Experience with the elective transfer of two embryos under the conditions of the german embryo protection law: results of a retrospective data analysis of 2573 transfer cycles

The German embryo protection law (Embryonenschutzgesetz, ESchG) does not allow embryo selection. Therefore, only as many oocytes at the pronuclear stage (PN), as are planned to be transferred, are allowed to be cultured. It is not known whether, under these conditions, it is possible to reduce the number of embryos for transfer without a corresponding reduction of the overall pregnancy rate (PR). We retrospectively analysed 2573 consecutive transfer cycles following either in-vitro fertilization (IVF) or IVF/intracytoplasmic sperm injection. Out of these cycles, 234, 329 and 792 were performed with one, two, and three embryos respectively, because only that number was available (non-elective transfer). Another 123 and 1095 transfer cycles were performed with two and three embryos, respectively, which were selected from a higher number of PN oocytes (elective transfer). The clinical ongoing PR were 3.9, 9.1 and 17.7% respectively for the groups with non-elective transfer of 1, 2 and 3 embryos, and 22.0 and 22.5% for the groups with elective transfers with two and three embryos, respectively. There was no statistically significant difference in PR between the two elective embryo transfer groups up to the age of 40 years. The multiple pregnancy rate was reduced by 7.9%. The reduction of the number of embryos transferred from three to two can be performed even under the conditions of the ESchG without an effect on the overall PR.

The effect of copayments on drug and alcohol treatment following inpatient detoxification under managed care

OBJECTIVE

The study examined the rate and duration of outpatient substance abuse treatment following inpatient detoxification under managed care.

METHODS

Seven years of claims data from a large behavioral health care carve-out plan were used to identify patients. Rates and duration of formal substance abuse treatment following detoxification were calculated, and regression models were used to explore factors that may affect participation in treatment.

RESULTS

Seventy-nine percent of the detoxification patients received formal substance abuse treatment, the majority within the week following discharge. Formal follow-up care lasted an average of ten weeks, with visits occurring on average about once a week. When other variables likely to influence participation in substance abuse treatment were controlled for, the level of outpatient copayments significantly affected the rate of participation in treatment.

CONCLUSIONS

These findings indicate that the rate of participation in outpatient treatment after detoxification is high, but room for improvement remains. The results suggest that reducing copayment levels is one mechanism for increasing the likelihood that individuals with severe drug and alcohol problems will receive subsequent treatment. The need for such treatment is underscored by the severity of illness of those who undergo detoxification and the societal costs of untreated substance use disorders.

Who leaves managed behavioral health care?

The growth of managed care and the possibility of biased enrollment and dis-enrollment rates have raised concerns about cost shifting. This article analyzes the duration of continuous enrollment in a managed behavioral health organization among members with and without behavioral health care utilization and among members with different mental health conditions. Eleven large employers with more than 250,000 members who are enrolled in managed behavioral health plans are studied. Compared to managed care 10 years ago, the rate of dis-enrollment among patients with depression appears to have dropped. Moreover, there appear few differences in dis-enrollment among users and nonusers of behavioral health services, except for employees for whom coverage is linked to job performance. However, patients with substance abuse problems or severe types of disorders are significantly more likely to dis-enroll than patients with less severe problems.

Tracking changes in behavioral health services: how have carve-outs changed care?

This special issue of the Journal of Behavioral Health Services & Research on mental health carve-outs brings together some of the latest research on recent policy and market changes affecting behavioral health services. This introductory article provides background information about carve-outs and the managed behavioral health care industry. This article also reviews prior research in the mental health carve-out field.

Substance abuse service utilization under managed care: HMOs versus carve-out plans

Managed behavioral health care organizations are increasingly managing Americans' substance abuse by using carve-outs, but little information is available about how this has affected service utilization and costs when compared to HMOs. One employer's claims for substance abuse services delivered under a carve-out arrangement are compared to prior HMO claims information. Under the carve-out arrangement, inpatient and outpatient service utilization are found to decrease, but intermediate service utilization dramatically increases. Costs per unit service decrease for all services. The pattern of changes is different from that seen for mental health services, suggesting that different factors may be applicable to substance abuse services.

Cost and quality trends under managed care: is there a learning curve in behavioral health carve-out plans?

The paper studies the performance of network plans over time using data from 52 managed behavioral health plans. Costs exhibit a 'learning curve' with additional cost declines of 10-15% with every doubling of experience, which are independent from time trends and scale economies. Process-of-care measures show increased appropriateness of follow-up care and reduced 30-day rehospitalization, but the relationship to experience or time is not statistically significant. Possible causes of organizational 'learning' could be faster referrals to network clinicians, increased acceptance of network providers by patients, selection of more efficient providers, improved care management procedures, or better monitoring techniques.

State mental health parity laws: cause or consequence of differences in use?

A new wave of state and federal legislation affecting mental health insurance was passed during the 1990s. Although patient advocacy groups have hailed the passage of numerous parity laws, it is unclear whether this activity represents a major improvement in insurance benefits or significantly increases access to mental health care. We investigated this issue with data from two new national studies sponsored by the Robert Wood Johnson Foundation. We found that states with below-average utilization were more likely to enact state legislation, but utilization in those states continues to lag behind the rest of the nation.

Fertilization potential of spermatozoa with abnormal morphology

One of the best discriminators for the fertilization potential of human spermatozoa is sperm morphology. The problem in the assessment of the sperm morphological characteristics is their pleiomorphism. Examination of spermatozoa with the light microscope can provide only limited information on their internal structure. More detailed examination of sperm structure using electron microscopy can reveal major, often unsuspected ultrastructural abnormalities. Results and cut-off values for sperm analysis depend on the criteria for normal morphology. World Health Organization recommendations provide a classification suitable for clinical practice. Clinically reliable cut-off limits for normal sperm morphology according to strict Tygerberg criteria were suggested to be 4% in in-vitro fertilization procedures. Patients with severe sperm head abnormalities have a lower chance of establishing successful pregnancies, even though fertilization may be achieved. The outcome of intracytoplasmic sperm injection is not related to any of the standard semen parameters or to sperm morphology. Sperm decondensation defects and DNA anomalies may be underlying factors for the unrecognized derangements of the fertilizing capacity of spermatozoa, regardless of sperm morphology. Centrosome dysfunction may also represent a class of sperm defects that cannot be overcome simply by the insertion of a spermatozoon into the ooplasm. In this article an overview on the composition and ultrastructure of spermatozoa is presented, while emphasizing sperm ultrastructural and sperm DNA anomalies and their effects on fertilization.

Intracytoplasmic injection of round and elongated spermatids from azoospermic patients: results and review

Microinjection is established as the method of choice in the treatment of severe male factor infertility as well as in azoospermic patients. Recent studies have shown that fertilization and cleavage can be achieved by injection of ejaculated as well as testicular elongated spermatids into oocytes. Here we report on the two first pregnancies worldwide resulting from elongated spermatid injection from frozen-thawed testicular tissue. Four patients with complete Sertoli cell-only syndrome (SCOS) and two with spermatogenetic maturation arrest were included in our microinjection programme. Tissues from open testicular biopsies were cryopreserved until the time of follicle puncture. A total of 67 oocytes were harvested. In the two patients with maturation arrest, cryopreserved elongated spermatids were successfully injected, while in two of the other four SCOS patients only cryopreserved round spermatids were available to be injected into the oocytes. Out of 18 injected oocytes, 10 were fertilized in the first group, while nine out of 49 injected oocytes showed fertilization and cleavage in the second group. Two clinical pregnancies were achieved with elongated spermatids from frozen-thawed testicular tissue, while no pregnancy was established in the case of round spermatids. This study confirms that fertilization, cleavage and pregnancy can be successfully achieved in cases with spermatogenetic maturation arrest by injecting cryopreserved elongated spermatids into oocytes. The literature on pregnancies following spermatid injection, as well as the problems using this technique and possible risks, are discussed.

The outcome of intracytoplasmic sperm injection in patients with retrograde ejaculation

The objective of this retrospective clinical study was to assess the benefit of assisted fertilization in cases of anejaculatory infertility due to retrograde ejaculation. We report the outcome of intracytoplasmic sperm injection (ICSI) treatment. In 16 couples in which the men suffered from retrograde ejaculation. We performed 35 cycles of ICSI with spermatozoa retrieved from post-ejaculatory urine. The patients had been instructed to alkalinize the urine by ingesting sodium bicarbonate before the procedure. The fertilization rate averaged 51.2%. Seven clinical pregnancies were achieved. Three spontaneous first trimester abortions occurred, but three live offspring were delivered and one pregnancy is ongoing. In conclusion, the use of ICSI may be feasible for patients with retrograde ejaculation who are resistant to medical treatment and whose sperm quality is so low or unpredictable that intrauterine insemination or conventional methods of in-vitro fertilization are not possible.

The design of Healthcare for Communities: a study of health care delivery for alcohol, drug abuse, and mental health conditions

There is a shortage of data to inform policy debates about the quickly changing health care system. This paper describes Healthcare for Communities (HCC), a component of the Robert Wood Johnson Foundation's Health Tracking Initiative that was designed to fill this gap for alcohol, drug abuse, and mental health care. HCC bridges clinical perspectives and economic/policy research approaches, links data at market, service delivery, and individual levels, and features a household survey of nearly 9,600 individuals with an employer follow-back survey. Public use files will be available in late 1999.

Pregnancies achieved after frozen-thawed pronuclear oocytes obtained by intracytoplasmic sperm injection with spermatozoa extracted from frozen-thawed testicular tissues from non-obstructive azoospermic men

The use of frozen-thawed testicular tissue as a source of spermatozoa for intracytoplasmic sperm injection (ICSI) in non-obstructive azoospermia yields favourable fertilization and pregnancy rates while avoiding both repetitive biopsies and unexpected cycle cancellations. Spermatozoa were obtained from frozen-thawed testicular biopsy specimens from 67 non-obstructive azoospermic men. Following fertilization, supernumerary two pronuclear (2PN) oocytes were frozen. After thawing, 17 cycles of embryo transfer were carried out with a mean number of 2.7 embryos and a mean cumulative embryo score (CES) of 18.3 per transfer. The clinical pregnancy and implantation rates per transfer in these cycles (23.5 and 8.3% respectively) were comparable to those of fresh embryo transfers (35.7 and 12.7% respectively) with a mean number of 2.7 embryos and a mean CES of 28.7 per transfer. Abortion rates, although higher with cryopreserved 2PN oocytes were not significantly different. With this approach, cryopreservation of supernumerary 2PN oocytes can be used to improve the cumulative pregnancy rates in a severely defective spermatogenetic population. To our knowledge, these are the first pregnancies reported which have been obtained by the transfer of cryopreserved pronuclear oocytes obtained from ICSI using cryopreserved testicular spermatozoa.

Effectiveness research and implications for study design: sample size and statistical power

Most clinical trials have started to incorporate more broadly defined outcome measures, such as health-related quality of life, to complement clinical status measures as well as direct costs and cost-effectiveness analyses. Contrasting a broad range of outcome and cost measures, we analyze the implications for sample sizes and study design using data from prior mental health and primary care studies that span a wide range of practice settings, patient populations, and geographic areas. While meaningful clinical symptomatic differences are often detectable with sample sizes of well under 100 per cell, detecting even large changes in health-related quality of life generally requires several hundred observations per cell. Reasonable precision in cost estimates usually requires sample sizes in the thousands. Very few clinical trials or observational effectiveness studies that incorporate quality of life or cost measures have such sample sizes, resulting in many (unreported) null findings and, due to publication biases favoring significant results, scientific publications that exaggerate true effects. It raises issues for the general direction of clinical trials and effectiveness studies, as well as for how cost and health-related quality of life results based on small studies should be dealt with in publications.

What outcomes matter to patients?

OBJECTIVE

This study estimates the relative value to patients of physical, mental, and social health when making treatment decisions. Despite recommendations to use patient preferences to guide treatment decisions, little is known about how patients value different dimensions of their health status.

DESIGN

Cross-sectional data from quasi-experimental, prospective study.

SETTING

Forty-six primary care clinics in managed care organizations in California, Texas, Minnesota, Maryland, and Colorado.

PATIENTS

Consecutive adult outpatients (n = 16,689) visiting primary care providers.

MEASUREMENTS AND MAIN RESULTS

Medical Outcomes Study 12-Item Short Form (SF-12) health-related quality of life and patient preferences for their current health status, as assessed by standard gamble and time trade-off utility methods, were measured. Only 5% of the variance in standard gamble and time trade-off was explained by the SF-12. Within the SF-12, physical health contributes substantially to patient preferences (35%-55% of the relative variance explained); however, patients also place a high value on their mental health (29%-42%) and on social health (16%-23%). The contribution of mental health to preferences is stronger in patients with chronic conditions.

CONCLUSIONS

Patient preferences, which should be driving treatment decisions, are related to mental and social health nearly as much as they are to physical health. Thus, medical practice should strive to balance concerns for all three health domains in making treatment decisions, and health care resources should target medical treatments that improve mental and social health outcomes.

How expensive are unlimited substance abuse benefits under managed care?

Substance abuse (SA) care has been excluded from recent federal and state legislation mandating equal benefits for mental health and medical care ("parity"), largely because of cost concerns. This article studies how many patients are affected by SA coverage limits and the likely implications of limits on insurance payments, using 1996-97 claims from 25 managed care plans with unlimited SA benefits. Changing even stringent limits on annual SA benefits has a small absolute effect on overall insurance costs under managed care, even though a large percentage of SA patients are affected. Removing an annual limit of $10,000 per year on SA care is estimated to increase insurance payments by about 6 cents per member per year, removing a limit of $1,000 increases payments by about $3.40. As long as care is comprehensively managed, "parity" for SA in employer-sponsored health plans is not very costly.

Use of psychiatrists, psychologists, and master's-level therapists in managed behavioral health care carve-out plans

OBJECTIVE

Outpatient claims data from a managed behavioral health company for 1996 were examined to determine the extent to which patients received services from different types of mental health care providers.

METHODS

Claims data for 1996 were obtained from 75 plans with more than 600,000 members that were managed by one behavioral health care organization. Data were examined by type of provider and diagnosis.

RESULTS

A total of 349,686 claims were examined. Doctoral-level psychologists accounted for most claims (33.4 percent), followed by psychiatrists (30.5 percent), social workers (19.8 percent), and other master's-level therapists (13.8 percent). Ninety-five percent of patients with a psychotic disorder and 86.2 percent of individuals with bipolar disorder were seen either by a psychiatrist alone or by a psychiatrist in combination with another provider. Among depressed patients, 62.9 percent were seen by a psychiatrist, alone or in combination with another provider. Only 23 percent of patients with an adjustment disorder and 14.1 percent of those with a V-code diagnosis were treated by a psychiatrist, alone or in combination with another provider. Because psychiatrists treated sicker patients, their proportion of patients treated (24.7 percent) was smaller than their proportion of all claims filed. Most patients (78.9 percent) saw only one type of provider.

CONCLUSIONS

The results allay concerns that managed care shifts patients away from psychiatrists to doctoral-level psychologists and less expensive providers. The majority of patients with depressive disorders and almost all patients with psychotic disorders had contact with a psychiatrist.

Costs and utilization of substance abuse care in a privately insured population under managed care

OBJECTIVE

Cost and utilization patterns of substance abuse and mental health treatment under private, employer-sponsored, managed behavioral health care plans were examined.

METHODS

Data were from claims made in 1995 in 93 behavioral health care plans covering 617,133 members. Rates of use of mental health and substance abuse care were determined, as were payments by insurers and patients for the two types of care. Means were calculated per plan member and per user of either of these service types.

RESULTS

Approximately .3 percent of plan members used any substance abuse services; 5.2 percent used mental health services. However, among substance abuse patients, average costs were more than twice as high as average costs for mental health patients. For substance abuse treatment, the annual cost per user was $2,188, compared with $979 for users of mental health care. Annual per-member costs were $6.51 for substance abuse treatment and $50.08 for mental health care. Higher costs for substance abuse treatment reflected greater rates of use of both inpatient and intensive outpatient treatment. Overall, substance abuse costs represented 13 percent of insurance payments for behavioral health care and perhaps .4 percent of the cost of health insurance overall.

CONCLUSIONS

Substance abuse coverage accounts for a small fraction of insurance payments for behavioral health coverage and a very small fraction of insurance payments for both physical and behavioral health care.

Implementing publicly funded risk contracts with community mental health organizations

The study analyzed the experience of the Los Angeles County Department of Mental Health with implementation of new contractual arrangements for services for patients with severe mental illness. The arrangements shifted the financial risk for treatment to community organizations and paid a fixed annual rate per enrolled patient without further adjustment for severity of illness. Patients were assigned to the program based on high prior treatment costs. The new contractual approach enhanced programs' flexibility and accountability and increased their emphasis on principles of psychosocial rehabilitation. Challenges in implementation included disenrollment of the majority of assigned patients by the community organizations at risk for high treatment costs. Prior treatment costs for continuing cases, while high, were lower than those for disenrolled cases. Existing information systems provided limited clinical and cost data, making it difficult to monitor providers' performance. Risk contracting required substantial clinical, fiscal, and management changes at community organizations and the mental health authority. The analysis suggests that mental health authorities that are planning to institute risk contracts need to balance fiscal incentives with performance guarantees and to pay particular attention to information systems requirements and to the severity of patients' illness. Although risk contracts present challenges, they can lead to improvements in service delivery that persist beyond the implementation phase.

Empirically defined health states for depression from the SF-12

OBJECTIVE

To define objectively and describe a set of clinically relevant health states that encompass the typical effects of depression on quality of life in an actual patient population. Our model was designed to facilitate the elicitation of patients' and the public's values (utilities) for outcomes of depression.

DATA SOURCES

From the depression panel of the Medical Outcomes Study. Data include scores on the 12-Item Short Form Health Survey (SF-12) as well as independently obtained diagnoses of depression for 716 patients. Follow-up information, one year after baseline, was available for 166 of these patients.

METHODOLOGY

We use k-means cluster analysis to group the patients according to appropriate dimensions of health derived from the SF-12 scores. Chi-squared and exact permutation tests are used to validate the health states thus obtained, by checking for baseline and longitudinal correlation of cluster membership and clinical diagnosis.

PRINCIPAL FINDINGS

We find, on the basis of a combination of statistical and clinical criteria, that six states are optimal for summarizing the range of health experienced by depressed patients. Each state is described in terms of a subject who is typical in a sense that is articulated with our cluster-analytic approach. In all of our models, the relationship between health state membership and clinical diagnosis is highly statistically significant. The models are also sensitive to changes in patients' clinical status over time.

CONCLUSIONS

Cluster analysis is demonstrably a powerful methodology for forming clinically valid health states from health status data. The states produced are suitable for the experimental elicitation of preference and analyses of costs and utilities.

Managed behavioral health services for children under carve-out contracts

OBJECTIVE

Service costs and utilization patterns of children in carved-out behavioral health care plans were examined and compared with those of adults.

METHODS

Twelve-month data on utilization and costs of behavioral health care from one managed behavioral health care carve-out organization, United Behavioral Health, were examined for three age groups of children--birth to five years, six to 12 years, and 13 to 17 years-and for adults. More than 600,000 enrollees in 108 different plans were included in the data. Rates of use and intensity of use were examined separately by type of service-inpatient, outpatient, and partial hospitalization.

RESULTS

Only a small number of all enrollees used any behavioral health care services--4.2 percent used outpatient services, .3 percent used inpatient services, and .2 percent used partial hospitalization services. Adolescents were more than twice as likely as adults and about seven times as likely as children aged 6 to 12 to use inpatient services. Adolescents also had a slightly higher probability of using outpatient care than adults, while younger children had lower rates of outpatient use than adolescents or adults. Adolescents were also more likely than adults and other children to have very high costs of inpatient care (mean costs=$8,975 for adolescents and $4,750 for adults). Adults were more likely than other groups to have higher outpatient costs ($640 for adults and $513 for all children).

CONCLUSIONS

The finding that children, and adolescents in particular, are more likely to have very high inpatient costs compared with adults implies that they may benefit most from the elimination of caps on mental health care costs covered by insurance. This profile of children's behavioral health care utilization patterns can be useful to policy makers in considering expansions in children's health insurance coverage.

Mental health and substance abuse benefits in carve-out plans and the Mental Health Parity Act of 1996

Legislation passed in the fall of 1996 required employers and insurers offering mental health benefits to raise dollar coverage limits on mental health services to the level of medical services. We analyze the benefit designs of 4,000 current behavioral health carve-out plans and contrast them to medical benefits. We find that almost 90 percent of all plans are inconsistent with the current legislation and need to be rewritten in the coming year. The restructuring of designs required by the Parity Act provides a unique opportunity because plans often are inconsistent and unnecessarily complex, a legacy of past attempts by employers to contain costs and control adverse selection and moral hazard in an unmanaged fee-for-service environment. Under managed care, the need for deductibles, limits, or other demand-side cost-sharing mechanisms may have diminished and restructuring outdated designs could benefit both enrollees and employers.