Assisted Reproduction Services:

Proposed Changes to the Schedule of Benefits for Physician Services

Ministry Presentation to Physician Services

Committee
August 17, 2015
Health Services Branch
Negotiations and Accountability Management
Division

Current Status
Under the Health Insurance Act (HIA) and its Regulation 552, the Ontario Health
Insurance Plan (OHIP) provides payments for medically necessary physician
services as listed in the Schedule of Benefits for Physician Services (Schedule).
Currently, OHIP insures a number of services related to infertility:
OHIP spends about $20M per year on physician services related to in vitro
fertilization (IVF) and intra-uterine insemination (IUI).

IVF OHIP insures the first three treatment cycles for women with complete bilateral
anatomical fallopian tube blockage not resulting from voluntary sterilization.

~1,000 patients/year for an approximate cost of $4M per year .

IUI OHIP insures unlimited cycles of IUI for all causes of medical infertility.

~10,000 patients/year for an approximate cost of $16M per year.

OHIP also insures a number of physician services for diagnosing

infertility, as well as a number of surgical services for the
correction of infertility.

There are also number of non-physician services related to IVF and IUI that are
not insured (e.g., embryology services for IVF, sperm washing for IUI, etc.).

Summary of Proposal
The Ministry of Health and Long-Term Care (ministry) is proposing changes to
Regulation 552 and the Schedule under the HIA that will remove IVF and IUI as
insured services under OHIP:
Overview:
The

ministry is proposing to remove IVF and IUI from the Schedule and therefore
remove $20M from the Physician Services Budget (PSB), which will have a positive
impact on managing fiscal pressures within the PSB.
The

ministry is proposing a new $70M program (re-investing the $20M with an additional
$50M investment) to fund assisted reproduction services outside of OHIP. The $50M
investment is outside the PSB.
The

program will fund both physician services and non-physician services related to IVF
and IUI through Transfer Payment Agreement (TPA) funding contracts with clinics.
Physician

services in the Schedule related to diagnosing and surgically correcting

infertility will remain insured.
The proposed effective date of the Schedule changes will be December 1, 2015, and
the first round of TPAs will come into effect immediately afterwards, in order to
ensure no gap in services for patients.

Government Commitment
The proposed change supports key government commitments:
Family Building
2007 Platform committed to explore the issue of infertility to
make treatment and adoption more accessible and affordable for
people, as everyone should have a fair opportunity to create a
family.
In 2009, the Government-appointed Expert Panel on Infertility
and Adoption (EPIA) released its report with 51 recommendations
related to infertility, including expanding public funding for
IVF services.
Funding for IVF and IUI
On April 10, 2014, the Government of Ontario announced its
intention to expand funding of assisted reproduction services by
contributing to the cost of one IVF cycle per patient per
lifetime for all causes of eligible infertility. IUI would
remain funded.
On April 30, 2015, the Ontario Legislature passed the 2015
Ontario Budget Building Ontario Up, which approved $70M in
funding for IVF and IUI.

Policy Rationale
The program design was informed by the following:
Policy Assumption: Social Program
Assisted reproduction services are not medically necessary and
should therefore be funded outside OHIP.
Social policy goal is to expand access for assisted reproduction
services to all Ontario residents (regardless of age, sex,
gender, sexual orientation, or family status), rather than
providing services based on a diagnosis of medical infertility.
Policy Objective: Increase Access
Aim to increase access to assisted reproduction services for
more people in Ontario.
Program will maintain access to IUI for 10,000 patients each
year, and will also expand access to IVF from 1,000 patients to
over 5,000 patients each year.
Program will also add fertility preservation services (oocyte
and sperm freezing) for medical reasons (i.e. cancer patients).

Program Development
To inform the development of the expanded program, the ministry completed an
advisory process to obtain expertise and advice on clinical services and eligibility.
Structure of the Advisory Process:
Members

included 8 physicians and 2 embryology lab directors with sector expertise, as

well as 3 patients with lived experience of infertility.
Physician

Obstetrics and Gynaecology;

Endocrinology,
Urology and Andrology;
Quality Assurance and Clinical Practice Guidelines; and
Fertility Services Program Delivery (Quebec and Israel).

Chaired
Three

and assisted reproduction sector expertise included:

by Dr. Ellen Greenblatt, Medical Director, Mount Sinai Hospital fertility clinic.

meetings were held between December 2014 and February 2015.

Recommendations

were provided in a final report to the ministry and were used to inform

this proposal.
The advisory process did not address issues related to the funding mechanism,
funding levels and pricing.

Program Details
Key elements of the program design are as follows:

Funding

Annual
Volumes

Patient
Eligibility

Fund both physician and clinic services through TPA contracts directly with
fertility clinics (hospital-based and non-hospital).

Fixed budget of $70M per year. Includes physician and non-physician costs.

Target of 18 IVF clinics (2 hospital-based) and 36 IUI clinics (8 hospital-based).

IVF approximately 5,000 cycles for 5,000 patients.

IUI approximately 22,000 cycles for 10,000 patients.

Each clinic will be assigned volumes in the TPA, determined based on historical
data in the OHIP billing database as well as data provided by clinics.

Open to all patients with an OHIP health card number.

Not restricted to medical infertility, but also for social reasons (e.g. same sex
couples). Access open regardless of age, sex, gender, sexual orientation, family
status, disability, etc.

IVF 1 treatment cycle, but with unlimited transfers for all resulting embryos.

IUI unlimited cycles, consistent with current policy under OHIP.

Surrogates can also receive one additional funded cycle of IVF.

Fertility preservation (collection and freezing of sperm/oocyte gametes) will also

be provided to patients for medical reasons (i.e. cancer patients).

Program Details
Key elements of the program design are as follows:

Payment for both physician and non-physician services will be made in the TPA.

Payment

Clinics required to enter into an arrangement with physicians to specify the

remuneration for provision of services, and must also set out a dispute resolution
mechanism for remuneration issues between the physician and the clinic.

Physician
Services

Medical assessments;
Performing and/or interpreting required laboratory or diagnostic imaging tests;
IUI procedure;
Oocyte retrieval procedure;
Sperm retrieval procedure (i.e., surgical sperm extraction); and
Embryo transfer procedure.
Diagnostic imaging services (ultrasound)

Embryology services to create and grow embryo(s), including fertilization of

oocytes with sperm (using traditional IVF or Intra-Cytoplasmic Sperm Injection
(ICSI) if medically necessary, Assisted Hatching, and Blastocyst Culture;
Embryology services to prepare and freeze embryo(s);
Embryology services to thaw and culture embryo(s); and
Operating costs, such as the cost of the premises, equipment, supplies,
personnel, and all administrative requirements.

NonPhysician
Services

Timelines & Next Steps

This information is presented to the OMA for consultation.

Consultatio
n on
Schedule
Changes

TPA
Contracts
Cabinet
Committees

The ministry requests that the OMA provide feedback

on the proposed amendments to Regulation 552 and the
Schedule by August 28, 2015.

Following approval, the ministry will release an INFOBulletin detailing

the updates to the Schedule, with links to supporting material that will
be available on the ministrys website.

The ministry intends to offer standardized template TPA

agreements to the clinics. The clinics are corporate entities, often
physician-owned.

The TPA will include funding for both physician and non-physician
services, and the funding will flow through the clinic.

The ministry requests that the OMA advise the ministry by August
28, 2015 what role the OMA would like have on the development of
the TPAs.