates from either the Boston study or the European study, are we talking about people that have discontinued with that provider, is there any follow up to see if they went to a different provider? Because I wonder what that percentage of people was?

Domar: In Europe because there is national health care, it doesn’t matter what provider you see, they know whether or not you’re doing another treatment cycle. At Boston IVF we actually did this by hand. When a patient seeks to move to a different clinic, they ask for their medical records. So we know whether or not they are seeking at a different provider. Plus with the last study we did in June, we actually asked them if they switched clinics. We only looked at patients who were pure dropouts.

Griffin: What are benchmarks for some clinics though? The number of people who are dropping out of treatment that don’t necessarily need to be?

Domar: What’s really sad is most clinics don’t track it. You know how you mention that clinics spend so much money to get a patient to walk in the door?

Griffin: They don’t track that either by the way, which drives me crazy.

Domar: Well, I can tell you that most clinics in this country have a significant marketing budget, they often have sales reps, they create relationships with referring OB GYNs and primary care physicians and it costs a lot of money to bring the patients in the door, and that first visit and work up is very labor intensive. Once the patient’s in the system, it doesn’t cost very much to do each IVF cycle. Once they are started it doesn’t cost very much to keep them, to go through the cycle each time. So you’d think, that clinics would be incredibly motivated that once a patient sees a physician, to keep that patient as a patient, through their treatment cycles. And yet I think there is very little effort throughout the world to keep patients in treatment. This whole new concept is called patient centered care, and it sort of started in Europe and I can describe all the research on patient centered care, but i think the problem is we don’t really know what patient centered care is in our patient population.

Griffin: When you say you don’t really know what patient centered care is within our patient population, what do you mean?

Domar: So basically we ended up with 893 insured patients who did one IVF cycle and did not return for treatment for at least one year and they didn’t achieve a live birth. 2/3rds of them did not seek care elsewhere. When we asked them why they dropped out, 40% said it was too stressful. 25% said they couldn’t afford the out of pocket cost, 25% said they lost insurance coverage, and 24% said they conceived spontaneously. Of those that said stress was the reason they dropped out, the top sources of stress were already having given IVF their best chance at 65%, feeling too stressed to continue 48%, and 36% said infertility was taking too much of a toll on their relationship. We then asked them, what could we have done to make your experience better, what could we have done better to keep you in treatment, and the most common suggestion were to offer evening and weekend office hours and to give easy access to a mental health professional.

Griffin: To clarify then, when we talk about dropout rate, we talk about people who have had an IVF cycle. We’re not even talking about people who have come in for a consult and never pursued the prognosis.

Domar: Right, these are pure IVF patients. I believe a study out of Europe came out recently that showed that 2/3rds of insured patients who have come in for an initial consult dropout before their first IVF cycle. So most of the dropouts happen before their first IVF cycle. So that’s in fact where the hemorrhage starts. It is getting them from their first visit to their first IVF cycle.

Griffin: That’s a huge hemorrhage in and of itself.

Domar: One thing we looked at at Boston IVF is how many patients come for the first consult and don’t come back. I believe the results were about 23 or 24 percent. So that’s a huge hit. That’s much higher than the European data. Only 6% dropped after the first visit.

Griffin: A Lot of this is when in your talks, people are surprised to hear that emotional burden of care is much more prevalent of a reason than cost and other reasons.

Domar: No, no, we’re only talking about insured patients. For uninsured patients, cost is the number one reason.

Griffin: Okay, that’s a good clarification. What has surprised me the most in your talks is the success or the lack thereof of different interventions. So talk to me about the different interventions that you’ve tested.

Domar: You want to hear something really shocking? As far as I can tell, there has only been one study to look at an intervention to decrease dropout rates and I did that study. Two different schools of thought, I can tell you what they are doing in Europe and I can tell you what our study showed. Starting with Europe- they have done a lot of work trying to identify this whole concept of patient centered care, there are a lot of studies across the continent trying to figure out what patient centered care is. So this is the story that i’ve followed, so they’ve done multi country studies, and what is really interesting, very close to 100% consistency in terms of what they want for patient centered care. The things they say they want don’t make sense. Of the top five one of them was more information about the semen analysis, more information on the impact of BMI on outcome. None of which makes sense to me as a psychologist. So what they did in these studies, they identified five factors that these patients said they wanted changed to be more patient centered. Then they did a couple of randomized controlled trials where they made those changes in half the clinics and didn’t in the other half and there were no difference. So what patients say they want doesn’t necessarily translate into better care.

The only study I have been able to find which dramatically changed patient perception of care, was a study done out of Spain. What they did was published in 2013 in FNS. What they did was an overview of 2000 patients about their perception of care, it was right after my first visit, and then they took their 13 physicians and make the go to a weekend retreat to train them in an empathic skills communication. I’m bedazzled by that. Anyone who can convince 13 physicians to spend a weekend learning empathy skills communication, that’s a really good center. After the training they then reassessed patient’s perception of care and patient perception of care skyrocketed. So much so that now at the clinics, every employee from receptionist, all the way to physicians gets trained in empathic communication skills. I have now been trained as someone who teaches empathy skills communications, but as far as I know there is no clinic in the US that has actually decided to train anyone formally in empathic skills communication. I do think that teaching healthcare professionals in our field in empathic skills communication would be a huge key to unlock the perception that we can’t change patient centered care. I think we do need to train them formerly in how to provide empathetic care.

Griffin: What does the training entail?

Domar: The company that I worked with is called by Empathetics, and is based out of Mass General and is actually based on randomized controlled trials with physicians, and they’ve really streamlined it. So with physicians they need to do three one-hour online trainings where they get CME’s and then one hour of live training with me. For nurses it's a one one-hour video and one-hour live training, but no one as far as I know has decided to do this. It's a relatively small investment financially, in our experience its very reasonably priced, but the downside is the training that they offer is not REI specific. It's just general physician skills. I’ve done the training on both, and its how to tell a cancer patient a bad prognosis, how to tell a diabetes patient how to be compliant. It's tough to get REIs to watch these kinds of videos. But a live training would be tailored just specifically to REI situations.

Griffin: I can speak to how important this is because our company handles reputation management for a lot of clinics and i've also done a lot of research, and I’ve gone through thousands of reviews in my analysis over the years, and the way it comes out is so clear, the patient’s reward in empathic communication, and the way they perceive it as not being empathetic it can really take a turn that ends up being a PR headache or a series of negative reviews that really upset physicians.

Oftentimes I’ve written about the triggers that people say back to them, one thing that i could imagine would be beneficial for empathetic training would be talking about prognosis for how you’re going to lower BMI before moving on to another prognosis. We can perceive that as “he called me fat” he told me i was too fat to ever get pregnant and that’s how it's related online. Or if it’s about advanced maternal age or ovarian reserve, he told me i was too old, so what’s this like when you pitch this idea of empathic skills?

Domar: I think there needs to be an RCT looking at the impact of training physicians and nurses in empathic skills communication, not just looking at the impact on patient perception of care, but looking at the impact on dropout rates. I think if you could do such an RCT showing that the training directly translates into lower dropout rates, you would have very valuable product.

Griffin: To begin with that, you would first need to know how many patients are dropping out in order to be able to make that decision about return on investment and justify that decision based on return on investment measure at the very least, as you mention, we don’t have that in place. They may think that they have a handle on dropout rates, they may say it’s about this much, but to your point when you ask them can I look at the data, they don’t have that.

Domar: When I got that first study funded, i wanted to just look at our dropout rates and see why, and it was funded by MERC, and I remember the day i found out i got the grant we had a physician dinner and one of the physicians said to me what’s new and I told him about the study and the physicians answer was our patients don’t drop out of treatment, i see patients all day, they don’t drop out. My answer was, because you don’t notice. The patients that you remember are the ones you keep on seeing. The patients who drop out, you don’t notice it. And so we have to start noticing it. Certainly Boston IVF and a lot of the big clinics are tracking dropout rates pretty carefully, and now we are doing lots of patient surveys and every month I get a printout of all the comments patients make. Last year I did a TED variation talk on Halloween and I talked about patient dropout rates and how to retain patients and how its not pregnancy rates.

Studies show that patients prioritize patient centered care over pregnancy rates. Do physicians think that patients prioritize pregnancy rates, they don’t. I gave this TED like talk and was reducing all this data, and I was like we need to start paying attention to patients that are dropping out so for this talk i looked at the top ten biggest clinics in the US. I looked at online patient comments, and they were frightening, for everyone. So in my TED talk I did a slide with examples of all of these comments and almost all of them came down to communication issues with the patients and nurses and physicians and the patients just don’t feel that they are being cared for or being heard.

Griffin: We talked about a similar overlap with Rebecca Flick on an earlier episode which is, at some point the digital technology which used to be marketing sort of overlaps with this and as we move into getting everything else instantly…. Something of 90% of people open a text within 10 minutes, contrast that with what clinics are able to provide and how quickly they are able to get information, that ultimately affects patient centered care.

Domar: I’ve been doing talks all over the country for the last five or six years and I have been giving a talk about the importance of empathic skills communications and now i’m doing a talk on patient centered care. One of the issues i’ve been talking about that nurses have been reporting to me is that millennials expect to get information instantly. And so you hear constantly well i called the nurse at 9:05 and now it’s 9:20 and no one has called me back. Or i’ve had my blood drawn at 7:30 and by 9:00 no one has called with my results.

Griffin: we got these on social media, we’ll get a Facebook message and I’ve called and a Instagram message saying I just Facebooked you guys…

Domar: It’s the instant thing. The one RCT that looked at dropout rates, so we got another study funded from MERC to look at can a psychological intervention change dropout rates. We recruited 160 women who were about to do their first IVF cycle who had insurance at Boston IVF and we randomized them. Half of them got routine care, and the other half we mailed them a packet. In this packet were two different forms of intervention, one was a cognitive coping sheet. Here are things you can do when you go to the waiting room to distract yourself. Or these are things you can do when waiting for test results. We had one series of suggestions for the stimulation phase and one series of suggestions for the waiting phase. We also had relaxation strategies, for the stimulation phase the instructions on how they could do mini relaxation exercises. They could use before a blood test or an injection.

For the waiting phase, included in the packet was a CD that had my voice leading them in several different forms of relaxation techniques. So all we did with the 75-80 intervention patients, we mailed them a packet. We don’t know if they used the packet, we just mailed it to them. Then we followed them for a year. What we found was the patients who got the packet, we don’t know if they used it, but their depression and anxiety scores were significantly lower than the control group. The control group had a 15% dropout rate, the intervention group had a 5% dropout rate.

Griffin: So three times as many.

Domar: So we reduced the dropout rate by 67%. We published this study in FNS and one clinic asked us how we could get that packet. When I presented this to the business managers, at the break pretty much everybody gave me their card and said how can I get the info on this packet. It’s crazy. If i stood up and said this drug that costs $12 is going to reduce your dropout rate 67% don’t you think they all would have said “where can I get this drug?” the packet cost us $12 to make.

Griffin: Is that packet the CD, the mailing out, and presumably the difficutling of that being adopted, is that the genesis of the apps you made?

Domar: Yes, that’s exactly right. I consider that packet to be a very small intervention. There was some cognitive coping methods, but millenials don’t like to read stuff, they like to look at stuff on their phone. Soon after the results came out, a psychologist at Cornell said everyone of my patients want something on an app that’s directed to infertility patients. Everything out there is general and have nothing to do with infertility. We sketched out Ferticalm on a napkin. Ferticalm has 100 times more power and information than the packet did.

Griffin: What was it like working with developers? Was that your first time working with software developers?

Domar: It’s really funny, 8 years someone wrote an article in the Atlantic Monthly and the title of the article was “Women Can’t Have It All.” Liz and I, she’s my business wife, we want to write the Atlantic Monthly about what it was like for the two of us to start a business together, two psychologists who have no technical background, no business background, no legal background, both clinicians, both mothers, both pet owners. We have so many insane stories. One night we had a conference call, and it happened to be a night when my daughter had to make hammantoshin to bring to school. Literally with my phone next to me on this conference call on the creation of the first app while my daughter and i made 266 hamantoshin, like little pastries. We had some help at the beginning, Jake Anderson and Deborah Bealis, who founded Fertility IQ, I’ve been friends with them for awhile. They had given us some ideas on how to talk to developers. One of our physicians, Steve Bayer, he knew of a startup in Boston that did app creation, they were the ones we went with and it was, if we talk about steep learning curve, this was Mount Everest, it was crazy that Liz and I are therapists and we had to write the content that would create an app. We lucked out along the way, we had this amazing developer, we found this incredible designer, we learned everything the hard way.

Griffin: It’s the only way to do it! I think that’s really incredible. It’s something that providers, practices, admin, nurses, can direct their patients to.

Domar: Both apps are free, throughout America and Canada, and it’s about to launch in Latin America, it’s available in both English and Spanish. It’s interesting because, Ferticalm has been very well received. I talked to my patient last week and suggested she download it and she came in yesterday and said oh my gosh, i’m just using it all the time. I remember last year there was a presentation, and I was asked to give a talk about psychological interventions for infertility patients, and i decided that it would be improper for me to mention ferticalm. I thought it would be obnoxious for me to mention it. I’m in my talk, there are maybe 60-80 physicians there, and i’m talking about all the interventions, in the middle of my talk, one of them stood up and interrupted me, and said, you are doing the audience a disservice, have you ever heard of this app, Ferticalm? And I’m like, yeah, i have. She said it's incredible, I have all my patients download it, and she later told me that whenever she has to do anything painful she meets the patient, has them download it on their phone, listen to one of the relaxations and then she does the procedure, and its made a huge difference for her because the patient has less pain.

Griffin: that is the perfect application for it too.

Domar: it is but it’s also, for my patients, what do you do if it’s 11 pm and you’ve just done your first IVF cycle, and its day 27 and you start bleeding. You know, you’re freaking out of your mind, can’t call your doctor, your partner doesn’t get why you’re upset, and you go to Ferticalm and you find that exact situation, and there are six cognitive behavioral relaxation techniques to calm you down in the moment. I don’t get paid for downloads, so I can talk about it. It's something that patients can use and its the only thing out there. Liz and I came up with 50 different situations that could come up and what they need in that moment to feel better.

Griffin: And anybody who has ever looked at the trying to conceive hashtag on Instagram knows that people are begging for these answers and that application is really contemporary way of being able to meet people where they are at. One big question that I have that I feel practice owners should know is because whether they agree with us or not, you and i both agree that they are not tracking dropout numbers.

Domar: Some clinics are, I know Boston IVF tracks it, I know a number of large centers are tracking dropout rates.

Griffin: But many aren’t, so those that aren’t, how do they start? How do they implement the system?

Domar: Pretty much everyone these days does EMR, and you can look at return rates. We have been doing options of this research so for example, our scientific director, came to me about two years ago and said to me, what's the relationship between age and dropout rates? I said women over 40 have the highest dropout rates. That makes sense because their prognosis is the worst, but does that mean women in their 20’s have the lowest dropout rates? I said no one has ever studied that. We went and did a study and looked at dropout rates of women in their 20’s, 30’s, and 40’s. And we published that.

What we found was not to our surprise, that women in their 40’s had the highest dropout rates, but women in their 20’s had the same rate of dropout as women up through age 39. So a 26 year old who has a phenomenal prognosis has the same dropout rate as a 38 year old, and it doesn’t make sense. I don’t know why these young women dropout. It might be because they figure they can dropout for a few years and get psychologically stronger, and come back, or it might be that because they are so young they just don’t have the coping skills. They just don’t know how to handle these negative cycles. Or it could be the physician and nurses haven’t adequately communicated to them how good their prognosis is. Whatever the reason we need to educate our younger patients in a very different way. We need to support them more and we need to make sure they know their prognosis. A 26 year old should not dropout of treatment.

Griffin: A good place to start to get the hard numbers of what it is in your practice would be the EMR.

Domar: Yeah!

Griffin: Dr. Alice Domar, it has been a pleasure having you on our inside reproductive health, is there anything you want to share with the audience that i didn’t ask you before i let you go

Domar: I feel that if we can figure out the best way to keep patients in treatment, it's a win win. I’m a psychologist, so i don’t make money keeping patients in treatment, but for me it's all about if patients stay in treatment they are much more likely to get pregnant and have a baby. That’s what we want for all our patients, to get pregnant and have a baby. I think for clinics it's about patients staying in treatment so they make more money, and so it's a win win for everyone. If patients stay in treatment they are far more likely to get pregnant and have a baby, which makes the patient happy, and along the way it makes the clinic happy as well.

Griffin: Ali, thanks so much for coming on the show, I loved talking to you.

Is reproductive health a field or an industry?

Show Notes: In this episode, Griffin talks to Rebecca Flick, Vice Presidents of Communications and Programs for Resolve, the national infertility association (http://resolve.org/). They discuss how the treatment of IVF and infertility as an industry has hurt patient advocacy and the ability to give access to people who may not have the insurance or out of pocket ability to go through infertility treatments. Rebecca explains how they are trying to change the internal viewing of fertility treatments by lawmakers and employers as a optional medical practice to one that anyone should be able to have access to. Griffin and Rebecca then continue to speak about how being a part of Resolve not only allows businesses to further influence the fertility community, but to give back to it as well. Also mentioned: http://fertilitymatters.ca/

Griffin: Today i’m here with Rebecca Flick, who is the vice president of communications and programs for Resolve, the national infertility association. Rebecca joined Resolve in 2005. Her main responsibilities include creating and implementing Resolve’s communication plans and overseeing some signature events like National Infertility Awareness Week and Night of Hope, their online strategies, as well as increasing the infertility community’s engagement in Resolve’s volunteer advocacy and fundraising activities. Rebecca has walked the walk; she was diagnosed with infertility in 2006, has been through the rigamorol, as we’ll talk today, she lives in Virginia with her husband, son, and daughter. Rebecca Flick, welcome to the program.

Flick: Thank you for having me.

Griffin: This is pretty cool because you and I have been friends for a few years. I’ve always used you as a sounding board for patient advocacy, patient relations, and just getting to the heart of what we should be keeping in mind when we’re communicating with patients, when we’re providing services, and I want to explore that today.

Flick: Well, I appreciate the opportunity. I probably have a lot to say.

Griffin: Well, let’s prove it.

Flick: Okay!

Griffin: I wanted to start off with is that you never liked the field being called an industry. You never liked assisted reproductive technologies being referred to as an industry and I wanted to start with that sentiment from you and see what that means.

Flick: Sure, so I want to give this some context, I think when i hear the term industry being used around infertility or IVF, it's usually in headlines, like “The IVF industry, or infertility industry set to reach billions this year” and I think when we hear the word industry as it relates to a field of medicine, it commercializes it. And that makes it harder for a group like Resolve, if that term is used over and over and over again, it makes it harder sometimes for us to advocate for increased access. So if a legislator, or law maker, or media person, if they internally feel like “this industry” if its an industry its commercialized, therefore there are big profits and all these people are making all this money off of these people who are just trying to have a family. It makes it harder for out point of view to get the message across that people who struggle to have a family deserve access to safe medical treatments. And that’s why sometimes with you I get on my soapbox about the word industry. Purely from an advocacy and awareness point of view.

Griffin: That makes sense. There's a couple points that I wrote down that we can hit. Who’s it coming from? Because it sounds like from what you just said, it's coming from just other people covering it. Like the newspapers or social media. Do you feel like it's also coming from within the field?

Flick: Well, sure, I mean there's different segments of the infertility community that are industry. I mean pharmaceuticals are industry, it doesn’t matter if its pharmaceuticals for diabetes or cancer or infertility. Pharmaceuticals are an industry. You know, so people internally might use the word industry. And again, Resolve is not here to say, no one can use that term. Ban it from your vocabulary, but the reason why Resolve chooses not to is because words matter, and that’s why you’ll hear myself or Resolve’s President and CEO Barb Clora, if she’s doing media interviews, she’s not referring to it as an industry.

Griffin:That totally makes sense from Resolve’s positioning, when you say that the word commercializes it. Is there any way of avoiding that? That’s the rabbit hole we’ll probably delve more into in this conversation. Is that, at the end of the day this is so difficult in the terms of science and technology, it’s so expensive, in terms of the advances, is there any way of this just not being commercialized? I always wonder, is it just semantics to say we’re not a business, we’re not industry, we don’t refer to people as customers, we’ll talk more about that. Does it end up being semantics if at the end of the day given the supply and demand of what’s going on, there are people that are exchanging products and services for money?

Flick: Correct, and I’m not a business person per say. It's not my 20 plus years, it's been in nonprofits and advocacy work, so the definition of business, yes you’re going to make a profit, there’s going to be a transaction involved, but in the US as a whole, you know, especially something as delicate as infertility treatments, commercialization of those treatments can often become dangerous for patients who are trying to access them. The haves and the have nots. And so I think I’m not a practice manager. Resolve is not in the business of telling practices how to run their businesses, and so we are just focused on awareness and advocacy, and that’s what our lense is. We know that constant reminders to influencers out there, who are influencing people’s access to medical treatments, if they perceive it as an industry, and commercialization and billions and billions of dollars, and all these people are getting rich off of infertility, then that’s not good for our cause. So I would hope that as a community we could together recognize what it is. It is very complex, and I know we are going to talk about patients verses customers, but its complex and it is made up of lots of different people seeking lots of different services.

Griffin: Do you feel like that lense of being referred to as an industry is more commonly applied to the fertility field as opposed to healthcare at large, or other segments of healthcare? Like oncology or pediatrics..?

Flick: Yeah, so often we say you never hear people use the term, “cancer industry,” so I kind of say that a little flippantly without much backing to it, so I Googled “cancer industry” and I Googled “infertility industry” and I Googled “diabetes industry,” and when you look at the searches under those terms, it all has not a positive connotation, it is all about the money and how these industries aren’t serving the patient, and so that’s another reason why I would say we would want to stay away from that in our field of medicine. It is very complex, it comes with a lot of opinions from the outside world, whether its religious or financial or spiritual, there are a lot of people who don’t agree with reproductive medicine. So let’s not keep piling on by commercializing it and calling it an industry.

Griffin: I’m forming this opinion right now, so, audience and Rebecca bear with me, this is coming into Griff’s mind, right, but based on things you’ve said, the main concern for Resolve for patient advocacy is that it makes it a lot more difficult to advocate for patients if they are viewed as a commercial interest, or if the field is referred to as an industry. And just from my end, I’ve felt like its harder for me to advocate for patients when practices or providers or I suppose, other people in industry, don’t consider themselves a business, don’t consider the patients as customers, because I often feel like, providers especially know what you’re saying, and agree, and don’t want to refer to their practices as a business, they don’t want to refer to patients as a customer, but at the end of the day, they still are. That practice still has to pay the bills, they have salary, they have profits, they have expenses, and so there's this inherent drive to increase profit, minimize expenses, or at the very least, sustain the business amid competition, but there isn’t often a willingness to say this is the amount of profit we want to generate or this is the business goal that we have and subsequently this is how we are going to serve our customers in order to get there. Does that make sense?

Flick: Sure, and you know I said before, I’m not a practice manager, so I would hope that from a patient advocacy point of view, practices were looking at their patients holistically and from a medical intervention point of view. They are there to treat the patient, treat the disease, or condition that has lead them into their offices, but from a business point of view, I would imagine they would want to follow best practices in treating someone like a customer, in hopes that the treatment works, or that they return or that they recommend their practice to someone else. So I’m sure from a business point of view there are people that need to guide this field of medicine from a consumer driven point of view. You know there is research that shows that people don’t access medical treatment out of fear or out of access. So either they are afraid of what is going to happen, or what is going to happen to them, or they don’t have access to insurance coverage or don’t have access to pay out of pocket. So those are two big barriers right then and there that a medical practice for someone with infertility needs to overcome, for their patient. So I’m sure that’s very customer- and business-driven for the things that they need to do to get those people in the door. I still think that best practices in a business setting can happen, while they are looking at the patient as a customer from the moment they walk into the door to the moment that they leave, but as a whole you’re still providing someone with medical care. From Resolve’s point of view, we want to make sure patients have access to safe and sound medical interventions. That's why it makes it harder if fertility is viewed as this massive industry that just cares about the bottom line. You know and I know that the people who are working in this field of medicine are some of the most compassionate people that we’ve ever come across, we don’t want to continue to hurt any reputation.

Griffin: By the way, to me that also includes some of the people who also work for some of these very large networks that are partly owned by private equity firms. I know it's pretty fashionable to just take a dig and say that some of those folks are just in it for the money, but we know a lot of those folks and some of them are 100% about the patient as though they worked for a health system or university or private practice or anyone else.

Flick: I think one of the leaders in this fields, a former doctor, David Sabel, he writes a great blog on Forbes.com. And he uses the word industry, I was reading something before we talked, and he uses the word industry, and I don’t think it's necessarily in a negative way, but he gives a really great perspective on the business side for this medical intervention and this healthcare field of medicine, so I would encourage listeners to read up on him. But he also gives a very compassionate plea for access, so he’s very much an advocate, and I should mention he’s a former Resolve board member, just for full disclosure, it’s not an endorsement by Resolve, but it is a recommendation of a great read.

Griffin: Is it fair to recap this in saying that people have a certain set of rights as patients, and a certain set of privileges as customers?

Flick: No, that’s interesting, because I think when you sent me the question in wasn’t necessarily phrased that way, but when you repeat it that way, it's actually pretty impactful. I’m going to sound like a broken record, but as a patient you’re entitled to safe and available medical treatment and as a customer especially one that is paying out of pocket for this medical treatment, there is certainly an expectation of being treated well, customer service, but it's a medical treatment so the outcome is up to so many factors.

I think something that is always a disservice to patients that are seeking medical intervention for fertility or those who have struggled to build a family for other reasons, everyone is always sort of afraid to admit that this is a course of treatment. If you were facing cancer, the oncologist would never say come in for chemo once, we’ll see how it goes and move on. There is an expectation there that you’re going to be facing a course of treatment. I think this field of medicine would help a lot patients understand, and erase the fear of failure, right out of the gate, if we approach this as a course of treatment. Again, if you’re a cash paying patient, that could set up for another of other fears and barriers. Again, I think that’s where that commercialization industry crosses over with medical care when people are so often paying out of pocket.

Griffin: And after time, it's difficult to decipher what’s the customer privileges, or what’s the patient rights, as technology and service and best practice just become part of the standard of care. For example, having a patient portal in 1995 isn’t a part of the standard of care. But in 2019, go online and view your protocol, it is. So there is this standard that just sort of raises. I bring this up because it's important to recognize in our field too.

Standard of just about everything, raises in almost every segment, whether its education or healthcare or commerce, because you can think of examples about everything. What was a school 100 years ago would not pass for a school in the 1950’s which didn’t have the smart chalk boards and the computers and the technological infrastructure that is has today. And what might have passed for a hotel 50 years ago, just drive into the motel and you’ve got a fan and theres a tv with three channels would not get you beyond a 1 star yelp rating.

Flick: Our expectations are higher and higher.

Griffin: And those expectations, even if they are driven by the consumer world, their ways into the field and ultimately affect the expectation for the standard of care. And especially because what we deal with at our company very often has to do with digital media, social media, that in the beginning that was just sort of marketing, that was just marketing on Facebook, but eventually Facebook Messenger just becomes the way people want to communicate. And in 2012 that was a nicety, but in 2023 that might be requisite. That if you’re not able to communicate in certain channels then you’re simply not participating in the process.

Flick: Yeah, and I think, patients need to understand too, every generation is more informed than the next. I went through treatment in 2006-2007, and it is so different then than it is today. And there is a constant…

Griffin: If i can give a thought, what are a couple of examples, can you think of any off the top of your head that treatment has changed so much since 2006?

Flick: Single embryo transfer, frozen embryo transfers have shown to be much more successful over the years, understanding trying to decrease multiples, education around dispensing your meds, the biggest I think is single embryo transfers. Now there is PGD, the big thing when I went through was ECKSY, that was the latest thing, and now it is not as talked about as much as it was back then. It's only been a decade. There are always people trying to make the science better, and i think patients need to, if they want to be good patients and good customers, that they should be informed, but also make sure that they have the information that they need from their practice to feel comfortable. Knowing how much time they need to take off of work, knowing where they can go for answers if it is 10 o’clock at night and they forget how to administer their medications. I think a lot of people go to the internet for those kinds of things and that information isn’t always the best. While patients are more informed now than ever, you also have to vet the quality of information that you are getting online. Know that if you’ve chosen the right practice and feel comfortable, you’re going to get the best information from them, in my point of view.

Griffin: It is definitely, I don’t want to call that a millennial habit either, but there is, I guess a behavior that is more prevalent among millenials and just aging up, which is the information ceiling is just higher and higher. Meaning, if I read this about single embryo transfer, I want to read every possible link if that is what my mind is occupied on right now. Because many of the people going through this are in a very stressful position where they are sometimes thinking singularly about one thing, that ceiling is very high, sometimes on a pretty narrow function of topics, and practices have a really hard time of meeting that information demand.

Flick: And you also don’t have probably a ton of time when you’re going through the process to ask a lot of questions. So always make sure, we’re kind of getting into more advice now, but always make sure you have your list of questions. But in terms of trusting information you find online, you know, just trusted resources are really important. If it is medical advice make sure it’s from a respected, accredited nonprofit, written by a medical expert. Obviously Resolve was founded on support, and we host a variety of free support groups across the country, and peer to peer support is really important and you’ll go to those people for information but backing it up with your own research is really important as well.

Griffin: Speaking of that, let me use this opportunity to give Resolve plug, I won’t ask you to, I will do it. I’m not doing it for Resolve, I’m actually not even doing it for the patients in this particular context. In this particular context, I’m doing it for the practices and I think this blends perfectly with how investing further into this standard of care benefits the business end and vice versa. Every single practice in the United States, every single REI practice, should be a professional member of Resolve. It’s cheap, it's too cheap in my opinion, I keep saying you should up your prices.

What if there are other clinics that are sponsors of Resolve, what are they getting for that? That’s to the value exchange. The value exchange is that there is a community of people of whom Resolve has already become a leader, information and support that they provide to those people, so the community is assembled, and then as an REI practice and IVF center, you have the opportunity to serve that community, because they’ve already gathered some of it together in your area, and you have the opportunity to associate your name with the brand of the community that they have built.

But by serving the community you increase your own leverage in the community. It's why I wrote a book called “The Ultimate Guide to Fertility Marketing” its 60 pages of free information for people. It's why I have a podcast called Inside Reproductive Healthy. It's why I have blogs based on insider knowledge from the field and inside perspectives. Its because by serving any community you increase your own social leverage in the community. I think that is one of the clearest ways I can illustrate that if you’re thinking of yourself as a business in a good way, if you’re just realizing this is what I’m out to do, then you reverse engineer how do I get there, and one of the ways you get there is by super serving the community. That’s a pretty straightforward way of doing it.

Flick: I know you didn’t want to make me give the plug, but I will definitely give a plug for Resolve and I think that when practices and businesses that serve, because we didn’t even touch on people that are trying to adopt, we would never call adoption an industry. That would also commercialize it in a way that is illegal. That's a whole other discussion for adoption experts, but Resolve’s community is so much more than the people going through medical treatment. They might start there or they might end there, or they might never get there, but they are using gestational carriers and they are adopting and they are using all sorts of services to help them through this.

If you want to set us apart in this community and not be focused on the industry, the best way that you can help do that is support the charities and the nonprofits in this space who are working to improve access and providing support. That is something we can all do together and flip the thought that we are this big bad multi billion dollar industry on its head, with how much the field gives back to nonprofits in this space, and not just Resolve, there are many.

Griffin: I think in any given field there is always examples of people who are going to do well, and then there are people who might do that that doesn’t really serve anyone but themselves. Probably the way i would wrap this all up is that there is tremendous business value in serving whichever population that you serve, but serving them as a community and I think that the competition of business can increase that, can increase the standard of care that way. Competitors are raising the expectations, society is raising the expectations, and that’s driven by commerce at large. Or it can just be some people living in the Hamptons that have always made some money, just making more money. I think that depends on how people in the field and in the economy participate in that. My preaching but also my learned business experience concludes that using business goals for the right purpose can benefit the community and serving the community with no expectation can benefit the business.

Flick: And words matter. Remember that.

Griffin: To you and the rest of society less than they do to me, but you’re absolutely right, they do to so many people. I personally hate that about our society but its the truth. Words do matter and people can sometimes get hung up on them, but beyond that so many people in this field want to help people and I’d rather have that side be seen than a different narrative.

Rebecca Flick is there anything I didn’t ask you that you want to conclude?

Flick: No, I think words matter, to sum it up. I know it's not your favorite, but if we continue to motivate this community, everyone who serves someone with infertility, to work together and help influence employers and lawmakers, state legislators, that access matters, we have a great voice and providing a better healthcare system for people struggling to build a family.

Griffin: Word sensitivity isn’t my favorite, but you are my favorite.

Flick: Back at you.

Griffin: Every REI practice in America should check out Resolve, for professional membership, we’ll put Fertility Matters for our Canadian friends in our show notes, UK friends, Australian friends, I don’t know who y'all are dealing with, email names, we can add those as well. Rebecca Flick thanks so much for coming on the show.

Flick: Thank you Griff, talk to you soon.

Who's Responsible For Lowering The Cost of IVF? An interview with Dr. Kiltz & Griffin Jones.

Show notes: In this episode, Griffin talks with Dr. Robert Kiltz, the founder and director of the first successful IVF center in Central New York, CNY Fertility Center. Griffin and Dr. Kiltz discuss the topic of who is really responsible for lowering the cost of fertility treatments. They discuss whether the responsibility falls on the insurance companies, pharmaceutical companies, medical device, hardware and software companies, or the providers themselves. They then discuss Dr. Kiltz’s methods of becoming a successful fertility specialist that offers a lower cost treatment plan, creating a new market with new levels of accessibility and affordability.

Griffin: I’m with Robert Kiltz, Dr. Kiltz, he is the founder and CEO of CNY Fertility Center with 4 locations in New York state, and one in Atlanta. Dr. Kiltz completed his fellowship at UCLA and practiced full time REI at Alta Bates IVF program while on the clinical faculty at UCSF. In 1995, he left Southern California, he picked up and relocated to Central New York and upstate New York, and began the area’s first IVF program. He’s a man who is not afraid to take on a challenging case and launch a new model, which we are going to talk about today. I’m really excited to speak with Dr. Kiltz about that. Dr. Kiltz, welcome to the program!

Dr. Kiltz: Griffin, I really appreciate you asking me to come on and have this conversation. This is really important, and what your doing, I must give you excessive and high accolades.

Griffin: So, I’m excited to talk to you about this particular topic which is, “Who is really responsible for lowering the cost of fertility treatments,” and the reason why I thought of you, is because a few years ago you and I were on Capitol Hill, and we were advocating for, among other things, expanded coverage for fertility treatments, and you made a remark to me, that stuck with me. So if I am paraphrasing, go ahead and correct me, but it was something to the effect of,” there’s a lot of people here, and we’re talking about having insurance be mandated to have coverage, but there’s a lot of other ways to lower costs, and there’s a lot of other ways that people could be doing this.” I think you were hinting at providers, and that stuck with me, that you had a different sort of message for lowering the cost of treatment.

Dr. Kiltz: So the question is…

G: The question is, who’s really responsible for lowering costs of IVF, because I feel like, you know, that maybe this speaks to healthcare in general, but it seems that no one feels they are the ones making the money in healthcare, the insurance companies, pharma, but who’s really responsible for lowering the costs of IVF?

K: Well, certainly… years of being a reproductive endocrinologist and fertility specialist over nearly 30 years actually, and, I do recall the experience on Capitol Hill where we were there shouting and asking people, “Do something. Do something. Do something.” I've always had a motto in life and I think I forgot it back then, that there are three people in life, there are the doers, the watchers, and the complainers. And what I realized at the time, there’s only one person that can make it more affordable, and that was me. And each of us individually must take on the things that we think is the most valuable in life. And for me, families, children, is powerful, and it is our foundation, and there’s so much pain and heartache in this world over infertility, and the fact that we as fertility doctors are responsible… I went in to medicine to help people - not that making money wasn’t important, but it wasn’t the reason I went into medicine and fertility. And I learned at the moment that we are asking other people to take the responsibility, but it’s not theirs, it's ours. OR actually, maybe it’s all of ours, but if it doesn’t start with the individual, and I realized, the only way to make it affordable - is to make it affordable. Now, I would say more affordable, as fertility treatment is more expensive than many treatments, but if you look at the cost of medicine in general, its overpriced and inaccessible to so many people.

G: And the argument has often been for the rest of health care has been, well there’s Medicaid here, there is insurance here, if it were more out of pocket, the cost would go down. But with IVF, seems to be a case study where it is mostly out of pocket, it doesn’t seem like the cost has really gone down compared to the cost of other consumer behavior, which is, like a flat screen tv doesn't cost anywhere near what it did a few years ago, a cell phone doesn’t cost anywhere near what it did ten years ago, but the price of IVF keeps going up. Why?

K: The reason I think is the supply and demand. In general there’s a shortage of reproductive endocrinologists and reproductive specialists. There was a purposeful reduction of REI who were graduating maybe 15-20 years ago, and there's no rush to train or grow the training programs, and there’s little incentive to train others. I call it like a $100 bottle of wine. Some can afford it, most cant, so it’s limited to who can afford to use it. Get back to the basics, everyone needs fertility services, it doesn’t discriminate against income, or race, or anything or socio-economic status. So, it is really a supply and demand - there aren't a lot of reproductive endocrinologists. The field is really only 40 years young, so I think the market forces are entering the scene a little bit more as we are seeing a sort of consolidation and seeing the profitability, there are going to be others like myself who are saying, listen, I came to this market, to this business, to help people and be busy as a fertility doctor, not just pick and choose the few cases for those that can afford it, but really open our arms to be accessible and affordable while maintaining quality and access. If we can train physician's assistant, NPs, and maybe others in the world of fertility, it might be helpful. I know many are going in to nurse practitioner and physician assistant programs, that may be an area we can grow on and teach them to care for more fertility issues in addition, fertility issues are not just related to IVF, but it seems that is what we are pushing more and more people to, and we are forgetting about the basic approach ,more natural. Reduce inflammation, stress, work on integrative approaches with Eastern and Western medicine, bring more people into that. I think ultimately the answer is supply and demand. We gotta increase access to bring down the price.

G: So, one way to increase the supply is to have more PAs and NPs involved in treatment. Is that a band-aid until we can have more REIs in the field, or do you think that is a long term solution? If more NPs and more PAs support what REIs do and then have REIs guiding them as teams, is is that, or is it having more REIs in the field?

K: Well, if we can train more specialists, but training more specialists is very expensive. So, my sense is that if we can train more NPs, PAs and maybe more OBGYNs, teach them more about general fertility, but a lot of what we've done is to manage to help those couples and individual get some of the care with their primary OBGYNS where they can then be the hub and spoke approach, where the IVF lab is really the more expensive component, but in essence, by increasing the volume, it should reduce the cost in most of this. Now, not to say that you want high volume, low care - you still need to supply really good high quality, but I think we can work on more streamlined ideas, because when it comes to ovulation induction and monitoring, it’s not a difficult as people make it out to be and we sometimes micromanage. I think we could help many more by coming up with some treatment protocols that make it easier for others to train and follow that is ovulation induction or whether it is IUI or IVF, or even helping people with intercourse cycles. We are seeing tremendous success with Ketogenic diet, with anti inflammatory approaches and slowing down.

G: Well wouldn’t some people say that that's sort of circumventing the idea of fellowship training, that if you have different people training OB-GYNs and PAs that it essentially sort of saying well, this as a subspeciality, as a fellowship training is not necessary, because the people that are already trained in this fellowship are able to train the other people - is it circumventing fellowship?

K: Well, I still think the fellowship training is excellent, but I am seeing so many fellows that come out of fellowship with very little idea or infertility experience. Many have not done but handful of retrievals, little to no transfers, and so I think we just need to help do more training at a grassroots level, because really why should IVF be $20-30,000? Very few people can afford that. The $4-5,000 range makes more sense. There's still plenty of room for profitability, but we can help many more. If you look around the world, the costs are lower, the volume is higher, outcomes are about the same in my opinion. So, we just have to begin to think of ways to help more providers learn more about general fertility treatment and how to make IVF lower cost.

G: Why do you think more people don’t try that model - some people do, you're not the only one using this model, I just think you’ve been doing this a long time and added more to it and have been really successful in proving it. There are some other people, but there’s not a lot, why do you think that is?

K: Once you make a lot of money, it's kind of nice. Once you have that model of higher cost and higher price, it's more difficult to shift it down. When I started in Syracuse 20+ years ago, I started at $2,000 for an IVF cycle. I was profitable and we were growing. I just think the mindset is that's what we really want to do, and I think because we are seeing a lot of consolidation, a lot of investment markets have come in to this area, which is maybe keeping the prices higher, but we are going to see more independents going out and saying I want to start my own shop, and in order to do that, I want to come in at this price. If someone comes in across the street and starts doing it? It's the same as all the businesses in America, the natural competitiveness in the marketplace. There's plenty of business. 85% of those with infertility don’t have access or coverage for fertility care. That’s not just IVF, but it may be surgical procedures, it may be IUI, it may be medicines that help reduce inflammation. I’m dealing a lot with this. Maybe it's 3-5 more years, but I am already seeing more saying they are going to lower their prices to make this happen, so as we talk more about it. If you have read about business, and really blue skies - and expense of business number of possibilities and opportunities, but when we think in a very reductive way of thinking, and that's much of medicine, because we are trained to be doctors- we don't know much about the business of medicine. As we all learn to get into the environment of the business of medicine - and I think the fact that most insurance doesn't cover it, it allows us to be more competitive. I Would like to see some of these insurance companies open up to see that there are providers that do it for a lower cost with the same success, such as in New York, but even around the country and around the world, they can open up and make fertility treatment a lot more accessible and affordable to more people.

G: Do you think that part of the reason why you - even if its not why are are doing it now, or how you are doing it now, but how you started, is given the location? People always ask me, how can he do that? How is he able to do that? Sometimes they wonder about location, you're from upstate NY, it’s cheaper here. Everything's cheaper here. You want that 7 bedroom house? Thats alot cheaper here in upstate that it is in say Austin, Texas or Southern, California or Seattle. Does location have anything to do with the how?

K: How does McDonald exist in Manhattan?

G: More volume.

K: There are plenty of businesses in many locations in different parts of the world, that you and I think, my God, how do they do it. They go and they do work. When you do work, the possibilities are infinite. But when you are automatically thinking it can be done,then that’s what's going to happen. But, I never thought that when I came in to do this, and I realized, because of this technology, and you know people thought that telemedicine,and the opportunities that people are traveling for medical care all day long for many other specialties, I mean 60% of our patients are coming from 5 hour drives, and flying. They come from around the worlds, and come not only for price, that may get them in the door, but realizing that we are much more open to non-traditional - OK, I’m going to say traditional philosophies of massage, acupuncture, herbs, HGH, immunology, surgical approaches, because of that, I think this is how we’ve done it. It's not just me, I have 4 other docs, I have 8 NPs, PAs, I have about 270 staff, so I kind of make it like I do it alone, but there’s no way. I think that when we can be more inspiring to our patients - because in general, medicine, especially infertility, we sometimes tend to be negative nellies. “Oh, that's not going to work, you need to go with donor eggs, or that's too expensive” and we can be very prejudiced against other medical conditions, previous failures, size, and I'm hopeful that we can all begin to change out ways - realize that ultimately, building a family is a basic for everyone, not just for those who can afford it. Because, nature didn’t say, when you can afford to have children, then we will give you children. Life gives us things, and then were meant to go out and do the work, through the challenges and the troubles that naturally happen for all of us. There's not a right time to have a child.

G: One of the things you brought up, part of the things you feel might make fertility treatment more expensive is venture capital, money from other sources, but when I see that you've proven the model - where you've got 60% of your patients coming from a 5 hour drive of more. People can look at the CDC numbers, ans see the volume you're doing, and if they didn't know where you were, they would think you were right in Manhattan given the volume that you are doing. Central NY is not a densely populated place. You have people coming from all over - to me, that's proving the model based on the volume that you have and how long you have done it for. So either have people approached you and said there's obviously a need for this, let's put some private equity into this - or have you thought I should knock on some doors and get some private equity involved and really take this to market?

K: I've looked, and had this conversation. It's a difficult choice and idea, because the most important part is that you want to make sure that whoever's coming into this has the same philosophy and belief. That's the critical part. I don’t know that answer. I’m 62, and feel 22. I'm energized and enjoy this. I can’t imagine going and doing anything other than doing this. There is that possibility that someone will come into the market, or we might partner with someone to make it more accessible and affordable for more, because there's a huge number that could use the help in this country for sure. So, looking at it, and having the conversations, and being open to the possibility for sure.

G: What about the response that if the price is low, that must mean the quality suffers, that must mean the IVF success rate is low as well.

K: I was trained as a physician. My job is quality care, individualising the approach, irrespective of what money comes in. We see people that can't afford to pay right now, need the longer payment plans - when we do 100% that is helpful, but… I think I am losing the question, maybe you could repeat it one more time, I apologize, my brain was going over here..

G: MErcedes is high price, so that must mean high quality, if there's low price, it has to equal low quality, or low success rates would be the criticism people would have.

K: I don’t believe it, and people can say anything they want, but I think that if we’re human beings focus on the quality of care and people in front of us, you're going to get it. You can't skimp when it comes to the IVF lab, and we’re inspected, you know, and we have very decent SART numbers and CDC numbers without cherry picking - we do very little PIGS, so we do alot day 3, day 5 on tested embryos, that’s what people want, but I would say that people may say and think whatever they want, they just need to experience it. I bet and believe that most physicians, providers, nurses, laboratory people, everyone at any end of the process through CNY fertility believes in the affordability can still equal high quality care and outcomes.

G: Our producer Stephanie found this, and maybe it's true and maybe it's not, it said that the average REI takes home $330,000 per year. Now I’m actually an apologist for people being able to make money. I see the same thing, the supply and demand, there's 1100 board certified fertility specialist in the country, it's really hard, 4 years of undergrad, 4 years of medical school, 4 years residency, 3 years fellowships, followed by some of the toughest boards in medicine period, and there is a lot of science and technology behind it that are really expensive - should REIs not be able to make money? I don't think that you are saying that, but I think this is a criticism that people have.

K: There's no guarantee of making money for anyone. Life is not a guarantee that you do this and you are going to make money - this isn't a socialist country, it's a capitalist open market system. Some people make this much money, some people make that much money, Some REIs go bankrupt. Some - what's the saying, you aim for the moon you hit the stars concept . I didn't go into this looking to make a lot of money, if fact I thought if I made $200,000 I would be a happy camper, and money doesn't make you happy anyway. Getting up and enjoying what you do matters. I know REIs that make 10x the amount and those that make less than that, but you know, $333,000 a year, is like the top tier of money in America, for sure. The majority of people don't make anywhere near that. So, I'm not sure why that's not considered a lot of money, but at the end of the day, there are no promises in life, just opportunities for each of us to create what we wish and desire to do. There's going to be a lot of trouble along the way, and the trouble is part of what I call the treasure of creativity - if one thing isn't working, try something else. If you're not a busy fertility doctor, then you want to go out and risk a lot- you know, because this is risky. I owe a lot of money, and everyday I need to go out and keep sharing and creating, because when you get big, the overhead grows, and so the need for the river widens, but we too can easily close it down, and shut it down, or I should say, narrow it, and we would still be doing will. Because really, as healthcare providers, all we need to do is focus on providing great health and wellness advices and treatment modalities. I believe the money in general can and will come, but there are a lot of challenging market forces going on I mean the entry cost of building an IVF lab is huge. I'm working on opening up my IVF lab in Buffalo, so were capitalizing that, growing that, so that's still all stuff we have to look at as entrepreneurs, and so the hat of the entrepreneur and the hat fo the physician come together and so that's stuff I focus on - but I enjoy that stuff. Lots of doctors just want to practice medicine. But I think a lot of doctors that went into this that are very creative and artistic, and they like to do it their way. I think we're going to see some more individual programs and people going out there to do something very similar.

G: To me it seems to be something exactly like what happened with craft breweries and regional banks, right, when it came to breweries, it seemed like 15 years ago, there was only going to be one beer company. You had Coors, Miller, you had Anheuser Busch, Anheuser Busch gets bought out by a global conglomerate, Another company buys Miller, and then they buy Coors, so it seems like you've got two beer companies for everybody, so then Yuengling starts to grow, Sam Adams start to grow, and people are opening up their own microbreweries, and I think we are seeing the same thing in our own field you know, were seeing consolidations. Little guys being bought up by big guys, and then some people are going off and starting their own practices, because exactly what you said, they just want to do it their way.

K: And that's the joy of life, going out and creating and doing it your way. My way isn't the right way, it's just the way we've done it, and so I think, I am practising more and more not to criticize, which is obviously a human challenge,not to criticize, not to judge, but to be open to different ways… “Gee, what are they doing, what are they doing, how can I pick and choose all these little pieces of the puzzle”, and this is how art opens up - and you're right, like coffeehouse, all these little coffeehouses and roasters. If you come to my Rochester office, we have the Fertile Grounds Cafe, I was working on starting to do roasting coffee and I've been working on that so we sell coffee there. We do a lot on diet, so I've been opening up to bringing in ketogenic menus and lifestyle, we have yoga, acupuncture, massage. Were now talking about CBD oil, and it's kind of crazy stuff with whos doing what, where's the studies, you have to have evidence based medicine, and I'm looking at the guys - they're not going to work for Starbucks or Budweiser, they're just saying I want to do something new and different. Look at GE, the shares are dropping, and we've got all these apps now, it's not just Facebook anymore. I think we're going to see the fertility world opening up and being more creative. But, some individuals need to be willing to put up the bank and, whether it's a venture capital company or your own local bank - Ive know plenty of local banks are still working the entrepreneurial world of helping people. We see people from around the globe, and that's the beauty of this environment. We can share on Facetime, Twitter, Instagram, and YouTube, our energy, and 1% of the billion is better than 50% of the 300,000 in Syracuse. As I begin to think outside the local box, I am sort of realizing that there are so many different ways to do this. We do our own financing. Everyone is financed, we don't check credit, everyone is capable. We are going to pharmacies and say OK, here's our prices we want, can you meet it or beat it. It’s like WalMart, they went out to the vendor's and said OK, here's the price we need, we've got all these locations, you want our business, this is what you have to meet. The same thing goes for other vendors, between medicins, hardware, software, all of it. We've got to do much better on going out and just put an offering out there. Here's what we do, here's the numbers. We’ve been growing about 30% every year. My bet is were growing the market. Because the people that cant afford the $30,000 aren't going to those people anyway. So, we are actually incentivizing the local REIs to do the monitoring, even at a rate that they do anyway or lower, they're going to get those clients eventually or they will just help build the market. That hey, I went and got my monitoring with that doctor, they really wonderful at that practices.The more we grow that energy and excitement for helping people, we are going to grow the market.

G: It’s almost, not easier, but it's a clear example when you are an REI that can show ok this is what I've done as an REI, I've proven the model. How do you then also say to pharmaceutical companies or device manufacturers or anyone else involved, listen I lowered my rates, this is what I expect. Are you able to do that? Who else is responsible for lowering the cost?

K: Well, no one is really responsible, in the sense that you need to come to the plate and do this, but there's a responsiveness, because they are seeing the amount of business that's coming to CNY Fertility centers around the country - and by the way we do have a satellite office in Montreal, Canada, also. But because we put it out there, they are coming to us because they know we are growing the marketplace, and like anything else, margins can go down in volumes go up. You know, low volume, high cost. You could buy this expensive bottle of wine, but not many people are buying it. You could go down to a local winery in the finger lakes, get a great value for a lower cost, and make them sell a lot more than that. In essence, supply and demand. We are increasing the supply of the opportunities for fertility treatment because we've created a very efficient team - we have 10-15 embryologist. We have docs at every location doing the retrievals and transfers, plus we have practitioners that are helping and a full nursing I call the global team - where they are talking to clients from around the country and globe, helping them make sure they are getting their testing, so they have the instructions, so they know what they are doing to give them the opportunities to move into IVF or donor eggs or gestational carriers. There's so many ways to do this, so we simply have to - growing the box, but we’ve gotta maybe get into a new box to learn how to do this. I invite clinicians to call me to come visit, we’re holding nothing. I've always been an open door to share the ideas. This isn't proprietary, these ideas are really open and out there. The more I share them, the more amazing things grow for all of us.

G: I think that's the way how most change happens, when they see a successful model, it's easier for them to wrap their heads around, and eventually that model becomes the standard, and I knew you were the guy to interview to talk about that. Dr Kiltz, is there any other thought that you would want to conclude with about being responsible for making fertility treatment more affordable and accessible?

K: I think we’ve spoken a lot of good ideas, and I'm really grateful. I think like anything else, when we realize that all the responsibility falls on ourselves for whatever change we want to see happen, we need to be the ones that are a part of the change first. There was a great story about an entrepreneur having a challenge with his business and needed to write a great speech to inspire his tea, he didn't know how, and his little son was bothering him and he didn't know how to tell his story. So, he took a picture of the world, and tore it up, and gave the picture to the son and told him, here son, go put this back together, thought it would take him some time. Two minutes later the kid came and knocked on the door, he asked son, how - the son replied, well, on the other side, there's a picture of a man, If I put the man together first, the world would be right. So, he was able to put the picture of the man together, since he knew what the man looked like, and turned it over, and viola. So, I think when we work on ourselves in this human amazing journey, that make the world better. I've always been and continue to be inspired by your energy and creativity and I am really grateful that you asked me to be a part of this.

G: We are happy to have you on. Dr Kiltz, thank you so much for coming on the program.

K: Griffin, it was a pleasure, and I look forward to many more to come. God bless you.

What REI Fellows Really Want. An interview with Valerie Libby and Griffin Jones.

Show Notes: In this episode, Griffin talks to Valerie Libby, a second year reproductive endocrinology and infertility fellow at UH Cleveland Medical Center. They discuss what millennial REI fellows want in the process of building their careers, such as mentors, work-life balance, and more business training, and analyze how the risk-averse nature of the medical field and an outdated business model keep fertility doctors from opening their own practices.