PGS utilization is higher in states without mandated coverage of IVF: a national cohort study

Abstract

The utilization of preimplantation genetic screening (PGS) for selection of euploid embryos has been increasing. In states mandated to cover IVF, utilization of IVF is higher on a per capita basis. The use of PGS for euploid embryo selection is a non-covered benefit. However, it is unclear if the impact of IVF coverage has a discernible effect on the elective utilization and out of pocket expenses of PGS. To compare the PGS utilization rates among states by their insurance mandated status. Retrospective cohort design. The most current available annual CDC data (2015) was abstracted from the CDC database for ART outcomes. All clinics reporting a total IVF cycle number with a corresponding proportion of their PGD/PGS cycles were included. All clinics within a single state were aggregated. Categorization of states divided them into IVF mandated and non-mandated groups. Risk ratios were calculated to investigate the relationship of PGS utilization in mandated versus non-mandated states. A fisher's exact test, chi squared and variance ratio test were conducted. A total of 228,720 IVF cycles were included for 2015. PGS utilization comprised a total of 14,852 (6.49%) of cycles. States that included an IVF mandate had a PGS utilization total of 3,241(6.06%) while states without a mandate had a higher utilization with 11,612 (6.62%). There was a risk ratio of 0.91 (95% CI: 0.88-0.95, p<0.0001) of PGS utilization during an IVF cycle in an IVF mandated state versus a non-mandated state. When a single IVF mandated outlier state was excluded, the PGS utilization rate in IVF mandated states was only 1.91%. This represents a risk ratio of 0.29 (95% CI: 0.27-0.31, p<0.0001) in an IVF mandated state versus a non-mandated state. Among states with no IVF mandate there was a positive correlation between total IVF cycles and the proportion of PGS utilization (Range: 0-16%). Among IVF mandated states, there was no discernible correlation between total IVF volume and PGS utilization (Range: 1-25%). There was an increase in the variance in PGS utilization in mandated versus non-mandated states (p<0.02). PGS utilization during IVF cycles is significantly higher in states without an IVF mandate. CDC data demonstrates vastly different PGS utilization rates, particularly in IVF mandated states. The underlying reason explaining the stark difference in PGS utilization between mandated and non-mandated states cannot be elucidated from this study. It may be speculated that IVF supplements with out-of-pocket expenses in mandated states represents an unacceptable financial burden to the covered patient. This study highlights an unanticipated association of IVF mandated coverage with respect to decreased PGS utilization.